WIC 342 Gastrointestinal Disorders

Disease(s) and/or condition(s) that interferes with the intake or absorption of nutrients. The diseases and/or conditions include, but are not limited to:

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer
• Post-bariatric surgery
• Short bowel syndrome
• Inflammatory bowel disease, including ulcerative colitis or Crohn’s disease
• Liver disease
• Pancreatitis
• Biliary tract disease

Presence of condition diagnosed, documented, or reported by a physician or someone working under a physician’s orders, or as self reported by applicant/participant/caregiver. See Clarification for more information about self‐reporting a diagnosis.

Category	Priority
Pregnant Woman	1
Breastfeeding Woman	1
NonBreastfeeding Woman	6
Infants	1
Children	3

Gastrointestinal disorders increase nutritional risk in a number of ways, including restricted food intake, abnormal deglutition, impaired digestion of food in the intestinal lumen, generalized or specific nutrient malabsorption, or excessive gastrointestinal losses of endogenous fluids and nutrients. Frequent loss of nutrients through vomiting, diarrhea, malabsorption, or infections can result in malnourishment and lowered disease resistance (1, 2). Nutrition management plays a prominent role in the treatment of gastrointestinal disorders.

Gastroesophageal Reflux Disease (GERD)

GERD is irritation and inflammation of the esophagus due to reflux of gastric acid into the esophagus (3). Nutritional care of GERD includes avoiding eating within 3 hours before going to bed; avoiding fatty foods, chocolate, peppermint, and spearmint, which may relax the lower esophageal sphincter; and coffee and alcoholic beverages, which may increase gastric secretion (4). Consumption of these items may need to be limited depending on individual tolerance.

Peptic Ulcer

Peptic ulcer normally involves the gastric and duodenal regions of the gastrointestinal tract (4). Because the primary cause of peptic ulcers is Helicobacter pylori infection, the focus of treatment is the elimination of the bacteria with antibiotic and proton pump inhibitor therapy. Dietary advice for persons with peptic ulcers is to avoid alcohol, coffee (with and without caffeine), chocolate, and specific spices, such as black pepper (4, 5).

Post-bariatric Surgery

Many types of surgical procedures are used for the intervention of morbid obesity. These procedures promote weight loss by restricting dietary intakes, e.g., adjustable gastric banding (AGB), and/or bypassing some portion of intestine to cause incomplete digestion and/or malabsorption of nutrients, e.g., Roux-y gastric bypass (RYGB). Therefore, the risks for developing nutritional deficiencies after bariatric surgery are greatly increased. Since gastric bypass individuals have both a decreased availability of gastric acid and intrinsic factor, vitamin B12 deficiency can develop without supplementation. Taking daily nutritional supplements and eating foods high in vitamins and minerals are important aspects of the nutritional management for the individuals who have had bariatric surgery (6).

Short Bowel Syndrome (SBS)

SBS is the result of extensive small bowel resection. SBS in infants is mostly the result of small bowel resection for the treatment of congenital anomalies, necrotizing enterocolitis, and congenital vascular. In adults, Crohn's disease, radiation enteritis, mesenteric vascular accidents, trauma, and recurrent intestinal obstruction are the most common conditions treated by small bowel resection and resulting in SBS (4). The loss of a large segment of the small bowel causes malabsorption syndrome. Total parenteral nutrition usually is started within the first few days after intestinal resection. Gradual supplementation with enteral feeding promotes intestinal adaptation in order to wean from parenteral nutrition therapy. Supplementation with fat soluble vitamins and vitamin B12 may be needed (7). The pediatric client’s nutritional status must be assessed and growth closely monitored (8).

Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease includes Crohn’s disease and ulcerative colitis. Weight loss, growth impairment, and malnutrition are the most prevalent nutritional problems observed in IBD. Nutritional support is essential. Exclusive elemental nutrition has been used in attaining the remission of Crohn’s disease. However, symptoms tend to recur promptly after resuming the conventional diet (9).

