Nutrition for Patients with Upper Gastrointestinal Disorders



Nutrition for Patients with Upper Gastrointestinal Disorders

















Table 17.1 The Role of the Upper Gastrointestinal Tract in the Mechanical and Chemical Digestion of Food



















Site


Mechanical Digestion


Chemical Digestion


Mouth


Chewing breaks down food into smaller particles.


Food mixes with saliva for ease in swallowing.


Saliva contains lingual lipase, which has a limited role in the digestion of fat, and salivary amylase, which begins the process of starch digestion. Food is not held in the mouth long enough for significant digestion to occur there.


Esophagus


Propels food downward into the stomach


Lower esophageal sphincter relaxes to move food into stomach.


None


Stomach


Churns and mixes food with digestive enzymes to reduce it to a thin liquid called chyme


Forward and backward mixing motion at the pyloric sphincter pushes small amounts of chyme into the duodenum.


Secretes pepsin, which begins to break down protein into polypeptides


Secretes gastric lipase, which has a limited role in fat digestion


Secretes intrinsic factor, necessary for the absorption of vitamin B12


Absorbs some water, electrolytes, certain drugs, and alcohol


Nutrition therapy is used in treating many digestive system disorders. For many disorders, diet merely plays a supportive role in alleviating symptoms rather than altering the course of the disease. For other gastrointestinal (GI) disorders, nutrition therapy is the cornerstone of treatment. Frequently, nutrition therapy is needed to restore nutritional status that has been compromised by dysfunction or disease.

This chapter begins with disorders that affect eating and covers disorders of the upper GI tract (mouth, esophagus, and stomach) that have nutritional implications. Table 17.1 outlines the roles these sites play in the mechanical and chemical digestion of food. Problems with the upper GI tract affect nutrition mostly by affecting food intake and tolerance to particular foods or textures. Nutrition-focused assessment criteria for upper GI tract disorders are listed in Box 17.1.




DISORDERS THAT AFFECT EATING


Anorexia

Anorexia is a common symptom of many physical conditions and a side effect of certain drugs. Emotional issues, such as fear, anxiety, and depression, frequently cause anorexia. The aim of nutrition therapy is to stimulate the appetite to maintain adequate nutritional intake. The following interventions may help:

Anorexia lack of appetite; it differs from anorexia nervosa, a psychological condition characterized by denial of appetite.



  • Serve food attractively and season according to individual taste. If decreased ability to taste is contributing to anorexia, enhance food flavors with tart seasonings (e.g., orange juice, lemonade, vinegar, lemon juice) or strong seasonings (e.g., basil, oregano, rosemary, tarragon, mint).


  • Schedule procedures and medications when they are least likely to interfere with meals, if possible.


  • Control pain, nausea, or depression with medications as ordered.


  • Provide small, frequent meals.


  • Withhold beverages for 30 minutes before and after meals to avoid displacing the intake of more nutrient-dense foods.


  • Offer liquid supplements between meals for additional calories and protein if meal consumption is low.


  • Limit fat intake if fat is contributing to early satiety.



Nausea and Vomiting

Nausea and vomiting may be related to a decrease in gastric acid secretion, a decrease in digestive enzyme activity, a decrease in GI motility, gastric irritation, or acidosis. Other causes include bacterial and viral infection; increased intracranial pressure; equilibrium imbalance; liver, pancreatic, and gallbladder disorders; and pyloric or intestinal obstruction. Drugs and certain medical treatments may also contribute to nausea.

The short-term concern of nausea and vomiting is fluid and electrolyte balance, which can be maintained by intravenous (IV) administration until an oral intake resumes. With prolonged or intractable vomiting, dehydration and weight loss are concerns.

Intractable Vomiting vomiting that is difficult to manage or cure.

