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Medical Nutrition Therapy
‫العالجية‬ ‫التغذية‬
1
Dr. Louay Labban
•‫العلوي‬ ‫الهضمي‬ ‫الجهاز‬ ‫أمراض‬
•‫السفلي‬ ‫الهضمي‬ ‫الجهاز‬ ‫أمراض‬
•‫السكري‬ ‫الداء‬
•‫الدموية‬ ‫واالوعية‬ ‫القلب‬ ‫أمراض‬
•‫الكلوية‬ ‫االمراض‬
NUTRITION AND DISORDERS OF
THE UPPER GASTROINTESTINAL
TRACT
‫العلوي‬ ‫العضمي‬ ‫الجهاز‬ ‫أمراض‬ ‫في‬ ‫التغذية‬
© 2006 Thomson-Wadsworth
Conditions Affecting the Esophagus
‫المري‬ ‫على‬ ‫تؤثر‬ ‫التي‬ ‫االمراض‬
Dysphagia ‫البلع‬ ‫عسر‬
The act of swallowing is complex.
The initial phase – oropharyngeal
The second phase - esophageal
© 2006 Thomson-Wadsworth
Types of dysphagia
– Oropharyngeal dysphagia – affects the transfer of
food from the mouth and pharynx to the esophagus.
• Symptoms include:
• Inability to initiate swallowing
• Coughing during or after swallowing
• Nasal regurgitation
• Other signs include:
• Bad breath, gurgling noise after swallowing, a hoarse or
“wet” voice, speech disorder
– Esophageal dysphagia – difficulty passing a bolus
of food through the esophageal lumen and into
the stomach due to either an obstruction in the
esophagus (usually a stricture) or to a motility
disorder (achalasia).
Complications of dysphagia
– Aspiration
– Malnutrition
– Weight loss may occur
– Increased risk of dehydration
Evaluating dysphagia
– Barium swallow study
– Endoscopy
– Neurological examination
Dietary interventions
– factors that may help:
– Physical properties of foods and beverages
– Food preparation
– Alternate feeding methods
– Reassessment of the dietary plan over time
– Adjustment to suit a person’s swallowing abilities
and tolerances
– Consultation with a swallowing expert – speech and
language therapist
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
Food Properties
– Easy-to-manage textures and consistencies
– Soft, cohesive foods – not hard or crumbly
– Moist foods – not dry or sticky or gummy
– Viscous beverages (milk shakes)
© 2006 Thomson-Wadsworth
Food Preparation
– Alteration of food texture – pureed, mashed,
ground, or minced
– One consistency
– Avoid nuts and seeds
– Addition of commercial starch thickeners or baby
cereals to thicken liquids
© 2006 Thomson-Wadsworth
Feeding strategies
– Learn exercises that strengthen the jaws, tongue,
or larynx
– Changing head and neck posture while eating
Speech and language therapists can help patients
learn these techniques.
© 2006 Thomson-Wadsworth
Enteral nutrition support
– Tube feedings given to patients – unable to
consume adequate amounts of foods
– Intestinal feedings used if an individual is at high
risk of aspiration
© 2006 Thomson-Wadsworth
Gastroesophageal Reflux Disease –
GERD
‫الطعام‬ ‫أرتداد‬ ‫أو‬ ‫القلس‬
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
Symptoms
– Hearburn – most common GI complaint
– Regurgitation – reflux of small amounts of stomach
acid into the mouth
With GERD – gastric reflux causes frequent discomfort
and, sometimes, tissue damage.
