348 Medical Nutrition Therapy for Upper Gastrointestinal Tract Disorders 上消化道疾病

Digestive Disorders  Common problem; more than 50 million outpatient visits per year  Dietary habits and nutrition play key roles in prevention and treatment of diseases of the gastrointestinal tract (GIT)  Medical nutrition therapy is necessary to prevent and treat malnutrition associated with the diseases of the GIT 2 Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Assessment Parameters  Screening: most important indicator is unintentional weight loss  Diet history: changes in appetite, nausea, vomiting, diarrhea, chewing and swallowing problems, food intolerances, typical intake  Laboratory parameters: vitamin B 12, folate, ferritin, 25-hydroxy vitamin D 3 Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Lower Esophageal Sphincter (LES) Disorders of Esophagus

348 Gastroesophgeal Reflux and Esophagitis (endoscope 檢查 ) Heartburn ：胃食物 ( 胃酸 ) 逆流至食道導致發炎 (gastroesophageal reflux disease ; GERD) 50% 新生兒最常見； 20-40% adult 徵狀：打嗝、咽喉刺激、聲音沙啞、惡化氣喘 發生在吃下食物後、突然改變飲食習慣 ( 特別 在晚上 ) - 食道 burning Barrett’s esophagus (BE) ：長期胃食物逆流至 食道導致遠端食道變得不正常和形成癌病前期  食道癌 (5-10% adult ， male, age >50, family history)

Esophagitis ( 潰爛型 GERD ) ：較嚴重食道發炎 Etiology Acute ： Ingestion of irritating agents, viral infection, intubation 插管 Chronic ： Reduced LES pressure, increased abdominal pressure, recurrent vomiting, delayed gastric emptying, hiatal hernia 服用抗發炎藥物 (aspirin, NSAIDS) 、腐蝕性藥物 放射線 硬皮症、 smoking 、 diet 、 SMC 鬆弛劑、黃體激素 ( 避 孕藥、月經晚期 ) 緊衣服 肥胖 高脂 大量食物

Medical Nutrition Therapy (p. 596) Objective ： 防止食道逆流 (LES)  avoid large meals ( 少量多餐 ) 、 dietary fat 、 alcohol 預防發炎黏膜疼痛刺激  avoid acid foods ( 酸果汁 ), spices 減少侵蝕力、胃酸  avoid coffee, 吸煙、 fermented alcoholic beverages 出血  補充 Fe, B12, protein

Behavioral Modification Avoid Eating within 3-4 hrs of retiring( 休息 ) Lying down after meals ：提高床頭 4-6 in Tight-fitting garments ：減肥 Cigarette smoking ： LES

Nutritional Care Guidelines for Patients with Reflux and Esophagitis Avoid large, high-fat meals. Avoid large, high-fat meals. Avoid eating at least 3 to 4 hours before retiring. Avoid eating at least 3 to 4 hours before retiring. Avoid smoking. Avoid smoking. Avoid alcoholic beverages. Avoid alcoholic beverages. Avoid caffeine-containing foods and beverages. Avoid caffeine-containing foods and beverages. Stay upright and avoid vigorous activity soon after eating. Stay upright and avoid vigorous activity soon after eating. Avoid tight-fitting clothing, especially after a meal. Avoid tight-fitting clothing, especially after a meal. Consume a healthy, nutritionally complete diet with adequate fiber. Consume a healthy, nutritionally complete diet with adequate fiber. Avoid acidic and highly spiced foods when inflammation exists. Avoid acidic and highly spiced foods when inflammation exists. Lose weight if overweight. Lose weight if overweight.

Medical management Proton pump inhibitors 氫離子幫浦抑制劑： 下降 胃璧細胞分泌胃酸 ( 最有效 ) 反流較輕微 ： Histamine-2 (H 2 ) receptor antagonist Antacids 制酸劑：降低胃酸分泌 胃排空較慢者 ： Prokinetic agents 助動劑： 增加胃 排空、 LES 壓力 藥物治療無效： Fundoplication 胃底摺疊術： 胃底纏繞至下食道防止逆流

Hiatal Hernia 食道裂孔脫疝 Sliding hernia Paraesophageal hernia 增加逆流危險 大餐後上腹部不舒服 原因 食道裂孔處肌肉 張力不足 腹壓過大 衣服太緊

Medial Nutrition Therapy 目的：減少逆流 ( 減重、防止大餐 ) 治療方法與食道炎同 少量多餐、低脂肪飲食、避免胃酸分泌 和降低 LES 壓力之食物 治療方法：藥物與飲食控制 ( 不需手術 )

