Asuhan Nutrisi

pada Saluran Cerna dan Hati

Nurpudji A Taslim
Bagian Gizi
Fakultas Kedokteran Unhas
@2005

Saluran Cerna dan Hati

Esofagus
Lambung
Hati
Empedu
Pancreas
Usus Besar
Usus Kecil

Dietary History- clues to GI disease

symptom
Ingestion of solid food causes
distress but liquid do not
Difficulty in swallowing
Epigastric pain when eating
Pain 2-5 hours after eating,
relieved after eating
Abdominal pain several hours
after a fatty meal
Cramps, distention, flatulance 1824 after drinking milk
Heatburn after eating a large of
fatty meal

Possible disorder
Esophageal stricture or tumor
Esophageal spasm, achalasia
Gastric ulcer
Duodenal ulcer
Pancreatic or biliary tract disease
Lactose intolerance probably
owing to lactase deficiency
Hiatal hernia, achalasia,
esophageal motility problem

Nutritional care for Esophagitis

Avoid food caused of heartburn
Eat small, frequent meals to prevent stomach distention
and resultant gastric acid secretion
Avoid high fat meals and decrease fat in the diet
Avoid chocolate, alcohol and caffeine-containing
beverages (coffee, tea and cola drinks)
Avoid peppermint and spearmint oils
Avoid lying down, bending over, or straining immediately
after eating
Avoid eating within 2-3 hours of going to bed
Avoid tight-fitting clothing, especially after a meal
Reduce weight if overweight
Avoid or quit cigarette smoking

Gastritis
Common cause of Gastritis
Helicobacter
aspirin
Chili
Alcohol
Cigarettes

pylori

Nutritional care for Gastritis

Hal yang perlu diperhatikan
1. Manajemen diet

Keaktifan sekret lambung, usus kecil, pancreas, liver,

dan empedu
Gerakan usus
Bakteri flora usus
rasa nyaman dan mudah dicerna
perbaikan dan maintenance mucosa usus

2. Pengaruh makanan terhadap asam lambung

Prot : buffering efek

Fat & CHO: menurunkan pengosongan lambung
Extr daging, tannin (teh), caffein (kopi) & alkohol
menyebabkan iritasi mucosa gaster

3. Pengaruh makanan terhadap gerakan

lambung
4. Efek makanan terhadap lesi
5. Pengaruh makanan terhadap rasa tidak nyaman

PENATALAKSANAAN
Tujuan :
makanan adekuat; tidak merangsang; menurunkan
produksi asam lambung; menetralisir kelebihan
asam lambung.
Syarat :
mudah dicerna, porsi kecil, frekuensi tinggi; protein
cukup untuk mengganti jaringan rusak; tidak
merangsang (mekanis, termis & kimia); memenuhi
kebutuhan gizi Normal

Faktor yang Meningkatkan Asam

Lambung dan Produksi Enzym
1. Stimulasi kimiawi (Extrak Daging,

Penyedap, Bumbu-bumbu, alkohol &

makanan kecut).
2. Makanan enak dan menarik selera
3. Keadaan bahagia
4. Suasana pada saat makan

Meningkatkan Tone dan Gerakan Usus

1. Makanan hangat
2. Makanan Cair dan lunak
3. Makanan Berserat
4. Tinggi CHO dan rendah Fat
5. Penyedap dan makanan manis
6. Takut, marah, dan stres

Faktor Menurunkan Asam Lambung dan

Produksi Enzym
Makanan berlemak tinggi (gorengan,
kacang-kacangan)
2. Porsi besar
3. Tidak dikunyah baik
4. Tidak menarik (bentuk dan
rasa)
5. Tidak disukai
6. Takut, marah, dan sakit
1.

Menurunkan tone dan Gerakan Usus

Makanan dingin
2. Padat dan kering
3. Rendah serat
4. Tinggi Fat
5. Defisiensi Vitamin B Comp.
(Utamanya B1)
6. Lelah
7. Takut, marah, dan sakit
8. Sedentary habit
1.

