GI LEARNING ACTIVITIES



GI Learning Activity

Name:  Dawn Ortiz

Fiber

1. What is the difference between dietary fiber and dietary residue?

Dietary residue refers to the roughage left in the digestive tract from fiber rich foods that the human body is unable to digest. These indigestible fiber compounds include; cellulose, hemi cellulose, lignin and pectin. As water binds to the residue, it helps keep the digestive tract healthy by promoting movement and increasing bulk of stool. A high-residue diet is the same as a high-fiber diet, which helps prevent constipation, hemorrhoids and diverticulitis.

2. List the physiological function and food sources of both water-soluble and water-insoluble fiber.

a. Soluble fiber:

This type of fiber dissolves in water to form a gel-like material. Soluble fiber helps lower LDL cholesterol and glucose levels, which may help reduce blood pressure and inflammation and potentially decrease the risk of heart disease. Soluble fiber is found in foods that slow transit time such as oats, flaxseed, peas, beans, apples, citrus fruits, carrots, barley and psyllium.

b. Insoluble fiber:

Insoluble fiber promotes the movement of material through your digestive system and increases stool bulk. It helps speed up transit time, which reduces constipation. Regular bowel movements help prevent hemorrhoids and colon diseases. Some good sources of insoluble fiber include; whole-wheat flour, wheat bran, nuts, beans and vegetables.

3. When counseling an individual regarding increasing the fiber in their diet, what recommendations would you make to assure better tolerance?

I would recommend to start increasing fiber intake gradually until reaching a final goal of 25g for women and 38g for men. Consuming too much soluble fiber too fast may lead to cramping, as food gets stuck in the digestive tract. Increasing insoluble fiber too much/too fast may cause diarrhea, as it may move too quickly through the digestive tract. In order to prevent constipation it is important to increase fluid intake, to at least 8 glasses of water a day (because fiber absorbs water). Gradually increasing fiber intake over a few weeks gives the body time to build up the healthy bacteria in the gut necessary to prevent gastrointestinal complications.

4. How may a higher fiber diet help prevent the development of diverticulosis?

Diverticulosis develops over time from consistent pressure build up in the colon causing small pouches to form in the colon wall. Fiber helps decrease this pressure by softening waste material and reducing transit time.

5. Bulking agents are often used to control the symptoms of irritable bowel syndrome (IBS) and to help prevent constipation. Explain the rationale for this treatment and list common bulking agents available.

Bulking agents are helpful because they increase the volume of stool, by attracting water, making it easier to move through the digestive tract. Types of bulking agents include; bran, polycarbophil (Fiberlax), methyl cellulose (Citrucel), psyllium (Metamucil), guar gum (Benefiber).

6. After a thorough work-up by a physician, an individual was diagnosed with IBS. What diet and lifestyle modifications should be considered when counseling this individual?

When counseling a newly diagnosed IBS patient, the key lifestyle modifications include:

• Maintaining a food record to help identify problem foods

• Eliminating potential foods that aggravate symptoms, such as; milk, caffeinated beverages, alcohol, fruit, spicy food, fast food, Chinese food, broccoli, cabbage, cauliflower, corn, legumes and beans, preservatives and artificial flavoring and baked goods

• Restricting foods containing lactose as needed

• Eating small, frequent meals

• Consuming at least 6-8 cups of water daily

• Exercise regularly

• Gradually increasing fiber intake to reach a goal of 25-38 gm/day

• Adding probiotic supplements

7. List the common causes of diarrhea.

There are many clinical and medical causes of diarrhea, which must be identified to determine the underlying cause when treating:

• Fever

• Dehydration

• Infection (bacterial or viral)

• Contaminated food or water

• Hospital/community borne illness (C-DIFF)

• Secretory (laxatives, bile acids)

• Medications (antibiotics)

• Electrolyte repletion (MagOx, Neutraphos)

• GI disorders/malabsorption (IBS, IBD, Celiac Disease, etc.)

