Radiation Enteritis: Nutritional Therapy

Radiation-induced impairment of mucosa cells (mucosal cells) leads to impaired small and large bowel function. As a result, depending on the degree of mucosal damage, food components can only be insufficiently absorbed (assimilated). This primarily affects:

Fat-soluble vitamins A, D, E, K.
Vitamin B9
Vitamin B12
Vitamin C
Magnesium
Phosphorus
Iron
Copper
Molybdenum
Selenium
Zinc
Essential fatty acids – linoleic acid and omega-3 fatty acids

When the lower part of the small intestine – ileum (ileum) – is irradiated, bile salts may be poorly absorbed, with malabsorption (“poor absorption“) depending on the extent of radiation damage. As a result, bile salts enter the colon and are excreted in the stool. The amount of bile salts in the body decreases and the bile salt concentration of the bile fluid decreases. As a result of the loss, the bile salts are no longer available for micelle formation. The critical micellar concentration results in decreased utilization of dietary fat and fat-soluble vitamins A, D, E, and K

Radiation sickness of the small intestine (radiation enteritis) and enteral protein loss syndrome

Impairment of the intestinal mucosa results in increased intestinal protein loss because leakage of plasma proteins through the intestinal mucosa into the interior of the intestine exceeds the rate of protein formation. The decrease in circulating plasma proteins is usually accompanied by a severe protein deficiency. The pathological protein loss may be promoted by a concomitant high dietary fat intake. When long-chain fatty acids are absorbed, lymphatic pressure is increased and large amounts of lymphatic fluid enter the intestine. As a result of increased lymph concentrations, there is a high enteral protein loss and eventually a decrease in plasma proteins. The increased intestinal protein loss ultimately leads to a decrease in oncotic pressure and thus – depending on the extent of the decreased concentration of plasma proteins (hypoproteinemia) – to the formation of edema. Since dietary fats cannot be adequately absorbed, the unabsorbed fats as well as fatty lipid products reach deeper parts of the intestine. There they accelerate the intestinal passage by stimulating peristalsis (intestinal movement) and finally – as a result of the increase in fecal fat excretion – trigger steatorrhea – chologenic fatty stools. By also promoting contraction waves in the colon and inhibiting water reabsorption from the intestine, bile salts increase fatty diarrhea. Increased fat loss through the stool also results in increased loss of fat-soluble vitamins A, D, E, and K, as well as essential fatty acids. Depending on the extent of the fat absorption disturbance, a negative energy balance occurs, resulting in weight loss [2.1]. In addition to steatorrhea, watery diarrhea may occur as a result of impaired small and large bowel function. Patients with this symptomatology are at increased risk of losing high amounts of fluids, water-soluble vitamins, such as vitamins C, B1, B2, B6, B9, and B12, and electrolytes, such as calcium, magnesium, potassium, and sodium chloride. It is not uncommon for specific symptoms of deficiency to develop from increased losses of vital nutrients

Nutritional medical recommendations

In cases of moderately pronounced absorption disorders resulting from impaired small and large intestinal function, primarily

Water-soluble vitamins – vitamins B1, B2, B6, B9, B12, C.
Fat-soluble vitamins – vitamins A, D, E, K
Minerals, such as calcium, magnesium, potassium, sodium chloride and phosphorus.
Trace elements, such as iron, zinc, selenium, copper and molybdenum.
Essential fatty acids – linoleic acid, omega-3 fatty acids and.
Proteins (protein)

Increased dietary intake and substitution, respectively. In particular, adequate intake of vitamins A, E, zinc and omega-3 fatty acids can reduce the inflammatory process, relieve symptoms and promote mucosal regeneration. An additional supply of the substrate glutamine reduces the extent of the external and functional mucosal changes in radiation enteritis.Glutamine plays an essential role in the energy metabolism of the small intestinal mucosa, as it is an important source of energy for the intestinal cells. In addition, glutamine can counteract mucosal damage. However, if malabsorption is severe as a result of acute mucosal damage, maintaining an optimal nutritional status may be difficult. In such cases, permanent parenteral nutrition must be considered to adequately meet nutrient and vital substance requirements. Importance of MCT fats1 for the dietary management of steatorrhea and enteral protein loss syndrome.
For dietary therapy, fat intake should be restricted – avoid high-fat foods and cooking and spreadable fat. Butter, margarine, and oil-long-chain fatty acids-should be replaced with medium-chain triglycerides-MCT fats