Factors that affect to Gastric Acidity

Effect of food in the stomach
Distension of the fundusparietal cellsproduce acid
Increased alkalinity of antrumrelease gastrinstimulates
gastric acid secretion
Distention of antrumrelease of gastrin
Substances in food and digestive productsincreased
acidity; coffee, alcohol, polypeptides and amino acids
Protein has an initial buffering effect
Fat, acid, and hyper osmolarity in the small intestine
stimulate release of one or more gastrointestinal hormones
that inhibit gastric acid secretion

Pathogenetic factors in the development

of peptic ulcer disease
Gasric ulcer
Ab-N pyloric function
Uodenopastric reflux
Defective gastric mucosal defences
Decreased mucosal prostaglandin
productiondecreased mucosal
bicarbonat production
Decreased mucous gel layer
Helicobacter pylori infection

Duodenal ulcer
Increased acid secretory
capacity
Increased basal acid
secretion
Increased parietal cell mass
and sensitivity
Ab-N gastric emptyng
Ab-n duodenal mucosal
defences
Decreased bicarbonate
secretion

Principles of nutritional care

for Peptic Ulcer Disease
Eat three regular meals daily
Eat small meals to avoid stomach distention
Avoid drinking coffee and alcohol
Cut down or quit smoking cigarettes
Avoid using large amounts of aspirin, other NSAID or
other drugs known to damage the stomach lining
Avoid foods or drinks that caused discomfort
Eat meals in as relaxed an atmosphere as possible
Take antacids 1-3 hours after meals and before
bedtime

Dumping syndrom
Is a complex physiologic response to presence of
undigested food in the jejunum
Following gastric surgery 2/3 of the stomach
removed
Symptom; abdominal fullness, nausea crampy
abdominal pain, following by diarrhea, 15 minutes
after ingestion.
Lying down immediately after eating reduces these
symptoms because food remains longer in the
stomach pouch
Alimentary hypoglycemiaoccurs 1-2 hours after
eating-caused by the rapid digestion and absorption
of food especially of sugar

Nutritional care in intestinal disease

Absorption--- jejunum
Terminal ileum fats, bile salts, vitamin
B12
Large intestine or colon purpose
absorbing water and excreting the fecal
mass

Constipation
Systemic
SE of medication
Metabolic and endocrine ab-n(hypothyroidism,
uremia and hyperglycemia)
Lack of exercise
Ignoring the urge to defacate
Vascular disease of the large bowel
Systemic neuromuscular disease
Poor diet low in fiber
pregnancy

Continues--

Gastrointestinal
Diseases
Sprue,

of upper GIT

duodenal ulcer, gastric ulcer, Cystic fibrosis

Diseases

of the large bowel that result in

Failure

of propulsion along the colon, failure of

passage through anorectal structures

Initial

bowel syndrom
Anal fissures or hemorhoids
Laxative abuse

INFLAMMATORY BOWEL DISEASE

CROHNS DISEASE
ULCERATIVE COLITIS

CROHNS DISEASE

ULCERATIVE DISEASE

Symptomatically similar
Gradual insidious devt of episode
diarrhea, abdominal pain, weight loss,
blood, pus or mucous in the stool
Focal, often granulomatous
inflammation in mucosal and submucosal layers in any area of
digestive tract
Generally affects the terminal ileum
and right colon, sometimes the entire
bowel, rarely the entire digestive tract
Diarrhea is less common
Segmental involvement is common
Stricture formationpalpable mass
in the lower right quadrant
Patients tent to be nonsmoker

Symptomatically similar
Gradual insidious development of
episode diarrhea, abdominal pain, weight
loss, blood, pus or mucous in the stool

Always affects the rectum, often the

sigmoid and descending colon in
continuity and sometimes entire colon
Diarrhea is common
Segmental involvement is rare
Patients tent to be nonsmoker

CIRROHIS HEPATIS
Final stage of liver injury & degeneration
& occurs 15% of heavy drinkers
Normal liver tissue destroyed replaced by
inactive fibrous connective tissue (scar
tissue)

HEPATIC FAILURE
Menurunkan liver function 30%
Seimbang hepatic encephalopathy (HE)
Meningkatkan AAA (phenylalanine tyrosine & free
tryptophan)
Menurunkan BCAA (Lececene, valine, isoleucine)
menyebabkan false neurotransmitters sehingga
terjadi HE
Meningkatkan aminobatyric acid inhibitory
neurotransmitter HE
N BCAA : AAA 3 : 1

Amino acids of importance in Liver Disease

Aromatic AA ( AAA)

Tyrosine, phenyl alanine*, free trypthopan*

Branched chain amino acids (BCAA)