© 2006 Thomson-Wadsworth
Causes of GERD
– Weakening or inappropriate relaxation of lower
esophageal sphincter
– Associated with pregnancy, asthma, and hiatal hernia
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
Consequences of GERD
– Reflux esophagitis
– Esophageal ulcers
– Scarring of ulcerated tissue
– Strictures
– Barrett’s esophagus – increased risk of cancer
– Pulmonary disease
© 2006 Thomson-Wadsworth
Treatment of GERD
– drug therapy
– Proton-pump inhibitors
– Histamine-2-receptor blocking agents
– Antacids
© 2006 Thomson-Wadsworth
lifestyle modifications
– Avoid eating bedtime snacks or lying down
immediately after meals
– Consume meals 2-3 hours before bedtime
– Elevate head of bed on 6-inch blocks
– Prop pillows under the head and upper torso
© 2006 Thomson-Wadsworth
– Consume small meals and drink liquids between
meals
– Limit foods that weaken lower esophageal sphincter
pressure or increase gastric acid secretion
– Avoid smoking and alcohol
© 2006 Thomson-Wadsworth
– Avoid bending over and wearing tight clothing that
increases pressure in the stomach
– Lose weight if needed
– Avoid foods and beverages that irritate the
esophagus during periods of esophagitis
© 2006 Thomson-Wadsworth
– Avoid use of non-steroidal anti-inflammatory drugs
(NSAIDS)
© 2006 Thomson-Wadsworth
• Other interventions
– Surgery – fundoplication
– Esophageal strictures – dilatation of the esophagus
© 2006 Thomson-Wadsworth
Conditions Affecting the Stomach
‫المعدة‬ ‫على‬ ‫تؤثر‬ ‫التي‬ ‫االمراض‬
© 2006 Thomson-Wadsworth
Dyspepsia ‫الهضم‬ ‫عسر‬
• Symptoms
– Indigestion in the upper abdominal area
– Stomach pain
– Heartburn
– Fullness
– Nausea
– Bloating
© 2006 Thomson-Wadsworth
Causes of dyspepsia
– Medical conditions – peptic ulcers, GERD, motility
disorders, malabsorptive disorders, gallbladder
disease, abdominal tumors
– Medications
– Dietary supplements
© 2006 Thomson-Wadsworth
– Systemic disorders – Diabetes mellitus, renal disease,
thyroid disease, heart failure
– Lactose intolerance and irritable bowel syndrome
can mimic dyspesia
© 2006 Thomson-Wadsworth
• Bloating and stomach gas
– Chewing gum
– Smoking
– Rapid eating, drinking carbonated beverages
– Using a straw
© 2006 Thomson-Wadsworth
Potential food intolerances
– Overeating
– Specific foods – spicy
– Coffee including decaffeinated
– High-fat foods
– Advised to consume small meals, well-cooked
foods - not overly seasoned, in a relaxed
atmosphere
© 2006 Thomson-Wadsworth
Nausea and Vomiting
• Causes
– Side effects of medications
– Triggered by motion sickness, food odors, and
emotional stress
– Common in pregnancy
– Chronic vomiting can lead to malnutrition and
nutrient deficiencies
© 2006 Thomson-Wadsworth
Treatment of nausea and vomiting
– Correct the underlying disorder
– Restore hydration
– Intractable vomiting may require intravenous
nutrition support
© 2006 Thomson-Wadsworth
Dietary interventions
– Eating and drinking slowly
– Drinking clear, cold beverages – carbonated drinks or
fruit juices may ease symptoms
– Dry, salty foods – crackers or pretzels
– Avoid fried or spicy foods at bedtime
– Avoid foods with strong odors
– Cold or room temperature foods better tolerated
© 2006 Thomson-Wadsworth
Gastritis
Inflammation of the stomach mucosa
• Causes – H. pylori, use of NSAIDS
• Can lead to disruption of gastric secretory