Nutrition intervention for nausea is a commonsense approach. Food is withheld until nausea subsides. When the patient is ready to eat, clear liquids are offered and progressed to a regular diet as tolerated. Small, frequent meals of low-fat, readily digested carbohydrates are usually best tolerated. Other strategies that may help are to



  • Encourage the patient to eat slowly and not to eat if he or she feels nauseated


  • Promote good oral hygiene with mouthwash and ice chips


  • Limit liquids with meals because they can cause a full, bloated feeling


  • Encourage a liberal fluid intake between meals with whatever liquids the patient can tolerate, such as clear soup, juice, gelatin, ginger ale, and popsicles


  • Serve foods at room temperature or chilled; hot foods may contribute to nausea


  • Avoid high-fat and spicy foods if they contribute to nausea



DISORDERS OF THE ESOPHAGUS

Symptoms of esophageal disorders range from difficulty swallowing and the sensation that something is stuck in the throat to heartburn and reflux. Dysphagia and gastroesophageal reflux disease are discussed next.

Dysphagia impaired ability to swallow.







Figure 17.1Swallowing phases and symptoms of impairments.


Dysphagia

Swallowing is a complex series of events characterized by three basic phases (Fig. 17.1). Dysphagia is an impairment in the swallowing process. It can have a profound impact on intake, hydration status, and nutritional status and greatly increases the risk of aspiration and its complications of bacterial pneumonia and bronchial obstruction.

Although aging causes natural changes in the ability to swallow, dysphagia is often related to neurologic impairments, such as cerebral vascular accident, dementia, amyotrophic lateral sclerosis (ALS), myasthenia gravis, brain tumor, traumatic brain injury, cerebral palsy, Parkinson disease, and multiple sclerosis. Mechanical causes include obstruction, inflammation, edema, and surgery of the throat. Refer patients with actual or potential swallowing impairments to the speech pathology department for a swallowing evaluation.



Nutrition Therapy for Dysphagia

Viscosity the condition of being resistant to flow; having a heavy, gluey quality.

The goal of nutrition therapy for dysphagia is to modify the texture of foods and/or viscosity of liquids to enable the patient to achieve adequate nutrition and hydration
while decreasing the risk of aspiration. Solid foods may be minced, mashed, ground, or pureed, and thin liquids may be thickened to facilitate swallowing, but these measures often dilute the nutritional value of the diet and make food and beverages less appealing. Emotionally, dysphagia can affect quality of life; patients with dysphagia may feel panic at mealtime, avoid eating with others, and stop eating even when they still feel hungry. Meeting nutritional needs is a challenge, and in some instances, enteral nutrition may be necessary.

The National Dysphagia Diet, developed through consensus by a group of dietitians, speech-language pathologists (SLP), and researchers, standardized nutrition therapy for dysphagia on a national level (National Dysphagia Diet Task Force, 2002). The National Dysphagia Diet is composed of three levels of solid textures and four liquid consistencies (Table 17.2).

The levels of solid food and liquids are ordered separately to allow maximum flexibility and safety in meeting the patient’s needs. The patient may start at any of the levels. The solid food consistencies include pureed, mechanically altered, and a more advanced consistency of mixed
textures. The liquids are described as “thin,” “nectar-like,” “honey-like,” or “spoon-thick,” which means they are thick enough to require the use of a spoon.








Table 17.2 National Dysphagia Diet









































Level of Diet


Description


Foods Allowed


Three levels of solid textures


Level 1: Pureed


Foods are totally pureed to a smooth, homogenous, and cohesive consistency. Eliminates sticky foods, such as peanut butter, and coarse-textured foods, such as nuts and raw fruits and vegetables


Smooth cooked cereals; slurried or pureed bread products; milk; smooth desserts such as yogurt, pudding, custard, and applesauce; pureed fruits, vegetables, meats, scrambled eggs, and soups


Level 2: Mechanically altered


Soft-textured, moist foods that are easily formed into a bolus. Eliminates coarse textures, nuts, and raw fruits and vegetables (except bananas)


Cooked cereals may have a little texture; some well-moistened, ready-to-eat cereals; well-moistened pancakes with syrup; slurried bread; moist well-cooked potatoes, noodles, and dumplings; soft poached or scrambled eggs; soft canned or cooked fruit; soft, well-cooked vegetables with 1/2 pieces (except no corn, peas, and other fibrous vegetables). Moist ground or minced tender meat in pieces no larger than 1/4 in, soft casseroles, cottage cheese, tofu; moist cobblers and moist soft cookies; soups with easy-to-chew meat or vegetables


Level 3: Advanced


Near-normal textured foods; excludes crunchy, sticky, or very hard foods. Food is bite-sized and moist.