Liver Disease

Since the liver plays an essential role in the metabolic processes of nutrients, liver disorders have farreaching effects on nutritional status. Acute liver injury is often associated with anorexia, nausea and vomiting. Therefore, inadequate nutritional intakes are common. Decreased bile salt secretion is associated with the maldigestion and impaired absorption of fat and fat-soluble vitamins. Defects in protein metabolism associated with chronic liver failure include decreased hepatic synthesis of albumin, coagulation factors, urea synthesis and metabolism of aromatic amino acids. For nutritional therapy, an important consideration should be the balance between preventing muscle wasting and promoting liver regeneration without causing hepatic encephalopathy. It is recommended that persons with chronic liver disease consume the same amount of dietary protein as that required by normal individuals (0.74g/kg) (10).

Pancreatic Disease

In chronic pancreatitis, there is a reduced secretion of pancreatic enzymes leading to malabsorption. In severe cases, tissue necrosis can occur. It is suggested that for patients with pancreatitis, a high carbohydrate, low-fat, low protein diet may be helpful (11).

Biliary Tract Diseases

Common diseases of the biliary tract are:

• Cholelithiasis (gallstones, without infection).

• Choledocholithiasis (gallstone in the bile duct causing obstruction, pain and cramps).

• Cholecystitis (inflammation of gallbladder caused by bile duct obstruction).

Obesity or severe fasting may increase risk for these disorders. Since lipids stimulate gallbladder contractions, a low fat diet with 25% to 30% of total calories as fat is recommended. Greater fat limitation is undesirable as some fat is required for stimulation and drainage of the biliary tract. Supplementation with fat-soluble vitamins may be needed for persons with fat malabsorption or a chronic gall bladder condition (12).

WIC nutritionists can provide counseling to support the medical nutrition therapy given by clinical dietitians, and monitor compliance with therapeutic dietary regimens. They can also review and provide WIC-approved medical foods or formulas prescribed by the health care providers. In certain circumstances, WIC staff may recommend an appropriate medical food or formula to the health care provider. They should also make referrals to an appropriate health care provider for medical nutrition therapy by a clinical dietitian when indicated.

1. Institute of Medicine. WIC nutrition risk criteria: a scientific assessment. National Academy Press, Washington, D.C.; 1996.

2. American Dietetic Association, Pediatric Nutrition Practice Group. Pediatric manual of clinical dietetics. Chicago: Pediatric Nutrition Dietetic Practice Group, American Dietetic Association, 1998.

3. Stenson W. The esophagus and stomach. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th Ed. Lippincott Williams & Wilkins 1999. p. 1125- 1133.

4. Beyer PL. Medical nutrition therapy for upper gastrointestinal tract disorders. In: Mahan LK, Escott-Stump S, editors. Krause’s food nutrition and diet therapy. 11th Ed. Philadelphia: Saunders; 2004. p. 688-690.

5. American Dietetic Association. Nutrition Care Manual. Gastrointestinal disease; Peptic ulcers; 2006. http://www.nutritioncaremanual.org. Accessed 1/08.

6. Allied Health Sciences Section Ad Hoc Nutrition committee: Aills L, Blankenship J, Buffington C, Furtado M and Parrott J. Bariatric nutrition: suggestions for the surgical weight loss patient. Review. Surgery for Obesity and Related Diseases 2008 May 17.

7. Scolapio JS, Fleming R. Short Bowel Syndrome. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th Ed. Lippincott Williams & Wilkins; 1999. p. 1135-1140.

8. Farrell M. Gastrointestinal disorders of infancy and childhood (with nutrition support and probiotics) In: Ekvall SW, Ekvall VK. editors. Pediatric nutrition in chronic diseases and developmental disorders. 2nd ed. Oxford University Press; 2005. p. 248-249.

9. Griffiths A. Inflammatory bowel disease. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th Ed. Lippincott Williams & Wilkins; 1999. p. 1141- 1149.

10. Lieber CS. Nutrition in liver disorders. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th Ed. Lippincott Williams & Wilkins; 1999. p. 1177- 1189.

11. Raimondo M, Dimagno EP. Nutrition in pancreatic disorders. In: Maurice ES, Olson JA, Shike M, Ross AC, editors. Modern nutrition in health and disease. 9th Ed. Lippincott Williams & Wilkins; 1999. p. 1169-1176.

12. Hasse JM, Matarese JE. Medical nutrition therapy for liver, biliary system and exocrine pancreas disorders. In: Mahan LK, Escott-Stump S, editors. Krause’s food nutrition and diet therapy. 11th Ed. Philadelphia: Saunders; 2004. p. 758-760.

Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A self-reported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CPA to validate the presence of the condition by asking more pointed questions related to that diagnosis.