functions
– Hypochlorhydria
– Achlorhydria
– Pernicious anemia
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
– Avoid irritating food and beverages
– Avoid food intake for 24-48 hours if food
consumption increases pain or causes nausea and
vomiting
– Nutrition support may be needed if food not
tolerated for prolonged period
– Supplementation of iron and B12 may be warranted
© 2006 Thomson-Wadsworth
Peptic Ulcer Disease
Primary cause –
H. pylori
• Gastric ulcers –
60%
• Duodenal ulcers 80%
• Zollinger-Ellison
syndrome
© 2006 Thomson-Wadsworth
• Effects of emotional stress
– Has effects on physiological processes
• Rapid stomach emptying
• Hormonal changes that impair wound healing
• Increased acid and pepsin secretions
– Behavioral changes
• Use of alcohol
• Tobacco use
• NSAID use
© 2006 Thomson-Wadsworth
Peptic Ulcer Disease
• Signs and symptoms
– Hunger pain
– Gnawing or burning pain in stomach region
– Sometimes aggravated by food – causes loss of
appetite and weight loss
© 2006 Thomson-Wadsworth
Complications
– GI bleeding, hemorrhage
– Perforations of the stomach or duodenum
– Gastric outlet obstruction
© 2006 Thomson-Wadsworth
Drug therapy
– Proton-pump inhibitors
– H2 blockers
– Antacids
– Bismuth preparations
– Triple therapy – two antibiotics (amoxicillin,
tetracycline, metronidazole, or clarithromycin) and
one other drug
© 2006 Thomson-Wadsworth
Dietary considerations
– Individualized to personal tolerances
– Avoid foods that irritate – alcohol, coffee, caffeine,
spicy foods
– Avoid large meals
© 2006 Thomson-Wadsworth
Gastric Surgery
• Effective treatment for severe obesity
• Treat peptic ulcers – resistant to drug therapy
or to correct ulcer complications
• Treat stomach cancer
© 2006 Thomson-Wadsworth
Surgical procedures
Bariatric surgery
– Gastroplasty ‫المعدة‬ ‫رأب‬
– Gastric bypass surgery ‫المعدة‬ ‫تجاوز‬
Total gastrectomy ‫المعدة‬ ‫أستئصال‬
Gastric resection ‫المعدة‬ ‫تقسيم‬ ‫أعادة‬
Vagotomy ‫المبهم‬ ‫فطع‬
Pyloroplasty ‫البواب‬ ‫رأب‬
© 2006 Thomson-Wadsworth
Gastric Surgery
© 2006 Thomson-Wadsworth
The post-gastrectomy diet
– Fluids and food withheld until some healing has
occurred
– Fluids initially given intravenously
– Fluid balance carefully monitored
– Ice chips or small sips of water allowed 24-48 hours
post-op
– Progressed from clear liquids to solid foods by 4th or
5th post-op day
© 2006 Thomson-Wadsworth
– Dietary adjustments influenced by the size of the
remaining stomach
– Small, frequent meals and snacks
– Includes mostly soft, low-fat foods
– High in complex carbohydrates
– Avoid sweets and sugars
– Liquids limited during meals (½ cup)
– Specific food intolerances
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
Dumping syndrome
– Group of symptoms resulting from abnormally rapid
gastric emptying
– Common complication of gastrectomy and gastric
bypass surgery
– Caused by hypertonic gastric contents rushing into
the intestines after meals
© 2006 Thomson-Wadsworth
– Early symptoms occur within 30 minutes
– Early symptoms include nausea, vomiting, abdominal
cramping, diarrhea, lightheadedness, rapid
heartbeat
– Above symptoms caused from
• Large fluid shift from blood plasma to intestines that
lowers blood volume
• An increase in peristaltic activity
© 2006 Thomson-Wadsworth
– Later symptoms occur several hours later –
