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of patients with SS and GI involvement is associated with increased morbidity&#44; mortality and reduced quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The main pathological changes consist of GI smooth muscle atrophy and intestinal wall fibrosis&#44; with dysphagia and gastroesophageal reflux being the most common digestive manifestations in SS&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Oropharyngeal Dysphagia</span><p id="par0015" class="elsevierStylePara elsevierViewall">It is due to oropharyngeal dysmotility&#44; hindering the passage of the bolus from the mouth to the oropharynx&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Patients may have skin involvement of the face and tongue&#44; 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This type of dysphagia may be due to a motor or sensitive mechanical disturbance&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In SS&#44; the overproduction of collagen leads to thickening and fibrosis&#46; Muscles weaken and cause dysmotility&#44; a mechanism that involves esophagea<span class="elsevierStyleSup">l</span> dysphagia&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> This alteration can range from a lack of coordination of esophageal motility to the existence of complete paralysis of the esophagus&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Esophageal dysfunction in SS mainly occurs in the lower two-thirds of the esophagus&#44; causing esophageal sphincter weakness and profound loss of peristaltic<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> action&#46; This dysfunction leads to reflux of stomach contents into the esophagus&#46; Esophageal damage may manifest as a peptic ulcer or erosive esophagitis progressing to hemorrhage and ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The ulcer may scar or progress to an esophageal stricture&#44; fistula&#44; achalasia and Barrett&#39;s esophagus with the risk of neoplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Dietary interventions not only depend on the degree of impairment but also must ensure adequate nutritional support&#44; and are intended to modify the texture of foods&#44; attaining adequate lubrication of food and a smooth consistency for each type of dysphagia&#44; as well as reducing and&#47;or preventing problems associated with itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;10&#8211;12</span></a> Dietary recommendations in cases of oropharyngeal dysphagia are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;11&#44;12</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Gastroesophageal Reflux</span><p id="par0045" class="elsevierStylePara elsevierViewall">Gastroesophageal reflux is defined as the regurgitation of gastric contents into the esophagus and duodenum mainly due to loss of lower esophageal sphincter pressure 13&#46; Recommendations are based on dietary changes and avoiding foods that promote reflux as well as reflux-inducing positions &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Esophageal Stricture</span><p id="par0050" class="elsevierStylePara elsevierViewall">Esophageal stricture is a narrowing of the esophagus causing difficulty for swallowing&#46; It is characterized by the appearance of a feeling of difficulty passing food or retrosternal pain right after swallowing&#44; chest pain during eating and regurgitation of undigested food&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a> Most patients are able to pinpoint the zone where this occurs&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In this case&#44; liquids are easier to swallow than solids&#46; Virtually all foods can be liquefied&#44; although for some of them it may be necessary to add a liquid &#40;e&#46;g&#46; milk for grain&#44; broth for meat&#44; vegetables or fish&#41;&#46; Dietary recommendations are presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Sometimes&#44; despite performing a dietary intervention with conventional diet components&#44; one may need to resort to commercial preparations or enteral<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> nutrition&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Delayed Gastric Emptying or Gastroparesis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Gastroparesis is a gastric motility disorder characterized by delayed emptying of solids and&#47;or fluids from the stomach without any mechanical obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Gastroparesis can worsen gastroesophageal reflux&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Vascular ectasia is a cause of chronic gastrointestinal bleeding in patients with SS&#44; who may experience a frank hemorrhage or bleeding causing microcytic or ferropenic anemia micro&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although no controlled trials evaluating the efficacy of dietary modification in the treatment of gastroparesis exist&#44; and the clinical benefits are modest&#44; some dietary recommendations may be useful in patients with milder forms of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Nutritional intervention is based on dietary measures to encourage gastric emptying such as correct mastication&#44; eliminating alcohol because it slows gastric emptying&#44; fractionating a diet characterized by low but frequent volumes of food &#40;5&#8211;6 meals a day&#41;&#44; which may be low-fat and low in fiber to prevent bezoar formation&#46; The soft consistency food or liquid is better tolerated&#46; Fluid intake during a meal may promote gastric emptying&#46; Orthostatic position or simply walking after eating in addition to other measures may facilitate gastric emptying&#46; Nutritional therapy should be tailored to the severity of the disease&#46; When weight loss