MCTs are broken down more rapidly in the small intestine than LCT fats under the influence of the pancreatic enzyme lipase2.
Due to their better water solubility, the small intestine can absorb MCT fats more easily
The presence of bile salts is not required for the absorption of MCTs
MCT fats can still be exploited both in the absence and deficiency of lipase and bile salts inside the intestine, respectively
The small intestine has a greater absorption capacity for MCT than for LCT.
Binding of MCT fats to the transport lipoproteins chylomicrons is not necessary, because medium-chain fatty acids are transported away via the portal blood and not via the intestinal lymphs
Due to the removal with the portal blood, the lymphatic pressure does not increase during the absorption of MCT and there is less lymph leakage into the intestine, reducing intestinal protein loss – increase in plasma proteins (blood protein).
When long-chain fatty acids are absorbed, on the other hand, the lymphatic pressure increases and thus the passage of lymph into the intestine – lymphatic congestion leads to a high loss of plasma proteins
MCT are oxidized faster in the tissue than LCT
Medium-chain triglycerides reduce water loss with stool by low stimulation of gallbladder contraction, resulting in low bile salt concentration inside the intestine – reduction of chologenic diarrhea
MCT fats improve overall nutritional status

Substitution of MCTs for LCTs subsequently leads to a reduction in fecal fat excretion – alleviation of steatorrhea – and enteric protein loss syndrome. MCT fatty acids are available in the form of MCT margarine – not suitable for frying – and MCT cooking oils – usable as cooking fat. The transition to medium-chain triglycerides (dietary fats) should be gradual, otherwise pain in the abdomen, vomiting and headaches may occur – increasing the daily amount of MCT from day to day by about 10 grams until the final daily amount of 100-150 grams is reached. MCT fats are heat labile and should not be heated for too long and never above 70 °C. In addition, care should be taken to cover the requirements of fat-soluble vitamins A, D, E, and K and essential fatty acids such as omega-3 and omega-6 compounds. When MCTs are administered, fat-soluble vitamins are adequately absorbed

Radiation sickness of the small intestine (radiation enteritis) – vital substance deficiency