Hypoglycemia due to spike in blood glucose
following meal – and excessive insulin response
– Small frequent meals, limit fluids during meals,
sugars restricted
– Addition of pectin and guar gum
– Medications – octreotide
– Additional surgery
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
Post-surgical complications and
nutrition status
– Discomfort with meals
– Food avoidance
– Weight loss
– Malnutrition
– Steatorrhea
© 2006 Thomson-Wadsworth
Steatorrhea
– Fat malabsorption
– Bacterial overgrowth
– Treat with medium chain triglycerides and
supplemental pancreatic enzymes
© 2006 Thomson-Wadsworth
Bone disease
– Fat malabsorption – calcium and vitamin D
malabsorption
– Avoidance of milk to minimize dumping syndrome –
increases risk of calcium and vitamin D deficiencies
– Osteoporois and osteomalcia incidence is high in
gastrectomy patients – monitor bone density –
during years after surgery
– Supplementation of calcium and vitamin D
© 2006 Thomson-Wadsworth
Anemia
– High risk for iron and B12 anemia
– May take several years to develop
– Reduced gastric secretions impair absorption of iron
and B12
– Duodenum is major site of iron absorption – iron
absorption reduced if duodenum has been removed
or bypassed
– Supplementation of iron and B12
© 2006 Thomson-Wadsworth
Bariatric surgery
– Effective treatments for morbid obesity
– Can dramatically affect health and nutrition status
– Patients require lifelong management
– Weight loss most rapid in first six months after
surgery – stabilizes after 18-24 months
© 2006 Thomson-Wadsworth
Dietary guidelines after bariatric
surgery
– First day or two – ice chips and small sips of water
– Full liquid diet – given 1-2 weeks
– Progressed to pureed foods for 1-2 weeks
– Progressed to soft foods and finally regular foods
– 5-6 small meals per day
© 2006 Thomson-Wadsworth
– Patient education and counseling – critical
– Food portion sizes – controlled
– Teach patient elements of a healthy diet
– Avoid foods that may cause abdominal discomfort,
vomiting or dumping syndrome
– Dietary supplements
© 2006 Thomson-Wadsworth
Post-surgical concerns
– Dumping syndrome
– Malabsorption
– Multiple nutrient deficiencies
– Gallbladder disease – patients at risk may have their
gallbladders removed during bariatric surgery
– Plastic surgery may be necessary to remove extra
skin
© 2006 Thomson-Wadsworth
Dental Health and Its Relationship with
Chronic Illness
© 2006 Thomson-Wadsworth
Dental Health
• Periodontal disease
– Inflammatory conditions involving the
periodontium – tissues that support the tooth in
its bony socket (gingiva, connective tissues, and
bone underneath)
– Gingivitis – characterized by redness, bleeding,
and swelling of gum tissue
– Periodontitis – inflammation of tissues
surrounding the tooth; may cause tooth loss if
untreated
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
– Risk factors
• Dental plaque
• Tobacco smoking
• Impaired immunity
– Signs and symptoms
• Gingivitis – bleeding, swollen, tender gums
• Gap between infected gum and tooth deepens
• Bad taste in mouth / persistent bad breath
• Treatments: cleaning, antimicrobial rinses, topical
antibiotics, surgery
© 2006 Thomson-Wadsworth
Dry mouth
– Many medications reduce salivary flow
– Poorly controlled diabetes
– Conditions that affect salivary gland function (e.g.