• Malnutrition/Hypoalbuminemia

• Post-op lactose intolerance

• Clear liquid diets

• Partial small bowel obstruction

8. Diarrhea can cause dehydration. What are the symptoms of dehydration and how should it be treated?

Symptoms of Dehydration:

• Dry, sticky mouth

• Lethargic; lack of energy

• Excessive thirst

• Decreased urine output

• Few/no tears when crying

• Dry skin

• Headache

• Hypotension

• Rapid heartbeat

• Rapid breathing

• Constipation

• Dizziness/lightheadedness

Treatment:

Typically, dehydration from diarrhea, vomiting or fever is treated by simply drinking plenty of water. Sports drinks are also a good treatment for dehydration because they are rich in electrolytes, which are usually depleted. Certain liquids, such as fruit juices, carbonated beverages or coffee should be avoided because they may act as a diuretic, prolonging dehydration. If diarrhea is severe, hospitalization and IV fluids may be necessary for treatment.

9. List the common causes of constipation.

• Low fiber diet

• Inadequate fluid/calorie intake

• Medication (pain meds tend to slow GI tract motility)

• Vitamin/mineral supplementation

• Food sensitivities

Treatment:

Constipation may be treated naturally by increasing dietary fiber along with increased fluids is helpful to improve motility. Daily exercise also helps improve motility. Probiotics such as, Lactobacillus acidophilus, also provide the healthy gut bacteria which help facilitate the digestion process and reduce constipation. Medications to relieve constipation include; laxatives, bulking agents, lubricants, stool softeners, osmotics, fiber supplements and stimulants.

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GERD / Hiatal Hernia

Mrs. Y is a 69 year old female, 5'2", 195 pounds, who has frequent complaints of heartburn and indigestion. Her diagnosis is gastrointestinal reflux disease (GERD). Her usual dietary intake is as follows:

Breakfast: 2 donuts

2 cups coffee with sugar and half & half

Lunch: Salad with low calorie Italian dressing

Coffee with sugar and half & half

Dinner: Meat Potato with gravy Carrots with butter Ice cream Coffee with sugar and half & half

Evening: Potato chips Coke Classic

1. What Medical Nutrition Therapy is recommended for GERD?

The MNT for GERD should begin with testing and limiting the foods that increase symptoms. Some potential foods to limit/avoid include; peppermint, spearmint, chocolate, and alcoholic, caffeinated and carbonated beverages. It may also help to limit or avoid high fat foods because they remain in the stomach for longer than the other macronutrients. GERD patients should wait at least three hours before lying down after eating and keep their head raised 6-9 inches while sleeping. Patients should try eating small, frequent meals throughout the day.

2. What changes would you recommend the patient make to her usual daily intake?

Mrs. Y needs to change her current dietary intake in order to reduce GERD symptoms. She needs to reduce her fat intake, along with the carbonated and caffeinated beverages. She should replace her breakfast of donuts with egg whites and wheat toast, or oatmeal, raisins and walnuts with a glass on non-fat milk. Her lunch looks good, but she should drink herbal tea instead of coffee at lunch. At dinner she should replace the fattening toppings on her potato and carrots by sautéing her vegetables in olive oil and garlic with a shake of salt and pepper. She could switch her ice cream dessert to a non-fat Greek yogurt with berries. Mrs. Y should snack on pretzels and hummus with a sparkling water instead of chips and soda in the evening. In general, Mrs. Y should make different food choices and eat small meals and snacks throughout the day to help reduce her GERD symptoms.