Vital substance	Deficiency symptoms
Vitamin A	Fatigue, loss of appetite Decreased production of antibodies and weakened immune system. Decreased antioxidant protection Impaired dark adaptation, night blindness Diseases of the respiratory tract, respiratory infections due to changes in the mucous membrane. Disorders of spermatogenesis Anemia (anemia) Increased risk of Tumors of the lung, bladder, prostate, larynx, esophagus, stomach and intestine. Kidney stone formation Drying up to cornification of mucous membranes Attrition of cell and tissue mass of salivary glands and larynx, regression of organs. Dry, brittle nails and hair Dry, rough, itchy skin with rashes Reduced sense of smell, touch, hearing disorders. Deficiency symptoms in children Growth disorders of the long bones Disorders in the formation of dental tissue – dentin disorders. Malformations of the auditory, digestive and genitourinary tracts
Beta-carotene	Decreased antioxidant protection, increased risk for lipid peroxidation as well as oxidative DNA damage. Weakened immune system Increased risk of skin, lung, prostate, cervical, breast, esophageal, stomach, and colon cancers Reduced skin and eye protection
Vitamin D	Loss of minerals from bones– spine, pelvis, extremities- leading to. Hypocalcemia Decreased bone density Deformities Muscle weakness, especially at the hips and pelvis Increased risk of later osteoporosis Formation of osteomalacia Symptoms of osteomalacia Bone pain – shoulder, spine, pelvis, legs. Spontaneous fractures, often in the pelvic ring. Funnel chest “Map heart shape” of the female pelvis. Loss of hearing, ringing in the ears Disturbed immune system with repeated infections. Increased risk of colon and breast cancer Deficiency symptoms in children Impairment of the development of bones and teeth. Reduced mineralization of bones with a tendency to spontaneous fractures and bone bending – formation of rickets. Symptoms of rickets Disturbances in the longitudinal growth of bones Deformed skeleton – skull, spine, legs. Atypical heart-shaped pelvis Delayed retention of deciduous teeth, jaw deformity, malocclusion
Vitamin E	Lack of protection against radical attack and lipid peroxidation. Decreases the immune response High susceptibility to infection Disease of muscle cells due to inflammation of muscle tissue – myopathies. Shrinkage as well as weakening of the muscles Disease of the peripheral nervous system, neurological disorders, disorders in neuromuscular information transmission – neuropathies. Reduced number and lifetime of red blood cells. Deficiency symptoms in children Anemia (anemia) Impairment of blood vessels leads to bleeding Disturbances in neuromuscular information transmission. Disease of the retina, visual disturbances – neonatal retinopathy. Chronic lung disease, respiratory distress – bronchopulmonary dysplasia.
Vitamin K	Blood coagulation disorders leading to Hemorrhage into tissues and organs. Bleeding from body orifices Can cause small amounts of blood in the stool Decreased activity of osteoblasts leads to. Increased urinary calcium excretion. Severe bone deformities
B group vitamins,such as vitamin B1, B2, B3, B5, B6.	Disorders in the central and peripheral nervous system lead to. Nerve disease in the extremities, pain or numbness of the extremities. Muscle pain, wasting or weakness, involuntary muscle twitching Hyperexcitability of the heart muscle, decrease in cardiac output – tachycardia. Memory loss General state of weakness Impaired collagen synthesis resulting in poor wound healing Insomnia, nervous disorders, sensory disturbances. Impaired response of white blood cells to inflammation. Anemia due to decreased production of red blood cells, white blood cells, and platelets Decreased production of antibodies Impairment of cellular and humoral immune defenses. States of confusion, headaches Gastrointestinal disorders, stomach pain, vomiting, nausea. Deficiency symptoms in children Disorders of protein biosynthesis and cell division. Disorders of the central nervous system Disturbance of nervous function and cardiac insufficiency – beriberi Skeletal muscle atrophy Increased risk of cardiac dysfunction and failure
Folic acid	Mucosal changes in the mouth, intestines, and urogenital tract lead to Indigestion – diarrhea (diarrhea). Reduced absorption of nutrients and vital substances Weight loss Blood count disorders Anemia leads to rapid fatigue, shortness of breath, decreased ability to concentrate, general weakness. Impaired formation of white blood cells leads to. Reduction of the immune response to infections. Decreased antibody formation Risk of bleeding due to decreased production of platelets Elevated homocysteine levels increase the risk for Atherosclerosis (arteriosclerosis, hardening of the arteries). Coronary heart disease (CHD) Neurological and psychiatric disorders, such as. Memory impairment Depression Aggressiveness Irritability Deficiency symptoms in children Disturbances in DNA synthesis – impaired replication – and decreased cell proliferation increase the risk for Malformations, developmental disorders Growth retardation Maturation disorders of the central nervous system. Bone marrow alteration Deficiency of white blood cells as well as platelets (thrombocytes). Anemia (anemia) Injuries to the mucosa of the small intestine Disorders of protein biosynthesis and cell division