Sjögren’s syndrome)
– Radiation therapy
– Can impair health: interferes with speech, bad
breath, mouth infections, difficulty
chewing/swallowing, discomfort or ulcerations
from dentures
© 2006 Thomson-Wadsworth
© 2006 Thomson-Wadsworth
Dental health and chronic illness
– Diabetes mellitus
• Periodontal disease is more prevalent
• High risk of dental caries and oral fungal infections
– Human immunodeficiency virus (HIV) / AIDS
• Decreased immunity increases risk of periodontal
disease
© 2006 Thomson-Wadsworth
– Oral cancers
• Radiation treatment can cause severe oral and dental
complications
© 2006 Thomson-Wadsworth
– Dental health and disease risk
• Immune response – inflammatory process induced by
periodontal disease activates cytokines and other
mediators
• Respiratory illnesses – caused by bacteria which colonize
teeth
• Atherosclerosis and heart disease – blood vessel cells
attacked by bacteria associated with gingivitis
• Diabetes mellitus – periodontal disease can make attaining
glucose control difficult

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Medical nutrition therapy 1

  • 1. Medical Nutrition Therapy ‫العالجية‬ ‫التغذية‬ 1 Dr. Louay Labban
  • 2. •‫العلوي‬ ‫الهضمي‬ ‫الجهاز‬ ‫أمراض‬ •‫السفلي‬ ‫الهضمي‬ ‫الجهاز‬ ‫أمراض‬ •‫السكري‬ ‫الداء‬ •‫الدموية‬ ‫واالوعية‬ ‫القلب‬ ‫أمراض‬ •‫الكلوية‬ ‫االمراض‬
  • 3. NUTRITION AND DISORDERS OF THE UPPER GASTROINTESTINAL TRACT ‫العلوي‬ ‫العضمي‬ ‫الجهاز‬ ‫أمراض‬ ‫في‬ ‫التغذية‬
  • 5. Conditions Affecting the Esophagus ‫المري‬ ‫على‬ ‫تؤثر‬ ‫التي‬ ‫االمراض‬
  • 6. Dysphagia ‫البلع‬ ‫عسر‬ The act of swallowing is complex. The initial phase – oropharyngeal The second phase - esophageal
  • 8. Types of dysphagia – Oropharyngeal dysphagia – affects the transfer of food from the mouth and pharynx to the esophagus. • Symptoms include: • Inability to initiate swallowing • Coughing during or after swallowing • Nasal regurgitation • Other signs include: • Bad breath, gurgling noise after swallowing, a hoarse or “wet” voice, speech disorder
  • 9. – Esophageal dysphagia – difficulty passing a bolus of food through the esophageal lumen and into the stomach due to either an obstruction in the esophagus (usually a stricture) or to a motility disorder (achalasia).
  • 10. Complications of dysphagia – Aspiration – Malnutrition – Weight loss may occur – Increased risk of dehydration
  • 11. Evaluating dysphagia – Barium swallow study – Endoscopy – Neurological examination
  • 12. Dietary interventions – factors that may help: – Physical properties of foods and beverages – Food preparation – Alternate feeding methods – Reassessment of the dietary plan over time
  • 13. – Adjustment to suit a person’s swallowing abilities and tolerances – Consultation with a swallowing expert – speech and language therapist
  • 16. © 2006 Thomson-Wadsworth Food Properties – Easy-to-manage textures and consistencies – Soft, cohesive foods – not hard or crumbly – Moist foods – not dry or sticky or gummy – Viscous beverages (milk shakes)
  • 17. © 2006 Thomson-Wadsworth Food Preparation – Alteration of food texture – pureed, mashed, ground, or minced – One consistency – Avoid nuts and seeds – Addition of commercial starch thickeners or baby cereals to thicken liquids
  • 18. © 2006 Thomson-Wadsworth Feeding strategies – Learn exercises that strengthen the jaws, tongue, or larynx – Changing head and neck posture while eating Speech and language therapists can help patients learn these techniques.
  • 19. © 2006 Thomson-Wadsworth Enteral nutrition support – Tube feedings given to patients – unable to consume adequate amounts of foods – Intestinal feedings used if an individual is at high risk of aspiration
  • 20. © 2006 Thomson-Wadsworth Gastroesophageal Reflux Disease – GERD ‫الطعام‬ ‫أرتداد‬ ‫أو‬ ‫القلس‬
  • 22. © 2006 Thomson-Wadsworth Symptoms – Hearburn – most common GI complaint – Regurgitation – reflux of small amounts of stomach acid into the mouth With GERD – gastric reflux causes frequent discomfort and, sometimes, tissue damage.