occurs&#44; the patient should be evaluated for the use of oral supplementation with enteral diets &#40;complete diets in liquid form which need not be masticated or require stomach emptying&#41;&#46; In later stages&#44; when the stomach cannot empty liquids&#44; enteral nutrition via a jejunostomy tube may be required&#44; but parenteral nutrition while should be restricted to patients with severe gastric dysmotility of the small intenstine&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;15</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Bowel Involvement</span><p id="par0085" class="elsevierStylePara elsevierViewall">SS may affect both the small and large intestine&#44; including the rectum and anus&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In the small intestine&#44; dysmotility involves the immobilization of intraluminal contents&#44; which promotes bacterial growth and consequent diarrhea&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> Pharmacological treatment with antacids also can support and&#47;or aggravate bacterial<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> overgrowth&#46; All this contributes to impaired absorption of nutrients&#44; causing malabsorption&#44; which together with pseudoobstructions may lead to severe malnutrition&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4&#44;7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Complications including the colon are&#58; luminal dilatation or pneumatosis&#44; pseudo-obstruction&#44; constipation&#44; diarrhea&#44; fecal incontinence and bleeding&#44; often hidden by telangiectasia<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> bleeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with severe manifestations of the small intestine and loss of response to antibiotics&#44; one must consider artificial nutrition&#46; An alternative may be nocturnal enteral nutrition&#44; although in most cases it is more convenient and acceptable for the patient to undergo a percutaneous<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> gastrostomy&#46; The natural history of the disease may require parenteral<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> nutrition&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Constipation</span>&#58; due to intestinal<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> dysmotility&#46; In the early stages there appears to be effective constipation<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> that can be initially treated with laxatives and soluble dietary fiber&#44; which can also help improve fecal incontinence&#46; Avoidance of non-absorbable carbohydrates such as sorbitol or lactulose is recommended as they may worsen the symptoms of bloating and discomfort&#44; also favoring bacterial overgrowth&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diarrhea</span>&#58; dietary advice in this case has a limited effect&#44; with the main objective being the reduction of clinical symptoms such as postprandial discomfort&#44; bloating and loss of weight&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The first step is to prescribe a diet low in fiber which may be easily digested and absorbed&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Restricting carbohydrates from the diet may reduce intestinal fermentation&#44; as they are the main energy source of bacteria&#44; and helps reduce symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For this reason&#44; the dietitian-nutritionist&#39;s diet should be tailored individually&#44; based on progression&#44; patient tolerance and habits&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Sometimes lactose intolerance appears&#44; forcing its removal from the diet plan&#46; Some studies have detected the anomalous presence of Lactobacillus or other probiotics in the small intestine&#44; so their usefulness is questionable in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In any case&#44; patients with advanced stages of the disease may be candidates for artificial nutrition&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods for Screening for Malnutrition</span><p id="par0125" class="elsevierStylePara elsevierViewall">To optimize resources and improve health care efficiency&#44; questionnaires have been considered useful in clinical practice as a systematic way of screening to detect the involvement of different portions of the GIT&#46; There are validated questionnaires developed by the CSRG<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; To assess the risk of malnutrition&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> the Malnutrition Universal Screening Test &#40;MUST&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> has already been used in this disease<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and is considered a practical tool for use in outpatient settings &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Proposal for a Nutritional Intervention Protocol in Patients With Systemic Sclerosis</span><p id="par0130" class="elsevierStylePara elsevierViewall">The overall assessment of the nutritional status of patients with SS should include a survey on the food habits of the patient&#44; ruling out any GI symptoms due to GI involvement &#40;such as dysphagia&#44; gastroparesis&#44; nausea&#44; vomiting&#44; heartburn&#44; rhythm disturbances&#8230;&#41; through a validated questionnaire developed by the CSRG&#44; and consider intercurrent disease&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">On physical examination one must determine the weight&#44; height&#44; body mass index&#44; and a complete inspection of the oropharyngeal cavity &#40;teeth&#44; chewing ability and salivation&#44; the presence of infection&#41;&#44; assessing the condition of the skin and mucosa