Vitamin B12	Decreased vision and blind spots Functional folic acid deficiency Weakened antioxidant protective system Blood count Anemia reduces the ability to concentrate, leads to fatigue, weakness and shortness of breath. Reduction of red blood cells, larger than average and rich in hemoglobin. Impaired growth of white blood cells weakens the immune system Risk of bleeding due to reduced production of platelets. Gastrointestinal tract Tissue atrophy and inflammation of the mucous membranes. Rough, burning tongue Reduced absorption of nutrients and vital substances Loss of appetite, weight loss Neurological disorders Numbness and tingling of extremities, loss of sensation of touch, vibration and pain. Poor coordination of the muscles, muscle atrophy. Unsteady gait Spinal cord damage Psychiatric disorders Memory disorders, confusion, depression Aggressiveness, agitation, psychosis
Vitamin C	Antioxidant deficiency Weakness of blood vessels leads to Abnormal bleeding Mucosal bleeding Hemorrhage into the muscles associated with weakness in heavily used muscles Inflamed as well as bleeding gums Joint stiffness and pain Poor wound healing Carnitine deficit leads to Symptoms of exhaustion, fatigue, indifference, irritability, depression. Increased need for sleep, decreased performance. Weakness of the immune system with increased risk of infection Decreased oxidation protection increases the risk of heart disease, apoplexy (stroke) Deficiency symptoms in children Weakened immune system Recurrent infections of the respiratory tract, urinary bladder, and the auditory tube, which is connected to the nasopharynx via the tympanic cavity of the middle ear Increased risk of vitamin C deficiency disease- Möller-Barlow disease in infancy with symptoms such as. Large bruises (hematomas). Pathological bone fractures associated with severe pain Wincing after every slightest touch – “jumping jack phenomenon”. Stagnation of growth
Calcium	Demineralization of the skeletal systemincreases the risk of Decreased bone density Osteoporosis, especially in women with estrogen deficiency. Bone softening as well as bone deformities – osteomalacia. Tendency to stress fractures of the skeletal system. Muscle cramps, tendency to spasm, increased muscle contraction. Cardiac arrhythmias Blood clotting disorders with increased bleeding tendency Increased excitability of the nervous system, depression. Increased risk of Hypertension (high blood pressure) Deficiency symptoms in children Impaired development of bones and teeth Decreased bone density in the newborn baby Decreased mineralization of bones with tendency to spontaneous fractures and bone bending – formation of rickets. Symptoms of rickets Disturbances in the longitudinal growth of bones Deformed skeleton – skull, spine, legs. Atypical heart-shaped pelvis Delayed retention of deciduous teeth, jaw deformity, malocclusion of teeth. Additional vitamin D deficiency leads to Hyperparathyroidism (enlarged parathyroid tissue) and increased production of parathyroid hormones – hyperparathyroidism. Hypercalcemic coma
Magnesium	Increased excitability of muscles and nerves leads to Insomnia, difficulty concentrating Muscle and vascular spasms Numbness as well as tingling in the extremities. Heart palpitations and arrhythmias, feeling of anxiety. Increased risk of Decreased immune response Myocardial infarction (heart attack) Acute hearing loss Deficiency symptoms in children Growth retardation Hyperactivity Insomnia, difficulty concentrating Muscle tremors, cramps Heart palpitations and arrhythmias Decreased immune response
Sodium	Fatigability, possible unconsciousness, apathy, confusion, lack of drive, decreased performance – short-term memory. Nausea, vomiting, loss of appetite, lack of thirst. Hypertension (high blood pressure); tendency to collapse, hyperexcitability of the heart muscle, reduction in cardiac output – tachycardia. Muscle cramps Decreased urination
Potassium	Muscle weakness, muscle paralysis Fatigue, apathy Nausea and vomiting, loss of appetite, constipation, decreased bowel activity to intestinal obstruction. Decreased tendon reflexes Cardiac arrhythmias, cardiac enlargement, tachycardia, dyspnea
Chloride	Acid-base balance disorders Development of metabolic alkalosis Severe vomiting with high salt losses
Phosphorus	Increased mobilization from bone with bone softening as well as bone deformities – osteomalacia. Disturbances in cell formation with impairment of red and white blood cell function. Disorders in the acid-base balance with the formation of metabolic acidosis. Disease of the nerves, which transport information between the central nervous system and the muscles leads to Tingling sensation, pain but also paralysis especially in the arms, hands and legs. Deficiency symptoms in children Increased mobilization from the bones – short stature, formation of rickets. Symptoms of rickets Disturbances in the longitudinal growth of bones Deformed skeleton – skull, spine, legs. Atypical heart-shaped pelvis Delayed retention of deciduous teeth, jaw deformity, malocclusion
Iron	Chronic fatigue syndrome (CFS) Loss of appetite Disorders of thermoregulation High susceptibility to infection of the upper respiratory tract Dry skin with itching Decreased concentration and retentiveness Increased lactic acid formation during physical exertion associated with muscle cramps. Increased absorption of environmental toxins Body temperature regulation may be disturbed Anemia Symptoms of deficiency in children Disturbance of physical, mental and motor development. Behavioral disorders Lack of concentration, learning disorders Disturbances in the child’s intelligence development Loss of appetite High susceptibility to infection of the upper respiratory tract Body temperature regulation may be disturbed