Valine*, leucine*, isoleucine*

Ammoniogenic amino acids

Glutamin, histidine*, lysine, asparagine, lycine*, serine,

threonin*,

* indispensable AA

Vitamin/Mineral Deficits in
Hepatic Failure

Vitamin

SIGN

Dermatitis, night blindness

Osteomalacia

Edema, Peripheral neuropathy

Bleeding

BG

Mucous membr lesions, dermatitis

B12

Megaloblastic an, glossitis, CNS dysfunction

Niacin

Megaloblastic an, glossitis, irritability

Folate

Dermatitis, dementia, diarrhea

B1

Neuropathy, ascites, edema, CNS dysfunction

Zn

Imunodef, impaired taste, wound healing, prot synthesa

Mg

Neyronyscular irritability, hypokalemia, hypocalcemi

Fe

Stomatitis, microcytic anemia, malaise

Tujuan Diet Penyakit Hati

Cukup makan mempercepat perbaikan hati
Syarat:
1.
Tinggi Energi, CHO meningkat, Fat sedang, Prot
berangsur
2.
Cukup mineral dan vitamin
3.
Rendah NaCl
4.
Mudah dicerna, tidak merangsang
5.
Hindari makan yang mengandung gas tinggi.

Bahan makanan tidak boleh diberikan :

a. Makanan mengandung fat tinggi (babi, daging
kambing)
b. Makanan mengandung gas (ubi, kacang merah,
kol, sawi, lobak, ketimun, durian, nangka)

NUTRITION CARE LIVER DISS

Rep/Cerrh
Rationale

- repair liver sel

- spare prot
- balance edema & asater

Coma rep
Limit ammonia

Kcal

3000 4000 /d

CHO

300-400 g/dl (50%)

50% kcal

Prot

1-2 g/kgBB

- 0-40 g/d
- Mengandung N balance
- BCAA (rendah
produksi ammonium)

Fat

liber/use MCT ril

30% kcal MCT rils

Vit/min

B comp.
Fat solulle vit
Vit C & Zn

idem + K+

Fluid

Restract ij edema / recites

+

idem

G /k g BB

1800 /d

GALL BLADDER DISS

Fs : menyimpan empedu metab & degest fat
Enz : cholecystkinine
Jenis Peny:
1.
2.
3.
4.
5.

Biliary dyskinesia (spasme sp. Oddi)

Cholelithiasis (batu empedu)
Cholecystitis (imflamasi GB)
Choledocholithiasis (batu pada sp. Oddi)
cholecystectomi.

Nutrition care in Gallbladder disease

Tujuan:

Memberi istirahat kantung empedu, mengurangi rasa sakit

Food adequate

Syarat:

Tinggi fat (mudah dicerna) mengurangi kontraksi

E, prot, CHO cukup

Tinggi (larut lemak)

Tinggi cairan

Tidak merangsang dalam porsi kecil

Acute related to obstruction:

makanan per oral sementara dihentikan
hindari makanan yang mengandung lemak
diet rendah lemak
20-30% dari kalori (fat tidal lebih dari 50 g/d)
Chronic--cholecystiasis
Rendah lemak (25% dari total kalori)
Turunkan BB bila overweight
Protein sesuai dengan kebutuhsn
CHO disesuaikan dgn kebutuhsn utk
mempertahankan BB normal
Batasi makanan yang mengandung gas
Supl. Vitamin yang larut dalam fat(ADEK)

Pancreatitis
Inflammation characterized by;
edema,cellular exudate,and fat necrosis
It can be mild and self limiting or severe with
necrosis of pancraetic tissue
Can be acute or chronic---pancreatic
destructiondecreased endocrine and
exocrine pancreatic function, steatorrhea or
diabetes results

Nutrition care in Pancreatitis disease

Acute and severe attacks oral feeding is withheld
and hydration is maintained intravenous
After 24-48 hours clear liquid diet as tolerance
Formula diet consisting of amino acid, glucose, and
small amount of fat will not stimulate pancreatic
secretions.
Prolonged severe pancreatitisTPN
Fat emulsion can be used as long as acute
pancreatittis is not the basis for hypertriglyceridemia

The Role of Probiotic In

Immunity System

God Bless us with Lactobacillus

and Befidobacteria. They benefit
mankind in many ways, though
medical science knows very little
about these bacteria.
Professor Mitsuoka
Bafidobacteria & Health
Morinaga Co.

DEFINITION
Probiotics are food that contain live
bacteria which are benefit to health
Prebiotics are substances such as
lactulose, lactitol, xylitol, inulin, and
certain non-digestible oligosaccharides
that selectively stimulate the growth of
bifidobacteria in the colon.
Symbiotic is a combination of probiotics
and prebiotic.