  • 23. © 2006 Thomson-Wadsworth Causes of GERD – Weakening or inappropriate relaxation of lower esophageal sphincter – Associated with pregnancy, asthma, and hiatal hernia
  • 25. © 2006 Thomson-Wadsworth Consequences of GERD – Reflux esophagitis – Esophageal ulcers – Scarring of ulcerated tissue – Strictures – Barrett’s esophagus – increased risk of cancer – Pulmonary disease
  • 26. © 2006 Thomson-Wadsworth Treatment of GERD – drug therapy – Proton-pump inhibitors – Histamine-2-receptor blocking agents – Antacids
  • 27. © 2006 Thomson-Wadsworth lifestyle modifications – Avoid eating bedtime snacks or lying down immediately after meals – Consume meals 2-3 hours before bedtime – Elevate head of bed on 6-inch blocks – Prop pillows under the head and upper torso
  • 28. © 2006 Thomson-Wadsworth – Consume small meals and drink liquids between meals – Limit foods that weaken lower esophageal sphincter pressure or increase gastric acid secretion – Avoid smoking and alcohol
  • 29. © 2006 Thomson-Wadsworth – Avoid bending over and wearing tight clothing that increases pressure in the stomach – Lose weight if needed – Avoid foods and beverages that irritate the esophagus during periods of esophagitis
  • 30. © 2006 Thomson-Wadsworth – Avoid use of non-steroidal anti-inflammatory drugs (NSAIDS)
  • 31. © 2006 Thomson-Wadsworth • Other interventions – Surgery – fundoplication – Esophageal strictures – dilatation of the esophagus
  • 32. © 2006 Thomson-Wadsworth Conditions Affecting the Stomach ‫المعدة‬ ‫على‬ ‫تؤثر‬ ‫التي‬ ‫االمراض‬
  • 33. © 2006 Thomson-Wadsworth Dyspepsia ‫الهضم‬ ‫عسر‬ • Symptoms – Indigestion in the upper abdominal area – Stomach pain – Heartburn – Fullness – Nausea – Bloating
  • 34. © 2006 Thomson-Wadsworth Causes of dyspepsia – Medical conditions – peptic ulcers, GERD, motility disorders, malabsorptive disorders, gallbladder disease, abdominal tumors – Medications – Dietary supplements
  • 35. © 2006 Thomson-Wadsworth – Systemic disorders – Diabetes mellitus, renal disease, thyroid disease, heart failure – Lactose intolerance and irritable bowel syndrome can mimic dyspesia
  • 36. © 2006 Thomson-Wadsworth • Bloating and stomach gas – Chewing gum – Smoking – Rapid eating, drinking carbonated beverages – Using a straw
  • 37. © 2006 Thomson-Wadsworth Potential food intolerances – Overeating – Specific foods – spicy – Coffee including decaffeinated – High-fat foods – Advised to consume small meals, well-cooked foods - not overly seasoned, in a relaxed atmosphere
  • 38. © 2006 Thomson-Wadsworth Nausea and Vomiting • Causes – Side effects of medications – Triggered by motion sickness, food odors, and emotional stress – Common in pregnancy – Chronic vomiting can lead to malnutrition and nutrient deficiencies
  • 39. © 2006 Thomson-Wadsworth Treatment of nausea and vomiting – Correct the underlying disorder – Restore hydration – Intractable vomiting may require intravenous nutrition support
  • 40. © 2006 Thomson-Wadsworth Dietary interventions – Eating and drinking slowly – Drinking clear, cold beverages – carbonated drinks or fruit juices may ease symptoms – Dry, salty foods – crackers or pretzels – Avoid fried or spicy foods at bedtime – Avoid foods with strong odors – Cold or room temperature foods better tolerated
  • 41. © 2006 Thomson-Wadsworth Gastritis Inflammation of the stomach mucosa • Causes – H. pylori, use of NSAIDS • Can lead to disruption of gastric secretory functions – Hypochlorhydria – Achlorhydria – Pernicious anemia
  • 43. © 2006 Thomson-Wadsworth – Avoid irritating food and beverages – Avoid food intake for 24-48 hours if food consumption increases pain or causes nausea and vomiting – Nutrition support may be needed if food not tolerated for prolonged period – Supplementation of iron and B12 may be warranted