3. Define the types of medications a physician might prescribe as listed below. List the reason for being prescribed, potential side effects, and names of drugs within the classification.

a. Antacids: Neutralize gastric acid, reducing the amount of acid available to be refluxed into the esophagus. Antacids also restrict the production of pepsin, an acidic digestive enzyme. Common antacid side effects include; dose-dependent rebound hyperacidity, magnesium containing antacids may cause diarrhea, aluminum hydroxide containing antacids may cause constipation, aluminum-intoxication, osteomalacia, and hypophosphatemia. Common antacids include; Maalox, Tums and Mylanta.

b. H-2 blockers: Histamine blockers, block the action of histamine, inhibiting the secretion of stomach acid. Potential side effects include; headache, rash, fatigue, diarrhea, muscle cramps and dizziness. Common H-2 blockers include; Pepcid, Zantac and Tagamet.

c. Proton-pump inhibitors: Prescribed to decrease gastric acid secretion by an irreversible inhibition of the H+/K+ ATPase, in the parietal cells of the stomach. Possible side effects include; rash, itch, flatulence, constipation and decreased vitamin B12 absorption. Common PPIs include; Prevacid, Protonix and Prilosec.

d. Motility altering: Promotility drugs enhance gastric emptying by increasing gastric, plyoric, and small bowel motor functions. Common motility altering drugs include; Reglan and Motilium. Side effects include; fatigue, agitation and abnormal muscle movements.

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Inflammatory Bowel Disease

1. Differentiate between Crohn’s Disease and Ulcerative Colitis. Include the area(s) affected, degree of inflammation, complications, age of onset and treatment in your answer. (Setting this up as a table may be helpful.)

Ulcerative Colitis: Ulcerative disease of the colon

Crohn’s Disease: Inflammatory disease in the terminal ileum

|DISEASE |UC |CROHN’S |

|AFFECTED AREAS |Rectum and colon |Mouth to anus |

|DEGREE OF INFLAMMATION |Mucosa and submucosa |Transmural |

|DISTRIBUTION |Continuous |Segmental |

|AGE OF ONSET |50-70 years old |15-30 years old |

|SYMPTOMS |Bloody diarrhea, weight loss, anorexia |Weigt loss, anorexia, diarrhea |

|TREATMENT |Diet: Soft, bland foods, multivitamin |Diet: Soft, bland foods, multivitamin |

| |with minerals to prevent deficiencies. |with minerals to prevent deficiencies. |

| |Medications: Mesalamine, |Medications: Antibiotics, |

| |Corticosteroids, antidiarrheals, |Sulfasalazine, Cholestyramine, |

| |antibiotics. |Corticosteroids, antibiotics. |

| |Surgery: removal of the entire colon |Surgery: removal of the diseased |

| |and rectum, with the creation of an |segment of bowel (resection), the two |

| |ileostomy or external stoma (an opening|ends of healthy bowel are then joined |

| |on the abdomen through which wastes are|together (anastomosis). |

| |emptied into a pouch, which is attached| |

| |to the skin with adhesive. | |

|DEFECTS FOR BOTH DISEASES |Macronutrient malabsorption, iron and zinc deficiency from diarrhea, meds may |

| |cause folate and B12 deficiency and long term steroids may cause vitamin D and |

| |Ca deficiency. |

2. Listed below are common medications to treat inflammatory bowel disease. State the rationale for their use, potential food and drug interaction and any other significant side effects.

Prednisone: Corticosteroids help reduce inflammation, but have many side effects so they are not usually administered long term. Side effects include; puffy face, excessive facial hair, night sweats, insomnia and hyperactivity. More-serious side effects include hypertension, diabetes, osteoporosis, bone fractures, cataracts, glaucoma and increased chance of infection. Prednisone may also decrease the absorption of calcium, vitamin D and phosphorus requiring supplementation. Prednisone increases sodium and water retention and the breakdown of protein, possibly requiring a fluid restricted, low sodium, high protein diet. Magnesium, potassium, zinc and vitamin C may also be depleted, requiring supplementation. Common drug interactions include; aldesleukin, mifepristone, which may cause bleeding/bruising (including antiplatelet drugs such as clopidogrel), as well as the effectiveness of NSAIDs and blood thinners such as, dabigatran/warfarin.

