DISORDERS OF THE PRIMARY ORGANS
Dyspepsia, or indigestion, is a condition of discomfort in the digestive tractthat can be physical or psychological in origin. Symptoms include heartburn, bloating, pain and, sometimes, regurgitation. If the cause is physical, it can be due to overeating or spicy foods, or it may be a symptom of another problem, such as appendicitis or a kidney, gallbladder, or colon disease or possibly cancer. If the problem is organic in origin, treatment of the underlying cause will be the normal procedure.
Psychological stress can affect stomach secretions and trigger dyspepsia.
Treatment should include counseling to help the client:
• Find relief from the underlying stress
• Allow sufficient time to relax and enjoy meals
• Learn to improve eating habits
Esophagitis is caused by the irritating effect of acidic gastric reflux on themucosa of the esophagus. Heartburn, regurgitation, and dysphagia (diffi-culty swallowing) are common symptoms. Acute esophagitis is caused by ingesting an irritating agent, by intubation, or by an infection. Chronic, or reflux, esophagitis is caused by recurrent gastroesophageal reflux (GER). This can be caused by a hiatal hernia, reduced lower esophageal sphincter (LES) pressure, abdominal pressure, recurrent vomiting, alcohol use, overweight, or smoking. Cancer of the esophagus and silent aspiration may be life-threatening for those with gastroesophageal reflux disease (GERD).
Hiatal hernia is a condition in which a part of the stomach protrudes throughthe diaphragm into the thoracic cavity (Figure 20-1). The hernia prevents the food from moving normally along the digestive tract, although the food does mix somewhat with the gastric juices. Sometimes the food will move back into the esophagus, creating a burning sensation (heartburn), and sometimes food will be regurgitated into the mouth. This condition can be very uncomfortable.
Medical Nutrition Therapy.The symptoms can sometimes be alle-viated by serving small, frequent meals (from a well-balanced diet) so that the amount of food in the stomach is never large. Avoid irritants to the esophagus such as carbonated beverages, citrus fruits and juices, tomato products, spicy foods, coffee, pepper, and some herbs. Some foods can cause the lower esopha-geal sphincter to relax, and these should be avoided. Examples are alcohol, garlic, onion, oil of peppermint and spearmint, chocolate, cream sauces, gravies, margarine, butter, and oil. If the client is obese, weight loss may be recommended to reduce pressure on the abdomen. It may also be helpful if clients avoid late-night dinners and lying down for 2 to 3 hours after eating.
When they do lie down, they may be more comfortable sleeping with their heads and upper torso somewhat elevated and wearing loose-fitting clothing. If discomfort cannot be controlled, surgery may be necessary.
An ulcer is an erosion of the mucous membrane (Figure 20-2). Peptic ulcers may occur in the stomach (gastric ulcer) or the duodenum (duodenalulcer). The specific cause of ulcers is not clear, but some physicians believethat a number of factors including genetic predisposition, abnormally high secretion of hydrochloric acid by the stomach, stress, excessive use of aspirin or ibuprofen (analgesics), cigarette smoking, and, in some cases, a bacterium called Helicobacter pylori may contribute to their development.
A classic symptom is gastric pain, which is sometimes described as burning, and in some cases, hemorrhage is also a symptom. The pain is typi-cally relieved with food or antacids. A hemorrhage usually requires surgery.
Ulcers are generally treated with drugs such as antibiotics and cimeti-dine. The antibiotics kill the bacteria, and cimetidine inhibits acid secretion in the stomach and thus helps to heal the ulcer. Antacids containing calcium carbonate can also be prescribed to neutralize any excess acid. Stress manage-ment may also be beneficial in the treatment of ulcers.
Sufficient low-fat protein should be provided but not in excess because of its ability to stimulate gastric acid secretion. It is recommended that clients receive no less than 0.8 gram of protein per kilogram of body weight. However, if there has been blood loss, protein may be increased to 1 or 1.5 grams per kilogram of body weight. Vitamin and mineral supplements, especially iron if there has been hemorrhage, may be prescribed.
Although fat inhibits gastric secretions, because of the danger of athero-sclerosis, the amount of fat in the diet should not be excessive. Carbohydrates have little effect on gastric acid secretion.
Spicy foods may be eaten as tolerated. Coffee, tea, or anything else that contains caffeine or that seems to cause indigestion in the client or stimulates gastric secretion should be avoided. Alcohol and aspirin irritate the mucous membrane of the stomach, and cigarette smoking decreases the secretion of the pancreas that buffers gastric acid in the duodenum. Currently, a well-balanced diet of three meals a day consisting of foods that do not irritate the client is generally recommended.