Oral cavity cancer and surgery 口腔、咽、食道癌 原因：腫瘤、阻塞、口腔感染 、 潰瘍  營養問題、進食困難 Treatment ：手術切除、放射線治療、化療  影響咀嚼、吞嚥、分泌唾液、味覺敏感度  蛀牙、 osteoradionecrosis ( 放射性骨壞死 ) 和 infection ( 感染 )  噁心、嘔吐、厭食 (chemotherapy)

Surgery of the mouth or esophagus 口腔、食道手術 - 補充液體 + 營養配方 ( 附錄 32)( 管灌、胃造口、空腸造口 ) 扁桃腺 ( 淋巴系統 ) 切除手術 ( 若發炎 )  下降 耳朵感染、鼻竇炎次數 手術後第一天：乳製品 ( 牛奶、蛋酒 ) 、 ice cream 、 cold yogurt 、水果冰 第二天：溫液體、軟食 傷口癒合後：熱食小心給予， 3-5 天 normal diet

Medical Nutrition Therapy 口腔癌不能進食 – tube feeding 手術後 - 流質 ( 清、半、全 ) or 軟食濕潤 食物 ( 易吞嚥 ) 少量多餐、高熱量濃度食物、醣類 ( 少單 醣、防止消化性低血糖 ) Artificial saliva ( 人工唾液 ) 、生理食鹽水 漱口 ( 減少黏膜炎 ) 、牙齒重建

Disorders of The Stomach Indigestion and Dyspepsia ( 脹氣 ) 症狀：上腹部疼痛、腹脹、噁心、反胃、打嗝、 吞嚥困難 Functional dyspepsia 原因：飲食、壓力、生活 習慣 ( 過度飲食、高脂、糖、咖啡因、 香料、酒精 ) 飲食處置：吃慢些、充分咀嚼、吃喝不過量 行為、情緒處理

Gastritis and Peptic Ulcer 原因：感染 ( 幽門螺旋桿菌 H.pylori) 、化學物 質 (aspirin, NSAIDS, steroid, alcohol, tobacco) 、 神經異常 ( 壓力 )  破壞黏膜、線體完整 ( 發炎 )  消化性潰瘍 (peptic ulcer) or atrophic gastritis (achlorhydria or loss of intrinsic factor) or cancer H.pylori ：具運動性鞭毛之格蘭氏陽性菌，可 抗胃酸 - 分泌尿素酶 ( 產氨促進鹼性化 )

Gastritis 胃炎症狀：噁心、嘔吐、食慾不振、出 血、上腹痛 慢性胃炎：老年人、胃璧細胞萎縮  減少分泌胃酸和內在因子 (Fe, B 12 & homocysteine) Endoscopy 檢查 治療：抗生素、制酸劑 (H 2 -recepter antagonist 、氫離子幫浦抑制劑 )

Medical Nutrition Therapy Lack of intrinsic factor( 內在因子 ) and acid – decrease absorption of B12, iron, Ca 若用劑量高的胃酸抑制藥或出血  anemia

Peptic Ulcer (p. 601) Etiology H. Pylori infection 幽門螺旋桿菌 Stress ulcer ：嚴重燒傷、創傷、手術、腎衰竭、 放射線治療之併發症 ( 出血、胃缺血 ) Alcohol, Aspirin and other NSAIDs ：刺激胃酸 分泌、危及黏膜完整 Use of tobacco  decrease HCO 3 - secretion & mucosal blood flow ， increase inflammation

Pathophysiology 發炎、潰爛發生在黏膜膜層至肌肉層 下降腸胃道防禦和修復系統 Symptom ： abdominal pain or discomfort, anorexia, wt loss, nausea, vomiting, heartburn 出血、穿孔 Melena – 黑便

胃小灣 增加酸液分泌 夜間酸分泌 降低 HCO 3 - 分泌 阻塞胃排出 胃炎、腔 壁細胞發 炎和萎縮 影響胃酸 和 pepsin 分 泌、出血 死亡率較 高 幽門下方

Stress Ulcers  Complication of severe burns, trauma, surgery, shock, radiation therapy, or renal failure  Gastric ischemia, hypoperfusion, oxidative injury, reflux of bile acids or pancreatic enzymes, microbial colonization, and mucosal barrier changes are implicated  Significant cause of morbidity in critically ill patients  Use of antioxidant compounds show promise 23 Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Factors That Affect Gastric Acidity Increase Gastric Acidity Cephalic Phase of Digestion Thought, taste, smell of food, and chewing and swallowing initiate vagal stimulation of the parietal cells in the fundic mucosa, resulting in secretion of gastric acid. Gastric Phase of Digestion Effect of food in the stomach: Distension of the fundus stimulates the parietal cells to produce acid. Increased alkalinity of antrum causes the release of gastrin, which stimulates gastric acid secretion. Distension of the antrum causes release of gastrin. Substances in certain foods and digestive products increase acidity (e.g., coffee, both with or without caffeine; alcohol; polypeptides and amino acids [products of protein digestion]). 24 Elsevier items and derived items © 2012, 2008, 2007 by Saunders, an imprint of Elsevier Inc.