Sulfasalazine: Used to treat bowel inflammation, diarrhea, rectal bleeding, and abdominal pain in patients with an inflamed bowel. Side effects include; gastric distress, nausea/vomiting, anorexia, headache, yellowing of the skin and infertility in males while on the medication. Sulfasalazine may cause reduced absorption of folic acid (leading to deficiency and anemia) and digoxin (reducing effectiveness). It may also increase blood levels of methotrexate, resulting in toxicity and folic acid deficiency. Sulfasalazine may increase the blood glucose lowering effect of oral anti-diabetic drugs, resulting in hypoglycemia. Taken in combination with NSAIDs may cause kidney dysfunction, combining with azathioprine may increase the likelihood of blood disorders, and taken with warfarin may increase the blood thinning effect. Alcohol should be limited and this drug should not be taken while breastfeeding. Folate supplementation should be included while taking this drug.

Cholestyramine: Commonly used to treat diarrhea resulting from bile acid malabsorption, especially in Crohn's disease patients after ileal resection. Cholestyramine prevents an increase in water by making the bile acids insoluble and osmotically inactive. Side effects include; constipation, increased risk of developing gallstones and increased plasma TG levels. Cholestyramine may prevent absorption and therefore effectiveness of the following drugs; digitalis, estrogens and progestins, diabetes medication, penicillin, Phenobarbital, Spironolactone, Tetracycline, Thiazide-type diuretic pills, thyroid medication, warfarin and leflunomide. Cholestyramine may interfere in the absorption of fat-soluble vitamins, such as vitamins A, D, E, and K, as well as calcium, folate, B12, calcium and iron.

Antibiotics: Help reduce harmful intestinal bacteria and suppress the intestine's immune system. Antibiotics may also help reduce the amount of drainage and heal fistulas and abscesses in people with Crohn's disease, and control for infection in ulcerative colitis. Side effects of antibiotics include; diarrhea, constipation, vomiting, abdominal cramps, vaginal itching and allergic reactions. Antibiotics may reduce the effectiveness of oral contraceptives. Drinking alcohol with antibiotics may reduce the effect of the antibiotic. Antibiotics may also reduce healthy, vaginal flora, causing yeast infections. Disruptions in the intestinal flora may cause vitamin K deficiency and C-DIFF. Long term antibiotic use may cause resistance to the drug. Lastly, tendon damage may occur if antibiotics are taken with corticosteroids.

Immunomodulators: Help suppress the immune response that releases inflammation-inducing chemicals in the intestinal lining. Side effects include; increasing the risk for infection and damage to the liver, pancreas and kidneys, nausea, vomiting, anorexia, fatigue, headache and hair loss. Women who are pregnant or breast feeding should not take immunomodulators. Combining alcohol with these medications may increase risk of liver damage. Immunomodulators may reduce the effectiveness of ACE inhibitor drugs, chemotherapy drugs, blood thinners, liver medications, and should not be combined with other drugs that may weaken the immune system.

Antidiarrheals: (Immodium, Lomotil, Paragoric): Help treat IBD by adding bulk to the stool. Side effects include; fatigue and dizziness. Potential drug interactions include; Quinidine or Ritonavir (may increase side effects of antidiarrheals) and Saquinavir (may decrease effectiveness of antidiarrheals). Alcohol may increase the side effects associated with antidiarrheals. High fiber foods should also be avoided.

References:

1. Mayoclinic: Diseases and Conditions, Inflammatory Bowel Disease. . Updated September 27, 2014. Accessed November 1, 2014.

2. . . Updated September 26, 2014. Accessed November 1, 2014.

3. Medicinenet. . Updated June 20, 2013. Accessed on November 1, 2014.

3. Patients with IBD are at the greatest risk for deficiencies of the following nutrients. List the reason(s) why the deficiency may occur in patients with IBD

Iron: Lost in bloody diarrhea; depleted from medications

Zinc: Not absorbed due to diarrhea; depleted from medications

Folate: Medications cause depletion

Vitamin B12: Ilium may be too inflamed for absorption, especially in Crohn’s Disease; medication depletion

Protein: Malabsorption; broken down from corticosteroids

Fat-Soluble vitamins: Malsbsorption; medication depletion

Calories: Malabsorption in the GI tract; loss of appetite from meds and disease

In general, patients should follow a low residue, low fiber diet to avoid malabsorption and nutrient deficiencies during IBD flare ups.