Diverticulosis is an intestinal disorder characterized by little pockets in thesides of the large intestine (colon) (Figure 20-3). When fecal matter collects in these pockets instead of moving on through the colon, bacteria may breed, and inflammation and pain can result, causing diverticulitis. If a diverticulum ruptures, surgery may be needed. This condition is thought to be caused by a diet lacking sufficient fiber. A high-fiber diet is commonly recommended for clients with diverticulosis.
Along with antibiotics, diet therapy for diverticulitis may begin with a clear liquid diet, followed by a low-residue diet that allows the bowel to rest and heal. Then a high-fiber diet will be a initiated. The bulk provided by the high-fiber diet increases stool volume, reduces the pressure in the colon, and shortens the time the food is in the intestine, giving bacteria less time to grow.
Inflammatory bowel diseases (IBDs) are chronic conditions causing inflam-mation in the gastrointestinal tract. The inflammation causes malabsorption that often leads to malnutrition. The acute phases of these diseases occur at irregular intervals and are followed by periods in which clients are relatively free of symptoms. Neither cause nor cure for these conditions is known.
Two examples are ulcerative colitis and Crohn’s disease (Table 20-1). Ulcerative colitis causes inflammation and ulceration of the colon, the rectum, or sometimes the entire large intestine. Crohn’s disease is a chronic progres-sive disorder that can affect both the small and large intestines. The ulcers can penetrate the entire intestinal wall, and the chronic inflammation can thicken the intestinal wall, causing obstruction.
Both conditions cause bloody diarrhea, cramps, fatigue, nausea, anorexia, malnutrition, and weight loss. Electrolytes, fluids, vitamins, and other minerals are lost in the diarrhea, and the bleeding can cause loss of iron and protein.
Treatment may involve anti-inflammatory drugs plus medical nutri-tion therapy. Usually a low-residue diet is required to avoid irritating the inflamed area and to avoid the danger of obstruction.
When tolerated, the diet should include about 100 grams of protein, additional calories, vitamins, and minerals.
In severe cases, total parenteral nutrition (TPN) (a process in which nutrients are delivered directly into the superior vena cava;) may be necessary for a period. As the client begins to regain health, the diet may be increasingly liberalized to suit the client’s tastes while maintaining good nutrition.
Clients with severe ulcerative colitis or Crohn’s disease frequently require a surgical opening from the body surface to the intestine for the purpose of defecation. The opening that is created is called a stoma and is about the size of a nickel. An ileostomy (from the ileum to abdomen surface) is required when the entire colon, rectum, and anus must be removed. A colostomy (from the colon to abdomen surface) can provide entrance into the colon if the rectum and anus are removed. This can be a temporary or a permanent procedure.
Clients with ileostomies have a greater-than-normal need for salt and water because of excess losses. A vitamin C supplement is recommended and, in some cases, a B12 supplement may be needed. Eating a well-balanced indi-vidualized diet will prevent a nutritional deficiency for clients with ileostomies and colostomies.
Celiac disease, also called nontropical sprue or gluten sensitivity, is a disorder characterized by malabsorption of virtually all nutrients. It is thought to be due to heredity.
Symptoms include diarrhea, weight loss, and malnutrition. Stools are usually foul-smelling, light-colored, and bulky. The cause is unknown, but it has been found that the elimination of gluten from the diet gives relief. Untreated, it is life-threatening because of the severe malnutrition and weight loss it can cause.
gluten-controlled diet (Table 20-2) is used in the treatment of celiac disease. Gluten is a protein found in barley, oats, rye, and wheat. All products containing these grains are disallowed.
Rice and corn may be used. A reduc-tion in the fiber content is also frequently recommended. If the client is under weight, the diet should also be high in calories, carbohydrates, and protein (Table 20-3). Fat may be restricted until bowel function is normalized. Vitamin and mineral supplements may be prescribed. Lactose intolerance sometimes develops with celiac disease.
It is not easy to avoid food products containing wheat. Breads, cereals, crackers, pasta products, desserts, gravies, white sauces, and beer contain wheat or other cereal grains with gluten. The client will have to learn to read food labels carefully and to avoid restaurant foods such as breaded meats or fish, meatloaf, creamed vegetables, and cream soups.