General functional disorders in Intestine
Irritable colon. The term irritable colon is given to the condition of general discomfort in the lower abdomen because of excessive motility or hyperactivity of the colon or a decrease in muscle tone. It is manifested in general changes in bowel habits, either frequent stools of a soft, segmented nature or larger, hard stools, which are difficult to pass. It is best treated by attending to the underlying muses and giving symptomatic care. Adjunct therapy with diet will usually involve fluid intake, modification of fiber content, and adjustment of specific foods according to individual tolerances.
Constipation. Dietary manipulation for constipation is often not a fundamental cure, but simply a helpful adjunct. In children psychogenic constipation may occur during the ages of 1 to 2 years, while the child is being toilet trained. Sometimes a compulsive, anally fixated mother who believes in an arbitrary timetable of elimination ("a daily bowel movement is absolutely essential to health") imposes stringent toilet disciplines on the child and scolds him for failures or rewards him for perfect performance. The child soon learns that he can suppress the natural impulse to defecate, and he uses this power as a weapon in his conflict with his mother. In time the habit weakens normal peristalsis, and stools become dry and difficult to pass. Correction of the problem involves adjustment of the parent-child relationship and a resultant easing of the conflict and tensions. The mother needs to learn two simple physiologic facts: toxins are not absorbed from fecal material, and therefore a daily stool is not essential to the child’s health.
Occasionally in children there occurs simple physiologic constipation, which is usually short in duration. It is aided by moderately reducing the milk intake, increasing the carbohydrate intake (for example, increasing the sugar somewhat in an infant formula), and increasing fruits, vegetables, and water intake. Similar diet adjustments’ are helpful to adults: increased water intake; increased fiber (bran), as in whole grains; more raw or lightly cooked fruits and vegetables; and more naturally laxative fruits such as dried prunes (or juice) and figs.
Diarrhea. Diarrhea in infants is a serious problem, especially if it is prolonged and associated with infection. Because of his relatively high water content and his large area of intestinal mucosa in proportion to body surface area, the infant’s fluid and electrolyte reserves may be rapidly depleted. The sequence of steps leading to dehydration may be reviewed in the discussion of water balance.
Common mild diarrhea usually responds to simple treatment. This consists of reducing the food intake, especially carbohydrate and fat in the formula, and increasing the water intake, sometimes including in it oral electrolyte replacements. More serious forms involving infection and producing marked dehydration and acidosis is medical emergencies calling for immediate intravenous fluid and electrolyte therapy. The loss of potassium can be dangerous, since lowered blood levels of potassium affect action of the heart muscle.
After initial essential replacement of fluid and electrolytes and when the infant is able to take oral feedings more readily, they are resumed. Water, glucose, and balanced salt solutions may be used. These are followed by milk mixtures, breast milk, or substitutes such as probana (a high-protein formula with banana powder) or Nutramigen (a casein hydrolysate free of falactose) as the stool volume decreases. Calories are increased to normal requirements as soon as possible.
Such agents as pectin and kaolin may thicken the stools, but most authorities agree that they have little or no therapeutic usefulness in severe infant diarrhea. Although views differ, pediatricians generally discount the previous practice of starving patients with acute diarrhea. This was a practice based on the erroneous belief that avoidance of oral intake puts the bowels at rest. Also tea should not be given to the child. The xanthenes in tea stimulate and excite children and in some cases cause excessive urination, which in turn only aggravates the fluid imbalance.
Organic diseases of the intestine may be classified into three general groups:
(1) Those involving anatomic changes, as in diverticulosis;
(2) Those relating to malabsorption difficulties, as in sprue and celiac disease; and
(3) Inflammatory and infections mucosal changes, as in ulcerative colitis.
Diverticulosis and diverticulitis. Diverticula are small protrusions from the intestinal lumen, usually the colon, and produce the condition diverticulosis. More often diverticulosis occurs in older people and develops at points of weakened musculature in the bowel wall. The condition is usually without symptoms unless the diverticula become inflamed, a state called diverticulitis. In such conditions fecal residue may cause increased irritation. There are pain and tenderness, usually localized in the lower left side of the abdomen nausea, vomiting distention, intestinal spasms and fever.
DIET THERAPY. During acute periods oral feedings may be limited to clear liquids with gradual progression to full liquids. Follow-up diet therapy is based on texture modification – at first a residue-free diet if necessary and then maintenance according to individual need on a low-residue diet plan in shown below.
In contrast, more recently there are indications that a high-residue diet may be better therapy for diverticular disease. Patients tend to develop pockets of high pressure in the colon because of segmental contractions of the bowel. Some clinicians suggest that these segmental contractions may occur more commonly in patients on a low-residue diet because of the ability of the colon when empty to contract completely, thus producing pressure and pain. Therefore a high-residue diet is used to prevent such contractions of the bowel. Advocates of this therapy recommend including 2 to 3 tablespoons of bran with each meal, mixed with the various foods used.
Malabsorption syndrome (sprue and celiac disease). Adult nontropical sprue is similar in nature to childhood Celia disease. In fact, most adults with sprue give a history of having had episodes of celiac disease as children.
CLINICAL SYMPTOMS. The characteristic diarrhea in sprue consists of multiple foamy, malodorous, bulky, greasy stools. Poor absorption of fact is evident in the large amounts appearing in the stools as soaps (fatty acids saponified with calcium salts) and fatty acids. Poor absorption of iron produces anemia. In other persons a lack of folic acid will produce another specific type of anemia. Poor absorption of vitamin K may lead to hemorrhagic tendencies. Poor calcium absorption may produce the disturbed serum calcium phosphorus ratio with resulting tetany.
