Nutrition and Digestive Issues

Notes from a talk given by Orla Hynes, Specialist Dietician

Nutrition is often a problem because:

  • The anatomical location of the disease can lead to dysphagia [swallowing problems]/delayed gastricemptying/vomiting
  • Decreased appetite, weight loss, metabolic alterations & inflammatory state
  • Treatments cause additional symptoms which impact on nutrition
  • Long treatment pathway – using a combination of chemotherapy, radiotherapy, surgery

Nutrition plays a pivotal role across the entire pathway from diagnosis to survivorship:

  • Helps to preserve performance status [ie fitness for treatment]
  • Helps to reduce the risk of treatment related toxicities so that you can get full doses of oncological
  • Treatments
  • Reduce risk of postoperative complications
  • Maintain/preserve quality of life

‘Survivorship’:

  • Refers to living with or beyond cancer - What happens to the patients after they have finished theirtreatment?
  • January 2010 National Cancer Survivorship Initiative published a vision document – findings that NHS are not meeting all cancer survivors’ needs following treatment
  • How should we follow up our patients after surgery? 

Aim: Quality of Life after Surgery:

Post Surgery:

  • Weight loss can be a problem
  • Eating and drinking is difficult
  • Maintaining a good nutritional status is challenging
  • Dietary assessment is important – in determining the problems and strategies to help manage these
  • Symptom management

Early Satiety [feeling full] and Reduced Appetite:

  • Smaller stomach capacity or none
  • Disruption of gut hormones and innervation [vagotomy]
  • Need to eat ‘little & often’ and be a ‘grazer not a feaster’
  • ‘Hard to change the habits of a lifetime’
  • ‘Don’t feel hungry’ is a common complaint
  • Worsened by weight loss and malnutrition
  • Eating pattern needs to be following a regime, rather than relying on feelings of hunger

Problems with Swallowing:

  • Bread and chunks of meat – likely to be a problem
  • Sips of fluid with meals can help
  • Anastomotic stricture ‘tightening of the [surgical] join’
  • Sensation of food sticking
  • Range of consistency - Solid foods Soft Diet Pureed Diet/Liquids
  • When dietary intake becomes a problem, intervention needs to be considered
  • Dietary advice to ensure nutritional adequacy
  • Endoscopy +/- stretch

Acid Reflux:

  • Common to require antacids
  • Loss of gastro-oesophageal junction, new position of stomach or ‘gastric tube’
  • Watch out for other signs – cough or hoarse voice in the morning
  • Important – can make ‘tightening of the join’ worse
  • Dietary advice of limited value as acid reflux is likely - but avoid obvious problematic foods 

Bile Reflux:

  • Burning, bad taste, nausea
  • Delayed gastric emptying 
  • Responds well to sucralfate suspension
  • Endoscopy & stretch
  • Delayed Gastric Emptying: Can present as bad reflux
  • Appetite in the morning but lessens as the day goes on
  • Regurgitation/Vomiting 

Management:

  • Prokinetics [medication that stimulates the pylorus, bottom end of the stomach, to empty]
  • Endoscopy & stretch 

Taste Changes:

  • Consequence of treatment
  • Transient hopefully
  • Bile reflux
  • Check Vitamin B12 & Zinc

Diarrhoea & Steathorrhea [fatty stools]:

  • Decreased gut transit, intestinal hurry
  • Loose stools to be expected after surgery
  • Improves with time
  • Loperamide/Immodium
  • Pale floating stools, difficult to flush – caused by fat malabsorption
  • Very unpleasant, weight loss, malnutrition
  • PERT – Pancreatic Enzyme Replacement Therapy
  • Bile Salt malabsorption
    • Diagnosed by SeCAT scan
    • Cholestyramine/Colesevelam
  • Small bowel bacterial overgrowth (SIBO)
    • hydrogen breath test
    • duodenal aspirates
    • antibiotics
    • probiotics
  • Dietary advice – last resort, fibre, fat, low FODMAPs. Aim to identify and treat cause is priority. 

Diarrhoea, Bloating & Flatulence:

  • Low FODMAPs diet
    • Fermentable Oligo-saccharides Disaccharides Monosaccharides And Polyols
  • Last resort…rule out other causes first 
  • Restrictive and complex, exclusion dietfor 8 weeks, slow and strategic reintroduction of foods. Motivation needed!
  • May besuitable in a small number of patients, but not to be implemented without close supervision of a dietitian. Not to betried when on treatment. 

Dumping Syndrome:

  • Early: bloating/nausea/fullness/palpitations/pain after eating/flushing/sweating/faintness/ loosestools or diarrhoea may follow
  • Late: Tiredness/tremor/palpitations/sweating/giddiness
  • Complex
  • Dietary advice may help
  • However seek advice from dietitian – avoid unnecessary restrictions
  • ********review other medications************
  • Immodium/loperamide
  • Acarbose/Octreotide

Fatigue:

  • Treatment, stress, anxiety, low mood/depression
  • Anaemia – reduced capacity tosend oxygen around the body
  • Causes:
    • Chemotherapy
    • Dietary deficiencies e.g. iron, Vitamin B12, folate
    • Iron & Vitamin B12 deficiency is common after surgery
  • Regular check of iron, vitamin B12& folate
  • Oral iron tablets, IV iron infusion, Vitamin B12 injections
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