to rule out nutritional deficiencies and the existence of edema&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">One may assess the risk of malnutrition by MUST and consider the evaluation of laboratory parameters&#46; The basic analytical determinations established by the U&#46;S&#46; expert panel include&#58; blood count&#44; hemoglobin&#44; vitamin A&#44; folic acid&#44; ferritin&#44; vitamin B<span class="elsevierStyleInf">12</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the absence of folic acid supplementation&#44; the detection of elevated plasma levels of this component may suggest the presence of bacterial overgrowth in the intestine&#46; Low levels of vitamin A may be indicative of the existence of intestinal malabsorption&#44; for which determination of zinc&#44; 25-OH vitamin D and vitamin K levels and prothrombin<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> time are recommended&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although these patients generally have normal plasma albumin levels&#44; and malnutrition is mostly caloric &#40;marasmus&#41;&#44; its determination in plasma may be useful for the diagnosis of mixed or protein-energy malnutrition &#40;marasmus-kwashiorkor&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Depending on the symptoms and test results&#44; one must consider assessing the need for additional tests &#40;endoscopy&#44; radiology tests&#44; breath test&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Dietary advice in writing should be provided and related to the pathology in question &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1&#8211;3</a>&#41;&#44; and the need to refer the patient to the dietitian-nutritionist assessed&#44; providing a food registry form to the patient &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The involvement of multiple parts of the digestive tract and the development of highly personalized dietary recommendations are fundamental&#46; In case the oral intake is insufficient with conventional foods&#44; nutritional supplements are indicated orally&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The indications for oral nutritional supplements and artificial nutrition do not differ from other chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;18</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Follow-up is done by weighing the patient&#44; as it constitutes the best indicator of malnutrition&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and normalization of laboratory parameters in case of alterations&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Alterations of the GIT in patients with SS are very common&#46; Throughout the entire gastrointestinal tract&#44; manifestations are observed in relation to the concerned section&#46; The common denominator of the GIT&#39;s condition is malnutrition&#46; Malnutrition is associated with increased morbidity&#44; mortality and reduced quality of life&#46; Screening&#44; detecting and early intervention by a multidisciplinary team&#44; including nutritional intervention&#44; are priorities in patients with SS&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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              "titulo" => "Oropharyngeal Dysphagia"
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              "titulo" => "Esophageal Dysphagia"
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              "titulo" => "Gastroesophageal Reflux"
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            3 => array:2 [
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              "titulo" => "Esophageal Stricture"
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            4 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Delayed Gastric Emptying or Gastroparesis"
            ]
            5 => array:2 [
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              "titulo" => "Bowel Involvement"
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          "titulo" => "Methods for Screening for Malnutrition"
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        6 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Proposal for a Nutritional Intervention Protocol in Patients With Systemic Sclerosis"
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          "identificador" => "sec0050"
          "titulo" => "Conclusions"
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    "fechaRecibido" => "2011-06-16"
    "fechaAceptado" => "2011-09-09"
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          "clase" => "keyword"
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            0 => "Systemic sclerosis"
            1 => "Nutrition"
            2 => "Diet"
            3 => "Malnutrition"
            4 => "Gastrointestinal system"
            5 => "Therapeutic approach"
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            0 => "Esclerosis sist&#233;mica"
            1 => "Nutrici&#243;n"
            2 => "Dietista"
            3 => "Desnutrici&#243;n"
            4 => "Tracto gastrointestinal"
            5 => "Abordaje terap&#233;utico"