INFLUENCES OF THE HUMAN INTESTINAL

MICROBIOTA ON THE HOST
Beneficial effects

Harmful effects

Inhibition of pathogens

Constipation

Stimulation if immune system

Diarrhoea

Synthesis of vitamins

Infection

Aid in digestion

Liver damage

Produce metabolic fuel for

enterocytes

Cancer

Maintain stability of ecosystem

Flatulence

Metabolise drugs
Patricia L. Conway, Selection Criteria for probiotic microorganisms,
Asia Pacific J Clin Nutr (1996) 5: 15-19

MECHANISMS OF PROBIOTIC
FUNCTIONALITY AND ITS BENEFICIAL
EFFECTS
M. Zubillaga et al., Nutrition Research 21 (2001) 569-579

Mechanisms of
Functionality

Beneficial Effects

Antimicrobial activity

Colonization resistance

Balancing of colonic
microbiota

Control of rotavirus and

clostridium difficile
Control of ulcer related to
H.p
Antibiotic therapy
Treatment of diarrhoea
associated
with travel

MECHANISMS OF PROBIOTIC
FUNCTIONALITY AND ITS BENEFICIAL
EFFECTS
M. Zubillaga et al., Nutrition Research 21 (2001) 569-579
Mechanisms of
Functionality
Immune effects
Adjuvant effect
Cytokine expression
Stimulation of
phagocytosis by peripheral
blood leucocytes
Secretory IgA

Beneficial Effects

Vaccine adjuvant effect

Enhance immune response
Enhance immune response

Influence on enzyme activity Reduction of fecal enzymes

implicated in cancer
initiation
Enzyme delivery

Reduction of serum
cholesterol
Amelioration of lactose
malabsorbtion symptoms

PUTATIVE MECHANISMS OF THE ACTION

OF FUNCTIONAL FOODS

Phase I

Phase II

Phase III

Functional
foods (eg.
Probiotic)
Production of
Quenchers
Gluthation
reductase, Vit. A,
E, C, etc

Captation of Iron
Increase the
and Lactoferrine
expression
Superoxide
dismutase,
Gluthation
Peroxidase and Influence on cell signalization
Catalase
Free radicals, nitric oxide, kinases, and cyclic nucleotids
Expression of transcriptional factors
Neutophil Factor Kk-B, Anti protease, etc

Phase IV

Influence on genic transduction

(Cytokines, Enzymes, Cellular markers)

M. Zubillaga et al. / Nutrition Research 21 (2001) 569-579

PRODUCTION OF ANTI-MICROBIAL
SUBSTANCES BY PROBIOTIC
C. Mishra and J. Lambert, Asia Pacific J Clin Nutr (1996) 5:
20-24

BACTERIOCIN

PRODUCER
ORGANISM

PROPERTIES

Nisin

Lactococcus latis
Subsp. Lactis ATCC
11454

Lantibiotic, broad
spectrum,
chromosome/plasmid
mediated, bactericidal,
produced late in the
growth cycle

Pediocin A

Pediococcus
Pentosaceus
FBB61 and L-7230

Broad spectrum,
plasmid mediated

Pediocin AcH

Pediococcus
Acidilactici H

Broad spectrum,
plasmid mediated

Table Properties of some well characterized bacteriocins

PRODUCTION OF ANTI-MICROBIAL
SUBSTANCES BY PROBIOTIC
C. Mishra and J. Lambert, Asia Pacific J Clin Nutr (1996) 5:
20-24

BACTERIOCIN

PRODUCER
ORGANISM

PROPERTIES

Leucocin

Leuconostoc
Gelidum UAL 187

Broad spectrum,
plasmid mediated,
bacteriostatic,
produced early in the
growth cycle

Helveticin J

Lb. helveticus 481

Narrow spectrum,
chromosomally
mediated, bacteridal

Cernobacteriocin

Carnobacterium
Pisciola L V17

Narrow spectrum,
chromosomally
mediated, bacteridal

Table Properties of some well characterized bacteriocins

IMMUNE SYSTEM
Fukushima et al. Int J Food microbiol 199;46:193-7

Intake of bifidobacteria can enhance local production

of IgA in milk and the intestine which may help to
protect both pups and dams from exposure to food
antigens
A study conducted to determine the effect of the
consumption of milk fermented by L. casei strain
Shirota, demostrated that the consumption of L. casei
Shirota fermented milk was able to modulate the
composition and metabolic activity of intestinal flora
and indicated that this milk didnt influence the
immune system of healthy immunocompetent males.

