Medical Nutrition Therapy

for Lower Gastrointestinal

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Common Intestinal Problems
 Intestinal gas and flatulence
 Constipation
 Diarrhea
 Steatorrhea
 Gastrointestinal strictures and obstruction

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Intestinal Gas and Flatulence
 Air that is swallowed (aerophagia) and
other gases are produced in the
gastrointestinal tract (GIT) by digestive
processes and bacteria
 Intestinal gases: nitrogen, oxygen, carbon
dioxide, hydrogen, and sometimes
methane
 Gas is passed by belching or flatus
 Gas production occurs in the stomach and
small intestine from bacterial fermentation
of carbohydrates and can result in
abdominal distension and discomfort
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Recommendations to Decrease
Gas
 Eat slowly chew with the mouth closed
 Avoid chewing gum; avoid using straws
 Avoid high-fat meals
 Upright position during and after meals; do
not remain sedentary if possible
 May need to limit lactose, sugar alcohols,
and high-fructose corn syrup

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Causes of Constipation: Systemic
 Side effect of medication
 Metabolic endocrine abnormalities, such as
hypothyroidism, uremia, and hypercalcemia
 Spina bifida
 Parkinson’s disease
 Lack of exercise
 Ignoring the urge to defecate
 Vascular disease of the large bowel
 Systemic neuromuscular disease leading to
deficiency of voluntary muscles
 Poor diet low in fiber
 Pregnancy
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Causes of Constipation:
Gastrointestinal
 Cancer
 Diseases of the upper GIT
 Diseases of the large bowel resulting in
– Failure of propulsion along the colon
(colonic inertia)
– Failure of passage though anorectal structures
(outlet obstruction)
 Irritable bowel syndrome
 Anal fissures or hemorrhoids
 Laxative abuse
 Patients on opioids
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Medical Nutrition Therapy for
Constipation
 Adequate soluble and insoluble dietary
fiber
 Recommended intake is 14 g per 1000
kcal
– About 25 g for women, 38 g for men, and 19 to
25 g for children
– Supplements may be helpful

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High-Fiber Diets
1. Increase consumption of whole-grain breads and cereals and other
whole-grain products to six to 11 servings daily.
2. Increase consumption of vegetables, legumes, and fruits, nuts, and
edible seeds to five to eight servings daily.
3. Consume high-fiber cereals, granolas, and legumes as needed to
bring fiber intake to 25 g or more in women and 38 g or more daily
in men.
4. Increase consumption of fluids to at least 2 L (or about 2 qt) daily.
5. Following these guidelines may cause an increase in stool weight,
fecal water, and gas. The amount that causes clinical symptoms
varies among individuals, depending on age and presence of GI
disease, malnutrition, and resection of the GIT. These guidelines
should be implemented slowly over a period of 1 to 2 weeks to give
the GIT time to adjust and thus minimize symptoms of discomfort
or gas.

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Diarrhea
 Osmotic
 Secretory
 Medication induced
 Malabsorptive

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Clostridium difficile
 Leading cause of nosocomial diarrhea in the
United States
 Opportunistic proliferation of pathogenic
organisms associated with antibiotic therapy
 Causes colitis, secretory diarrhea, severe dilation
of the colon, peritonitis, and even death
 Spore forming and can be spread
 Diagnosed by stool sample
 Treatment with probiotics so far inconclusive

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Medical Nutrition Therapy for
Diarrhea
 Identify and treat underlying problem
 Replace fluid and electrolytes; oral glucose
electrolyte solutions with potassium, soups
and broths, vegetable juices, and other
isotonic liquids
 Introduce starchy CHOs, low-fat meats,
and small amounts of vegetables and fruits
followed by lipids
 Avoid sugar alcohols, lactose, fructose
 Prebiotics and probiotics

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Strictures and Obstruction
 GI surgeries, IBD, peptic ulcer, radiation
enteritis
 Obstructions may be partial or complete
 It is believed that fibrous foods contribute,
although there are no controlled studies

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Celiac Disease: Gluten-Sensitive
Enteropathy
 Adverse reaction to gluten; gliadin fraction
 Intestinal mucosa damaged
– Malabsorption of nutrients
– Iron deficiency
– Osteomalacia
– Growth failure
– Projectile vomiting

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Normal Human Duodenal Mucosa (A) and
Peroral Small Bowel Biopsy Specimen (B)
from a Patient with Gluten Enteropathy

A B
(From Floch MH. Nutrition and Diet Therapy in Gastrointestinal Disease. New York: Menum Medical Book Co., 1981.)

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Celiac Disease: Pathophysiology

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Medical Nutrition Therapy for
Celiac Disease
 Omit sources of gluten: wheat, rye, barley
 Label reading is critical
 Use uncontaminated corn, potato, rice,
soybean, tapioca, arrowroot, amaranth,
quinoa, millet, and buckwheat
 Oats are questionable
 Cross-contamination must be considered

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Tropical Sprue
 Cause unknown; imitates celiac disease
 Results in atrophy and inflammation of villi
 Symptoms: diarrhea, anorexia, abdominal
distension
 Treatment: broad-spectrum antibiotics, fluid
and electrolytes, folate 5 mg/day,
intramuscular vitamin B12 (1000 mg/mo)

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Intestinal Brush Border
Enzyme Deficiencies
 Lactose intolerance
 Causes: genetic or secondary deficiency of milk
sugar enzyme, lactase
– African Americans, Asians, South Americans
– Secondary: infection, inflammatory disorders, HIV, or
malnutrition
 Diagnosis: history, lactose tolerance test or breath
hydrogen test
 Treatment: avoid large amounts of lactose,
individual tolerance, foods made with lactase
enzyme; processed dairy sometimes tolerated