  • 44. © 2006 Thomson-Wadsworth Peptic Ulcer Disease Primary cause – H. pylori • Gastric ulcers – 60% • Duodenal ulcers 80% • Zollinger-Ellison syndrome
  • 45. © 2006 Thomson-Wadsworth • Effects of emotional stress – Has effects on physiological processes • Rapid stomach emptying • Hormonal changes that impair wound healing • Increased acid and pepsin secretions – Behavioral changes • Use of alcohol • Tobacco use • NSAID use
  • 46. © 2006 Thomson-Wadsworth Peptic Ulcer Disease • Signs and symptoms – Hunger pain – Gnawing or burning pain in stomach region – Sometimes aggravated by food – causes loss of appetite and weight loss
  • 47. © 2006 Thomson-Wadsworth Complications – GI bleeding, hemorrhage – Perforations of the stomach or duodenum – Gastric outlet obstruction
  • 48. © 2006 Thomson-Wadsworth Drug therapy – Proton-pump inhibitors – H2 blockers – Antacids – Bismuth preparations – Triple therapy – two antibiotics (amoxicillin, tetracycline, metronidazole, or clarithromycin) and one other drug
  • 49. © 2006 Thomson-Wadsworth Dietary considerations – Individualized to personal tolerances – Avoid foods that irritate – alcohol, coffee, caffeine, spicy foods – Avoid large meals
  • 50. © 2006 Thomson-Wadsworth Gastric Surgery • Effective treatment for severe obesity • Treat peptic ulcers – resistant to drug therapy or to correct ulcer complications • Treat stomach cancer
  • 51. © 2006 Thomson-Wadsworth Surgical procedures Bariatric surgery – Gastroplasty ‫المعدة‬ ‫رأب‬ – Gastric bypass surgery ‫المعدة‬ ‫تجاوز‬ Total gastrectomy ‫المعدة‬ ‫أستئصال‬ Gastric resection ‫المعدة‬ ‫تقسيم‬ ‫أعادة‬ Vagotomy ‫المبهم‬ ‫فطع‬ Pyloroplasty ‫البواب‬ ‫رأب‬
  • 53. © 2006 Thomson-Wadsworth The post-gastrectomy diet – Fluids and food withheld until some healing has occurred – Fluids initially given intravenously – Fluid balance carefully monitored – Ice chips or small sips of water allowed 24-48 hours post-op – Progressed from clear liquids to solid foods by 4th or 5th post-op day
  • 54. © 2006 Thomson-Wadsworth – Dietary adjustments influenced by the size of the remaining stomach – Small, frequent meals and snacks – Includes mostly soft, low-fat foods – High in complex carbohydrates – Avoid sweets and sugars – Liquids limited during meals (½ cup) – Specific food intolerances
  • 56. © 2006 Thomson-Wadsworth Dumping syndrome – Group of symptoms resulting from abnormally rapid gastric emptying – Common complication of gastrectomy and gastric bypass surgery – Caused by hypertonic gastric contents rushing into the intestines after meals
  • 57. © 2006 Thomson-Wadsworth – Early symptoms occur within 30 minutes – Early symptoms include nausea, vomiting, abdominal cramping, diarrhea, lightheadedness, rapid heartbeat – Above symptoms caused from • Large fluid shift from blood plasma to intestines that lowers blood volume • An increase in peristaltic activity
  • 58. © 2006 Thomson-Wadsworth – Later symptoms occur several hours later – Hypoglycemia due to spike in blood glucose following meal – and excessive insulin response – Small frequent meals, limit fluids during meals, sugars restricted – Addition of pectin and guar gum – Medications – octreotide – Additional surgery
  • 60. © 2006 Thomson-Wadsworth Post-surgical complications and nutrition status – Discomfort with meals – Food avoidance – Weight loss – Malnutrition – Steatorrhea
  • 61. © 2006 Thomson-Wadsworth Steatorrhea – Fat malabsorption – Bacterial overgrowth – Treat with medium chain triglycerides and supplemental pancreatic enzymes