The condition varies widely among individuals, but four basic types of symptoms of intestinal malabsorption are general:
(2) Multiple foul, bulky, foamy, greasy stools,
(3) Distended abdomen because of accumulation of improperly digested and absorbed material and gas accumulation, and
(4) Secondary vitamin and mineral deficiencies.
DIET THERAPY. Since the discovery that gluten is an important factor in the cause of nontropical sprue or celiac disease, the gluten-free or low-gluten diet has been widely used with great effect. Gluten is a protein found mainly in wheat, with additional amounts in rye, oats, and barley. Therefore these four grains (wheat rye, oats, and barley) are eliminated from the diet. Corn and rice are the substitute grains used. The offending grains are obvious in cereal form, but they are also used as ingredients such as thickeners or fillers in many commercial products. Therefore close attention should be given to label reading and food preparation. The gliadin fraction of the gluten proteins seems to be the offending agent in sensitive individuals. In addition, the basic principles of therapy for patients with celiac disease, especially in the early stages, are as follows:
- Calories – high, usually about 20% above normal requirement to compensate for fecal loss
- Protein – high, usually 6 to 8 gm./kg. Body weight.
- Fat – low, but not fat free because of impaired absorption
- Carbohydrate – simple, easily digested sugars (fruits, vegetables) should provide about one half the calories
- Feedings – small, frequent feedings during ill periods; afternoon snack for older children
- Texture – smooth, soft, avoiding irritating roughage initially, using strained foods longer than usual for age, adding whole foods as tolerated and according to age of child.
- Vitamins – supplements of vitamins A and B in water-miscible forms, and vitamin C
- Minerals – iron supplements if anemia present
Ulcerative colitis. The cause of ulcerative colitis is unknown, and no specific cure has been devised. However, treatment today is far more effective, based on new drug therapy with more potent antibiotics and endocrine agents. This treatment has improved the condition of many patients. Ulcerative colitis usually occurs in your adulthood. It sometimes occurs in patients having various degrees of anxiety and insecurity. However, this is by no means true in all cases.
CLINICAL SYMPTOMS. The common clinical symptom is a chronic bloody diarrhea, which occurs at night as well as during the day. Ulceration of the mucous membrane of the intestine leads to various associated nutritional problems, such as loss of appetite, nutritional edema, anemia, avitaminosis, protein losses, negative nitrogen balance, dehydration, and electrolyte disturbances. Weight loss, often general malnutrition, fever, skin lesions, and arthritic joint involvement occur.
PRINCIPLES OF TREATMENT. The management of patients with active but uncomplicated chronic ulcerative colitis involves the three important factors of rest, nutritional therapy, and sulfonamides. There must be physical gastrointestinal rest and emotional rest. Vigorous nutritional therapy must be instituted. Indeed, nutrition is the key to successful treatment.
DIET THERAPY. Nutritional therapy for ulcerative colitis is based on restoration of nutrient deficits and prevention of local trauma to the inflamed area.
High-protein diet. The raw surface of the inflamed colon may be regarded as equivalent to an extensive wound or burn of the skin. There are massive losses of protein from the colon tissue. There are losses associated with impaired intestinal absorption of protein. Only if adequate protein is provided for tissue synthesis can healing take place. The diet should supply from 120 to 150 gm. Of protein per day. Protein supplements, such as between-meal feedings using nonfat dry milk. Sustagen, Gevral, Protenum, or Meritene, are helpful to achieve the necessary intake. Tasteful ways of including protein foods of high biologic value (egg. Meat and cheese) must be devised. Milk causes some difficulty with many patients, so it is usually omitted at first and then only gradually added in cooked form, such as in creamed soups or puddings.
High-calorie diet. At least 3,000 calories a day are needed to restore nutritional deficits from daily losses in the stool and consequent weight loss. Also only if sufficient nonprotein calories are present to support and protect the main function of protein – rebuilding of tissue – will healing take place and the negative nitrogen balance be overcome.
Increased minerals and vitamins. When anemia is present, iron supplements may be ordered. However, many patients do not tolerate such iron preparations, and blood transfusions may be used instead. Extra vitamins to aid in the healing process and the metabolism of the increased calories and protein are especially needed. These are vitamin C and B vitamins – thiamine, riboflavin, and niacin. Usually additional supplements of these vitamins are ordered. Potassium therapy may also be indicated because of losses of potassium from diarrhea and tissue destruction.
Low-residue diet. To avoid irritation to the colon the diet at first if fairly low in residue. In acute stages it may be almost residue free (based mainly on lean meat, rice, white bread, Italian pasta, strained cereal, cooked eggs, sugar, butter, and cream). The graduated low residue diet may be used initially with additional protein, calories, vitamins, and minerals in interval feedings.
As the patient improves, however, a full diet with high-protein feedings should be used. Only heavy roughage needs to be avoided, since the primary concern is to supply necessary nutrition in as appetizing a manner as possible.
Perhaps no other condition better illustrates the need for a close working relationship among all members of the health team and the patient than does chronic ulcerative colitis. The appetite is poor, but the nutritional intake is imperative. In many individually creative ways the fundamental therapeutic needs must be met through attractive, nourishing food given with supportive warmth and encouragement.