Zinc	Instead of zinc, the toxic cadmium is integrated into the biological processes, resulting in Inflammatory changes in the mucous membranes of the nose and throat. Cough, headache, fever Vomiting, diarrhea, cramping pain in the abdominal regions. Renal dysfunction and increased protein excretion. Osteoporosis, osteomalacia leads. Disturbances in the functioning of the immune system. Inhibition of cellular defense leads to increased susceptibility to infection Wound healing disorders and mucosal changes, as zinc is required for connective tissue synthesis Increased keratinization tendency Acne-like symptoms Progressive, circular hair loss Metabolic disorders, such as. Weight loss despite increased food intake Failure of beta cells in the pancreas – high risk of developing adult-onset diabetes (type II diabetes mellitus) Blood clotting disorders, chronic anemia. Reduction of the sense of smell and taste, reduction of vision, night blindness, sensorineural hearing loss. Fatigue, depression, psychosis, schizophrenia, aggressiveness. Permanent male infertility due to hypofunction of the gonads. Deficiency symptoms in children Low concentrations of zinc in the plasma and white blood cells cause Malformations and deformities especially of the central nervous system. Growth disorders and retardation with delayed sexual development. Skin changes in the extremities – hands, feet, nose, chin and ear – and natural orifices. Wound healing disorders Hair loss Acute and chronic infections Hyperactivity and learning disability
Selenium	Weight loss, intestinal sluggishness, indigestion. Depression, irritability, insomnia. Memory loss, difficulty concentrating, headaches Immunodeficiency Chronic fatigue syndrome (CFS) Thyroid dysfunction due to deficiency of selenium-dependent deiodases. Decreased activity of glutathione peroxidases leads to an increase in peroxides and thus to increased radical formation and increased formation of pro-inflammatory prostaglandins Joint pain due to pro-inflammatory processes. Increased susceptibility of the mitochondria Male infertility Increased risk of Liver damage Muscle pain and stiffness Keshan disease – viral infections, disease of the heart muscle – cardiomyopathy, heart failure, cardiac arrhythmias. Kashin-Beck disease – degenerative joint disease with disorders of bone and joint metabolism, which can lead to osteoarthritis and severe joint deformities. Deficiency symptoms in children Immunodeficiency Thyroid dysfunction Increased radical formation Increased susceptibility of the mitochondria Increased susceptibility to infections Increases the need for vitamin E
Copper	Neurological deficits Reduced sperm motility with fertility disorders. Elastin depletion in the vessels, vasoconstriction or occlusion, thrombosis. Anemia (anemia)due to impaired blood formation. Increased susceptibility to infection Increased total cholesterol and LDL cholesterol levels. Glucose intolerance Hair and pigment disorders Osteoporosis due to impaired collagen synthesis Proliferation of smooth muscle cells Weakness, fatigue Copper metabolic disorders Liver damage, hepatitis, cirrhosis – Wilson’s disease. Failure to thrive – Menkes syndrome Skin laxity – Cutis laxa Progressive muscle weakness, insufficiency of respiratory muscles – amyotrophic lateral sclerosis. Deficiency symptoms in children Anemia due to impaired hematopoiesis leads to maturation disorders of white blood cells and lack of defense cells in the blood Failure to thrive Skeletal changes with changes in bone age. Increased susceptibility to infections, frequent respiratory infections
Molybdenum	Nausea, severe headache, central visual field defects. Visual disturbances Hyperexcitability of the heart muscle, decrease in cardiac output – tachycardia. Accelerated respiratory rate – tachypnea. Coma Amino acid intolerance with deficient degradation of sulfur-containing amino acids – homocysteine, cysteine, methionine. Kidney stone formation Hair loss
Essential fatty acids- omega-3 and 6 compounds.	Weakened immune system, increased susceptibility to infections. Disturbed heart rhythm Disturbed vision Disturbed wound healing Disturbed blood clotting Hair loss (alopecia) Hypertension (high blood pressure) Hyperlipidemia (lipid metabolism disorder) Kidney damage and blood in the urine Reduced functionality of the red blood cells Skin changes – flaky, cracked, thickened skin. Fertility disorders in women and men Decreased liver function Increased symptoms of arthritis, allergies, atherosclerosis, thrombosis, eczema, premenstrual syndrome (PMS) – fatigue, poor concentration, marked change in appetite, headache, joint or muscle pain Increased risk of cancer Deficiency symptoms in children Disorders in whole body growth Insufficient development of the brain Reduction in the ability to learn Neurological disorders – poor concentration and performance
High quality protein	Disturbances in digestion and absorption of vital substances and resulting water and electrolyte losses. Muscle atrophy Tendency to accumulate water in the tissues – edema
Amino acids, such as glutamine, leucine, isoleucine, valine, tyrosine, histidine, carnitine.	Disturbances in the function of nerves and muscles Decreased performance Limited energy production and resulting fatigue and muscle weakness. Impairment of hemoglobin formation Severe joint pain and stiffness in arthritis patients. High depletion of muscle mass and protein reserves. Insufficient protection against free radicals Weakening of the immune system, since amino acids are the main sources of energy for the immune system Disturbances in the digestive system Fluctuations in blood sugar levels Increased blood lipid and cholesterol levels Cardiac arrhythmias

1 MCT = fats with medium-chain fatty acids; their digestion and absorption is faster and independent of bile acids, so they are preferred for diseases of the pancreas and intestine. 2LCT = fats with long-chain fatty acids; they are absorbed directly into the body’s fat depots without much conversion and are released from them only very slowly. They are also known by the term “hidden fats”.