  • 62. © 2006 Thomson-Wadsworth Bone disease – Fat malabsorption – calcium and vitamin D malabsorption – Avoidance of milk to minimize dumping syndrome – increases risk of calcium and vitamin D deficiencies – Osteoporois and osteomalcia incidence is high in gastrectomy patients – monitor bone density – during years after surgery – Supplementation of calcium and vitamin D
  • 63. © 2006 Thomson-Wadsworth Anemia – High risk for iron and B12 anemia – May take several years to develop – Reduced gastric secretions impair absorption of iron and B12 – Duodenum is major site of iron absorption – iron absorption reduced if duodenum has been removed or bypassed – Supplementation of iron and B12
  • 64. © 2006 Thomson-Wadsworth Bariatric surgery – Effective treatments for morbid obesity – Can dramatically affect health and nutrition status – Patients require lifelong management – Weight loss most rapid in first six months after surgery – stabilizes after 18-24 months
  • 65. © 2006 Thomson-Wadsworth Dietary guidelines after bariatric surgery – First day or two – ice chips and small sips of water – Full liquid diet – given 1-2 weeks – Progressed to pureed foods for 1-2 weeks – Progressed to soft foods and finally regular foods – 5-6 small meals per day
  • 66. © 2006 Thomson-Wadsworth – Patient education and counseling – critical – Food portion sizes – controlled – Teach patient elements of a healthy diet – Avoid foods that may cause abdominal discomfort, vomiting or dumping syndrome – Dietary supplements
  • 67. © 2006 Thomson-Wadsworth Post-surgical concerns – Dumping syndrome – Malabsorption – Multiple nutrient deficiencies – Gallbladder disease – patients at risk may have their gallbladders removed during bariatric surgery – Plastic surgery may be necessary to remove extra skin
  • 68. © 2006 Thomson-Wadsworth Dental Health and Its Relationship with Chronic Illness
  • 69. © 2006 Thomson-Wadsworth Dental Health • Periodontal disease – Inflammatory conditions involving the periodontium – tissues that support the tooth in its bony socket (gingiva, connective tissues, and bone underneath) – Gingivitis – characterized by redness, bleeding, and swelling of gum tissue – Periodontitis – inflammation of tissues surrounding the tooth; may cause tooth loss if untreated
  • 71. © 2006 Thomson-Wadsworth – Risk factors • Dental plaque • Tobacco smoking • Impaired immunity – Signs and symptoms • Gingivitis – bleeding, swollen, tender gums • Gap between infected gum and tooth deepens • Bad taste in mouth / persistent bad breath • Treatments: cleaning, antimicrobial rinses, topical antibiotics, surgery
  • 72. © 2006 Thomson-Wadsworth Dry mouth – Many medications reduce salivary flow – Poorly controlled diabetes – Conditions that affect salivary gland function (e.g. Sjögren’s syndrome) – Radiation therapy – Can impair health: interferes with speech, bad breath, mouth infections, difficulty chewing/swallowing, discomfort or ulcerations from dentures
  • 74. © 2006 Thomson-Wadsworth Dental health and chronic illness – Diabetes mellitus • Periodontal disease is more prevalent • High risk of dental caries and oral fungal infections – Human immunodeficiency virus (HIV) / AIDS • Decreased immunity increases risk of periodontal disease
  • 75. © 2006 Thomson-Wadsworth – Oral cancers • Radiation treatment can cause severe oral and dental complications
  • 76. © 2006 Thomson-Wadsworth – Dental health and disease risk • Immune response – inflammatory process induced by periodontal disease activates cytokines and other mediators • Respiratory illnesses – caused by bacteria which colonize teeth • Atherosclerosis and heart disease – blood vessel cells attacked by bacteria associated with gingivitis • Diabetes mellitus – periodontal disease can make attaining glucose control difficult