Factors That Affect Gastric Acidity Decrease Gastric Acidity Gastric Phase of Digestion Acidification of the antrum reduces gastrin release and thus gastric acid secretion. Food, especially protein, has an initial buffering effect. Intestinal Phase of Digestion Fat, acid, and protein in the small intestine stimulate release of one or more GI hormones that inhibit gastric acid secretion.

Medical management 少用 NSAIDs 用 antibiotics, sucralfate ( 胃乳 ) 制酸藥 antacids 、 proton pump inhibitors or H2-receptor blockers 手術已少見，但嚴重需 gastrectomy, vagotomies 迷走神經切除術

Behavioral management Avoid tobacco product ：下降 HCO 3 - 分泌、 黏膜血流、增加發炎反應、感染併發症

Nutrition management (Bland diet) Protein foods: temporarily buffer gastric secretion, but stimulate secretion of gastrin, acid and pepsin (milk is no longer considered) PH of food has little therapeutic important Decrease consumption of alcohol, spices, caffeine ：增加胃酸分泌，胃壁發炎、改變消 化道 permeability or motility, mucosa damage ， but turmeric ( 薑黃 ) 減少 H. pylori 黏附胃壁。

Nutrition management Use of probiotics( 益生菌 ) ：預防 H.pylori Increase intake of n-3 and n-6 fatty acid ： Prostaglandin (PGE 3 減少 PGE 2 ) ( 抗發炎、增加 免疫力、保護 GI mucosa) 高品質飲食 (adequate nutrient, fruit, vegetable and fiber intake) 、避免營養素缺乏 ( 影響消化道 細胞修護 ) 或難消化食物、少量多餐 ( 減少胃酸 反流、增加胃部血液循環 )  增加免疫力、 防止 H.pylori

Bland diet ( 溫和飲食 ) 少量多餐 無刺激性食物 軟食 實驗課本 P.34 食物選擇表 N-3 fatty acid : EPA, DHA ( 鮭魚、鯖魚 鮪魚、 曼魚、沙丁魚 ) 、亞麻子油、南 瓜、胡桃子油等

Carcinoma of the Stomach 病因不明 危險因子： H. pylori 慢性感染、吸煙、喝酒、 肥胖、低纖、高鹽、微量營養素不足 會因過量血液、蛋白質流失導致營養不良 早期症狀： loss of appetite 厭食 ( 流質飲食、 TPN) 、 achylia gastrica (absence of HCl & pepsin) 手術切除 (gastrectomy) - 出血、穿孔、阻塞

Medical Nutrition Therapy after gastric surgery Anorexia ： TPN or liquid diet 消化道功能恢復 (1) ice water (2) liquid diet ：全、半流質飲食 (3) soft diet (low fat, species, frequent diet) 手術後亦導致吸收不良 (dumping Syndrome)

Dumping syndrome 傾食症 高張內容物快速排空，進入十二指腸或空腸之複合性 生理反應 ( 發生在餐後 )( 手術後 ) 症狀： ( 早期 ) 吃下 min 後高張物  血液水分流入 消化道  下降週邊血管張力  臉紅、心跳加快、冒汗、 躺下  ( 中期 ) 20 min -1 h 後無法消化食物在大腸發酵  脹氣、 絞痛、腹瀉  ( 晚期 )1-3 hr 後導致消化性低血糖 (alimentary or reactive hypoglycemia) ： CHO 快速分解  insulin  blood sugar decline  分泌何爾蒙 (gut peptides, glucose insulinotropic polypeptide, glucagon-like polypeptide-1)  anxious, weak, shaky, hungry, difficulty concentrating 保留胃近端或新增小儲囊的手術可改進症狀

Dumping syndrome Complication ： loss wt, malabsorption, steatorrhea  anemia, osteoporosis, vitamin & mineral deficiency (Fe & B 12 ) 藥物治療： somatostatin analogs ( 延緩胃 空 ) acarbose ( 抑制消化醣類酵素 acarbase)

Diet: Fat 35-45%, (MCT oil) Protein: 20% Ca & Vitamin D 恢複營養狀 態、生活品 質

膳療實驗 第 1, 2 组 ： Soft diet (exp. 4) 2000 kcal 3 ： Semiliquid diet ( exp. 5) p. 15 (2000 kcal) 4 ： Full liquid (exp. 6)(2000 kcal) p.18 5 ： Clear liquid diet (exp. 8) p.25 範例 6 ： Bland diet (exp. 11) p.35 第四題 7,8 ： Diet for Dumping Syndrome (Exp. 16) ： protein 20%, Fat 45%, CHO 35%, 2000 kcal

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