4. What dietary considerations are necessary with an ileostomy?

In an ileostomy the Iloscal valve is removed, which increases the risk of diarrhea and nutrient malabsorption. Diet considerations include early PO intake to re-train and recondition the bowel, tpn and PO (overlapping feeding modalities), and a diet high in soluble fiber, low fat and lactose free.

5. What is Short Bowel Syndrome?

SBS usually occurs in patients that have had IBD, especially after extensive small bowel recession. It is also likely to occur in patients who have had radiation enteritis and elective weight loss surgery. The inadequate absorptive capacity of decreased length or decreased amount of functional bowel leads to fluid and substrate load in the digestive tract exceeding the absorptive capacity remaining viable mucosa in the intestine. Therefore, cardinal symptoms of SBS usually result in diarrhea and steatorrhea since 70-75% of small bowel lost.

6. What is the minimal length of functional bowel believed to be necessary for provision of enteral nutrition?

A normal adult small bowel is 400 cm. A minimum of 120 cm of small bowel without a colon, or 50 cm with a colon, with the ileocecal valve intact, is necessary for sufficient absorption of nutrients in the GI tract. If greater than 100 cm of terminal ilium in lost, then bile salt pool cannot be maintained resulting in steatorrhea and fat soluble vitamin loss.

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Celiac Disease

1. Define Celiac Disease, including the frequency of the condition and causes.

Celiac disease is an autoimmune response to the exposure of gluten, which results in an inflammatory process that damages the lining of the small intestine. The etiology is genetic susceptibility, or it may be environmentally triggered during pregnancy or infection. Celiac disease effects 1 out of 141 people.

2. What types of foods must be avoided by patients with Celiac Disease?

Foods containing gluten must be avoided in order for the intestines to heal. Gluten is a protein common in wheat, rye and barley. Patients with Celiac Disease should avoid foods such as, pasta, bread, pizza, flour tortillas and baked goods; as well as less obvious gluten-containing foods such as, beer, sauces, gravies, candy and supplements. Cross-contamination must also be considered when following a strict gluten-free diet.

3. What nutrients might be deficient in this diet?

Most gluten-containing pastas, cereals, and breads are made from flour that has been enriched or fortified with iron and B vitamins (especially B12 and folate). Also, a common source of fiber is whole grains, which contain gluten. Therefore, eating whole foods (fresh fruits and vegetables) and supplementing these nutrients while following a gluten free diet may help prevent deficiencies.

4. Write a one-day menu for a patient on a gluten-free diet.

Breakfast—Vegetable and cheese omelet, gluten free toast, orange juice and coffee.

Snack—Apple slices

Lunch—2 corn tortillas with grilled chicken, black beans, fresh salsa and cabbage and unsweetened iced tea with lemon.

Snack—1/4 cup mixed nuts and raisins

Dinner—Grilled salmon with brown rice and broccoli and sparking water.

Dessert—Yogurt with berries

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Gallbladder Disease

1. Define the following terms:

Cholecystitis: Inflammation of the gallbladder, usually caused by bile build up and gall stones.

Cholelithiasis: The presence of gall stones in the gallbladder.

Cholecystectomy: Surgical removal of the gallbladder.

2. You are asked to counsel an individual regarding a diet post cholecystectomy. What diet modifications would you recommend both short and long term?

Immediately post-surgery, patients should only consume clear liquids and very low fat. Patients should transition gradually to a low fat (40g per day), bland solid foods diet and eat small, frequent meals rich in lean protein, whole grains, fruits and vegetables. Over time, patients may gradually add more fat to the diet as the body adjusts to not having a gallbladder, while maintaining a healthy weight.

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