IMMUNE SYSTEM
Schiffrin et al., Am J Clin Nutr 1997;66:515-205

L. acidophilus La 1 and B. bifidus Bb 12 do not

modify lympocyte subsets in humans, but
phagocytosis of E. Coli sp was enhance in both
groups.
In the contraty, another study suggested the
involvement of lactic acid bacteria in cytokine
production under healthy condition
Yogurt intake containing 10 bacteria led to
increase in 2-5 synthetase activity in human
blood mononuclear cells
This result may suggest an interferon action in
peripheral way

THE EFFECT OF PROBIOTICS ON

Heliobacter pylori
To have a stimulatory effect on the motor
and emptying function of the gastric
stump whereas milk and milk whey,
cottage, cheese, and butter was shown to
have inhibitory effects
The diatetic management of the patients
undergoing gastric operations or with H.
pylori colonization should be carried out
on a strictly individualized basis

SHORT-CHAIN FATTY ACIDS PRODUCED BY

INTESTINAL BACTERIA
David L. Topping Asia Pacific J Clin Nutr (1996) 5: 15-19

SCFA
Total

SPECIFIC EFFECT
Lowering of pH

BENEFIT

Acetate

Propionate

Possible increase in Ca
and Mg absorption
Relaxation of
resistance
vessels

Enhance coloric
muscular
contraction
Relaxation of
resistance
vessels

Diminished bioavailability
of alkaline cytotoxic
compounds
Inhibition of Growth of
pH sensitive organism
Diminished faecal loss of
Ca and Mg
Greater colonic and
hepatic portal venous
blood flow

Easier laxation, relief of

constipation
Greater coloric and
hepatic
portal venous blood flow

Table General and Specific health benefits of SCFA in the colon

SHORT-CHAIN FATTY ACIDS PRODUCED BY

INTESTINAL BACTERIA
David L. Topping Asia Pacific J Clin Nutr (1996) 5: 15-19

SCFA
Propionate

SPECIFIC EFFECT

Butyrate

Stimulation of colonic
muscular contraction
Colonic epithlial
proliferation

Relaxation of
resistance
vessels
Metabolism ny
colonocytes

Maintenance of normal
colonocyte phenotype
Stiulation of colonic
electrolyte transport

BENEFIT

Greater ion and fluid

absorption, prevention of
diarrhoea
Possible greater
absorptive capacity
Greater colonic and
hepatic venous blood flow
Maintenance of mucosal
integrity, repair of
diversion and ulcerative
colitis, colonocyte
proliferation

Diminished risk of
malignancy
Greater ion and fluid
absorption, prevention of
diarrhoea

HABITUAL INTAKE OF LACTIC ACID

BACTERIA AND RISK REDUCTION OF
BLADDER CANCER

Yasuo Ohashi et al., Urol Int 2002;68:273-280

To assess the preventive effect of the intake

of L. casei, widely taken as fermented milk
products in Japan, against bladder cancer,
conducted a case control study
The Odds ration of smoking was 1,61 (95%
confidence interval: 1.10-2.36). Those of
previous (10-15 years ago) intake of
fermented milk products were 0.46 (0.270.79) for 1-2 times/week and 0.61 (0.380.99) for 3-4 or more times/week,
respectively
It was strongly suggested that the habitual
intake of lactic acid bacteria reduces the risk
of bladder cancer

SAFETY OF PROBIOTIC BACTERIA

Donohue DC and S. Salminen, Asia Pacific J. Clin Nutr (1996) 5: 2528
Safety studies

Probiotic
strain

In vitro

Animal
studies

Human
studies

Reported effects

Lactobacilus
acidophilus
NCFB 1748

Treatment of
constipation, alleviation
of radiotherapy related
diarrhoea, lowering of
faecal enzymes

Lactobacilus
Casei shirota

Balancing intestinal
microflora, prevention
of intestinal
disturbances treatment
of superficial bladder
cancer

Table Safety studies and reported effects of current successful probioitic and yogurt strain

SAFETY OF PROBIOTIC BACTERIA

Donohue DC and S. Salminen, Asia Pacific J. Clin Nutr (1996) 5: 2528

Safety studies
Probiotic
Strain
Lactobacilus GG
(ATCC 53103)

Reported effects

In vitro

Animal
studies

Human
studies

Treatment of accute viral

and bacterial diarrheoa
in infants, prevention of
antibiotic associated
diarrhoea, immune
enhancing, stabilisation
of intestinal premeability

Lactobacilusaci
Immune enhancing,
+
+
+
d
vaccine adjuvant,
balancing intestinal
Ophilus
microflora
LAI
Table
Safety studies and
reported effects
of current successful
probioitic
Biofidobacteriu
Prevention
of rotavirus
+
+ and yogurt
+ strain
m bifidum
diarrhoea

The Future Perspective

Microecology sciences :

Microecology of the gut

Microecology of the reproductive system

Microecology of the skin

Microecology of the lungs

etc

CONCLUSION
A lot of benefit of Probiotics, but
until recently the medical
profession still ignore this
situation.

See You next time