All breads are allowed except for those that are crusty; moist cereals; most desserts except those with nuts, seeds, coconut, pineapple, or dried fruit; soft, peeled fruit without seeds; moist tender meats or casseroles with small pieces of meat; moist potatoes, rice, and stuffing; all soups except those with chewy meats or vegetables; most cooked, tender vegetables, except corn; shredded lettuce. No nuts, seeds, coconut, and chewy candy.


Four standard liquid consistencies


Thin


All regular unthickened beverages and supplements


Clear juices, frozen yogurt, ice cream, milk, water, coffee, tea, soda, broth, plain gelatin, liquidy fruits such as watermelon


Nectar-like


Liquids thicker than water but thin enough to sip through a straw


Nectars, vegetable juices, chocolate milk, buttermilk, thin milkshakes, cream soups, other properly thickened beverages


Honey-like


Liquids that are too thick to sip through a straw; can be eaten with a spoon but do not hold their shape


Honey, tomato sauce, yogurt


Spoon-thick


Liquids thickened to pudding consistency that need to be eaten with a spoon


Pudding, custard, hot cereal


Source: National Dysphagia Diet Task Force. (2002). The national dysphagia diet: Standardization for optimal care. Chicago, IL: American Dietetic Association.


Generally, a SLP performs a swallowing evaluation on the patient to determine the appropriate consistency of food and liquids and recommends feeding techniques based on the patient’s individual status. Changes to the diet prescription are made as the patient’s ability to swallow improves or deteriorates.



Solid Textures

Generally, moist, semisolid foods are easiest to swallow, such as pudding, custards, scrambled eggs, and yogurt, because they form a cohesive bolus that is more easily controlled. Dry, crumbly, and sticky foods are avoided. Some foods, such as bread, are slurried to create a texture easily swallowed while retaining the appearance of “regular” bread.

Pureed food is often described as having poor sensory appeal with items indistinguishable from one another (Keller & Duizer, 2014). Commercial thickeners added to pureed foods can allow pureed foods to be molded into the appearance of “normal” food (Fig. 17.2). However, a study comparing the acceptability of molded pureed meats and vegetables to the same items but in scooped form found the scooped pureed food was more acceptable and identifiable (Lepore, Sims, Gal, & Dahl, 2014). Although no one chooses to eat a pureed diet, many patients are grateful they can consume food orally.

Slurried a slurry is a thickener dissolved in liquid that is added to dry or pureed foods to produce a texture that is soft and cohesive.


Liquid Consistencies

Thickened liquids are more cohesive than thin liquids and are easier to control. Commercial thickening agents provide instructions on how to mix the product with liquids to achieve the desired consistency, yet wide variations in consistency occur depending on the beverage type,
type of thickener (e.g., starch based or gum based), temperature of the liquid, and time between thickened fluid preparation and service to the patient (Adeleye & Rachal, 2007). Commercially prepared thickened beverages eliminate issues related to quality control.






Figure 17.2Examples of pureed and molded foods.

Thickened beverages are often poorly accepted, making it difficult to maintain an adequate fluid intake. Potential complications include dehydration, decreased compliance with swallowing guidelines, increased risk of aspiration pneumonia due to aspiration of thickened liquids, and decreased quality of life (Panther, 2005). Although thickened liquids may reduce the risk of aspiration in some patients, research suggests that drinking plain water alone is less likely to cause problems if it is aspirated than if it is consumed with food or other liquids. Consequently, free water protocols (FWP), such as the Frazier Free Water Protocol, are being used to permit patients with documented aspiration to drink plain water between meals (Garcia & Chambers, 2010). A randomized controlled trial of an FWP showed no adverse events from using the FWP and identified increased fluid intake and reported high quality of life outcomes among the FWP participants (Carlaw et al., 2011).

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Nov 8, 2018 | Posted by in NURSING | Comments Off on Nutrition for Patients with Upper Gastrointestinal Disorders
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