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Inflammatory Bowel Disease
 Crohn’s disease or ulcerative colitis
 Both cause diarrhea, fever, weight loss, anemia,
food intolerances, malnutrition, growth failure, and
extraintestinal manifestations (arthritic,
dermatologic, and hepatic); associated with
malignancy
 Crohn’s disease: may involve any part of the GIT;
most in distal ileum and colon; segments of
inflamed bowel; transmural
 Ulcerative colitis: is a mucosal disease of the large
intestine, including the rectum

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Pathophysiology and Care
Management for IBD

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Medical Nutrition Therapy for
Inflammatory Bowel Disease
 Fears and misconceptions; individualize
 Nutrition support with parenteral or enteral
nutrition to bring clinical remission
 “Complete bowel rest” using PN not necessarily
required
 Enteral nutrition may temper inflammatory
process and be steroid sparing and is preferred
over PN
 Children benefit from enteral nutrition to maintain
growth and reduce steroid dependence
 Vitamins, folate, vitamin B6, and vitamin B12 may
require supplementation
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Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc. 22
Disorders of the Large Intestine
1. Irritable bowel syndrome
– Common syndrome involving abdominal
discomfort and altered intestinal motility,
bloating, feelings of incomplete evacuation,
mucus in stool, straining or increased urgency,
GI distress with psychosocial distress
– Ensure adequate nutrient intake, tailor diet for
specific pattern of IBS, management of
symptoms, adequate fiber, prebiotics

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Disorders of the Large Intestine
(cont’d)
2. Diverticular disease
– Herniations of the colon, chronic diverticulosis,
acute diverticulitis
– Diverticulosis: high-fiber diet, increase gradually,
supplements if necessary, adequate fluid intake
– Diverticulitis: low-residue or elemental diet,
possibly low-fat diet
• Seeds, nuts, or skins unresolved

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Disorders of the Large Intestine
(cont’d)
3. Intestinal polyps and colon cancer
– Colorectal cancer is the third most common
cancer among U.S. adults
 Polyps are considered precursors of
colon cancer
– Recommend sufficient exercise, weight
maintenance or reduction, modest and
balanced intake of lipids, adequate
micronutrients, and limited alcohol

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Short Bowel Syndrome (SBS)
 Loss of 70% to 75% of the small bowel
usually results in SBS:
- 100 to 120 cm of small bowel without a colon
- 50 cm of small bowel with the colon intact
 Causes weight loss; diarrhea; decreased
transit time; malabsorption; dehydration;
loss of electrolytes; hypokalemia

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Short Bowel Syndrome (SBS)
(cont’d)
 Removal of ileocecal valve causes more
complications
 Fat malabsorption frequent
– Steatorrhea
– Saponify calcium, zinc, and magnesium
– Remove ileum and lose vitamin B12 and bile salt
absorption

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Short Bowel Syndrome (SBS)
(cont’d)
 Factors affecting the severity of
malabsorption, number of complications,
and dependence on parenteral nutrition
– Length of remaining small intestine
– Loss of ileum, especially distal third
– Loss of ileocecal valve
– Loss of colon
– Disease in remaining segments(s) of the GIT
– Radiation enteritis
– Coexisting malnutrition
– Older age
– Surgery
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Short Bowel Syndrome:
Nutritional Care
 Step 1
– Parenteral only for most patients

 Step 2
– Gradually introduce enteral nutrition; start early
– Glutamine, nucleotides, SCFAs, are important
nutrients for the gut
– Narcotic drugs for pain cause GI problems and
should be evaluated

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Short Bowel Syndrome
 Eventually, the remaining bowel increases
its absorptive surface, and problems
decrease; adaptation takes up to 1 year
 Nutrition support is designed to meet each
patient’s needs
 Intestinal transplant

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Blind Loop Syndrome
 Bacterial overgrowth from stasis in the
intestine, obstruction, radiation enteritis,
fistula, or surgical repair
 Treatment
– Antibiotics for bacterial overgrowth, prebiotics
and probiotics
– Limit refined carbohydrates; emphasize whole
grains, vegetables, oligosaccharides; may use
MCT

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Fistula: Abnormal Opening
Between Organs
 Causes: birth defects, trauma,
inflammatory disease, malignant disease
 Treatment
– Restore fluid and electrolyte balance
– PN may be necessary and depends on location
of the fistula
– Enteral nutrition may be possible using
predigested formulas

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Ileostomy or Colostomy: Surgical
Opening of Intestine to Outside
 Causes: ulcerative colitis, Crohn’s disease,
colon cancer, trauma
 Treatment
– Nutrition needs vary with location and individual
– Avoid gas- and odor-forming foods
– Fluid and electrolyte needs
– Vitamin B12 if loss of terminal ileum

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Focal Points
 The GIT has the largest surface area of any tissue (70% of
the body’s immune cells), contains more bacterial than
somatic cells in the body, and has the greatest exposure to
elements of the environment.
 The function of the GIT in preventing inappropriate
interaction between environment (primarily food, beverages,
contaminants, endogenous ingested microbes), known as
the gut barrier, plays a primary role in health maintenance.
 Disruptions in the gut barrier after injury from drugs, toxins,
infection, malnutrition, allergic responses, bacterial
overgrowth, and oxidative stress have been linked to
immune dysregulation and a number of GI disorders,
including inflammatory bowel disease, celiac disease, food
allergy, and multiorgan system failure.
 New medical and nutritional approaches are being evaluated
to improve gut barrier function and tolerance between the GI
luminal environment and host tissues and treat lower
intestine disease.
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