            6 => "Malnutrici&#243;n"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic sclerosis is a connective tissue disease characterized by inflammation and fibrosis of multiple organs &#40;skin&#44; gastrointestinal tract&#44; lung&#44; kidney and heart&#41;&#46; After the skin&#44; the organ most affected with a frequency of 75&#37;&#8211;90&#37;&#44; the gastrointestinal tract is more often involved&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Gastrointestinal tract involvement is manifested by the appearance of oropharyngeal dysphagia&#44; esophageal dysphagia&#44; gastroesophageal reflux&#44; gastroparesis&#44; pseudo-obstruction&#44; bacterial overgrowth and intestinal malabsorption&#44; constipation&#44; diarrhea and&#47;or fecal incontinence&#46; These effects influence food intake and intestinal absorption leading to the gradual emergence of nutritional deficiencies&#46; About 30&#37; of patients with systemic sclerosis are at risk of malnutrition&#46; In 5&#37;&#8211;10&#37;&#44; gastrointestinal disorders are the leading cause of death&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Therapeutic strategies currently available are limited and aimed at reducing clinical symptoms&#46; The multidisciplinary management of these patients&#44; including nutritional intervention&#44; helps improve gastrointestinal symptoms&#44; and avoid malnutrition&#44; morbidity and improve quality of life&#46;</p>"
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        "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La esclerosis sist&#233;mica es una enfermedad del tejido conectivo caracterizada por inflamaci&#243;n y fibrosis de m&#250;ltiples &#243;rganos &#40;piel&#44; aparato digestivo&#44; pulm&#243;n&#44; ri&#241;&#243;n y coraz&#243;n&#41;&#46; Despu&#233;s de la piel&#44; el &#243;rgano m&#225;s afectado&#44; con una frecuencia del 75 al 90&#37;&#44; es el tracto gastrointestinal&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La afectaci&#243;n del tracto gastrointestinal se manifiesta por la aparici&#243;n de disfagia orofar&#237;ngea&#44; disfagia esof&#225;gica&#44; reflujo gastroesof&#225;gico&#44; gastroparesia&#44; seudoobstrucci&#243;n&#44; sobrecrecimiento bacteriano y malabsorci&#243;n intestinal&#44; estre&#241;imiento&#44; diarrea y&#47;o incontinencia fecal&#46; Estas afectaciones condicionan la ingesta alimentaria y la absorci&#243;n intestinal y conducen a la aparici&#243;n progresiva de deficiencias nutricionales&#46; Alrededor de un 30&#37; de los pacientes con esclerosis sist&#233;mica presentan un riesgo de malnutrici&#243;n&#46; En el 5-10&#37;&#44; los trastornos gastrointestinales son la principal causa de muerte&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las estrategias terap&#233;uticas existentes en la actualidad son limitadas y est&#225;n dirigidas a reducir la sintomatolog&#237;a cl&#237;nica&#46; El manejo multidisciplinar de dichos pacientes&#44; que incluya la intervenci&#243;n nutricional&#44; contribuye a mejorar la sintomatolog&#237;a gastrointestinal&#44; adem&#225;s de evitar la malnutrici&#243;n&#44; la morbilidad y aumentar la calidad de vida&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please&#44; cite this article as&#58; Recasens MA&#44; et al&#46; Nutrici&#243;n en la esclerosis sist&#233;mica&#46; Reumatol Clin&#46; 2012&#59;<span class="elsevierStyleBold">8</span>&#58;135&#8211;40&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Eat and chew slowly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Eat small amounts of food and often &#40;5&#8211;6 meals a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">To facilitate swallowing it is recommended that food to be consumed slightly cold</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drink water or other liquids between bites to aid swallowing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Carry a water bottle and drink in small sips of water throughout the day &#40;6&#8211;8 glasses of water a day total&#41; to ensure all bodily functions as well as production and quality of saliva</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">The consumption of sugar-free gum may help in some cases to stimulate the production of saliva and prevention of dental cavities</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Soften food with oil&#44; butter&#44; margarine or sauces&#44; especially meat and vegetables</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Moisten dry foods like bread or crackers in liquid</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Get the desired consistency by adding water&#44; milk or broth or thickeners &#40;cornstarch&#44; flour&#44; commercial infant cereal or prepared specific&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Recommended foods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Milk&#44; yogurt&#44; puddings&#44; custards&#44; cream&#44; cheese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ice creams&#44; sorbets&#44; puddings&#44; mousses&#44; souffl&#233;s&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gelatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Food with soft texture or can be crushed&#44; pureed vegetables&#44; pureed vegetables&#44; omelets&#44; scrambled eggs&#44; fruit compote&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Foods to avoid</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sticky foods such as boiled rice&#44; sliced bread&#44; mashed potatoes&#44; banana&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Foods such as grilled meat&#44; artichokes&#44; asparagus&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dry foods such as nuts&#44; toast&#44; potato &#8220;chip&#8221;&#44; cookies&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fish with bones and meat with small bones &#40;rabbit&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dietary Recommendations in Case of Swallowing Problems&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drink plenty of fluids &#40;6&#8211;8 glasses a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Make small volume but frequent meals &#40;5&#8211;6 a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eat and chew slowly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eat soft consistency or pureed foods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid extremes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid fat &#40;butter&#44; cream&#8230;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Use simple cooking &#40;grilled&#44; baked&#44; steamed&#44; boiled&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sit for 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h after meals&#44; because gravity will aid peristalsis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Elevate the head of the bed and eat 2&#8211;3<span class="elsevierStyleHsp" style=""></span>hours before bedtime</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid the following food</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Carbonated beverages&#58; glusoft drinks&#44; cola&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chocolate and derivatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Caffeine &#40;coffee&#44; tea&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Wine&#44; vinegar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Spices &#40;pepper&#44; mustard&#44; cloves&#44; oregano&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Citrus fruits &#40;orange&#44; tangerine&#44; lemon&#44; grapefruit&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fermented cheeses &#40;Manchego&#44; Cabrales&#44; Roquefort&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Whole grains bread&#44; brown rice&#44; whole wheat pasta&#44; whole grains&#44; bran&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Garlic and onion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>According to tolerance&#58; cucumber&#44; peppers and melons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dietary Recommendations in Cases of Gastroesophageal Reflux&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Liquid foods are easier to swallow than solids&#46; Virtually any food or food can be liquefied&#46; Grind or blend all possible foods to get a semi-solid or soft texture&#44; adding any liquid or food support such as&#58; cereal with milk&#44; beef broth&#44; vegetable broth with rice or vegetables&#44; milk or water with fruit&#44; cake and ice cream or sorbet &#8230; smoothie crushed texture should be smooth</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Chew food thoroughly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drink fluids to stay well hydrated &#40;6&#8211;8 glasses a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid dry foods like toast or biscuits&#44; cookies&#44; French fries or &#8220;chips&#8221;&#44; snacks&#44; nuts&#8230;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid sticky foods like textured white bread&#44; dried fruit&#44; mashed potatoes&#44; soft candy&#8230;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid foods high in fiber or chips &#40;bread&#44; artichokes&#44; asparagus&#8230;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid spicy foods spice and vinegar&#44; and do not eat salty foods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Recommended semisolid food</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Porridge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8220;Baby jars&#8221; or commercial purees&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Meals baked egg souffle type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cakes vegetables&#44; meat or fish&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pudding&#44; mousse&#44; jello&#44; pudding&#44; custard&#44; ice cream&#44; sorbet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fruit Compote&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Dietary Recommendations in Cases of Esophageal Stenosis&#46;</p>"
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        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Baron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">1&#46; I have &#40;or had&#41; a lack of appetite almost every day&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46; I have &#40;or had&#41; difficulty swallowing&#59; food or liquid sometimes sticks in my chest when I swallow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; I have &#40;or had&#41; food or a sour taste returning to my nose and mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; I wake up &#40;or have done so&#41; with a breathless sensation at night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; I have &#40;or had&#41; a burning sensation in my stomach or lower chest that ascends to my throat almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46; I have &#40;or had&#41; a sensation of fullness shortly after starting to eat on most days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46; I have &#40;or had&#41; visible abdominal swelling or the sensation of abdominal swelling &#40;making me loosen my clothes&#41; almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46; I have &#40;or had&#41; nausea and&#47;or vomiting almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46; I have &#40;or had&#41; constipation almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46; I have &#40;or had&#41; diarrhea almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46; I need &#40;or have needed&#41; antibiotics to control diarrhea&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46; I have &#40;or had&#41; greasy&#44; foul smelling stools&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46; I have &#40;or had&#41; fecal incontinence &#40;soiling my clothing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46; I need &#40;or have needed&#41; intravenous feeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Questionnaire Used by the Canadian Scleroderma Agency Research Group&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
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            0 => array:3 [
              "identificador" => "bib0005"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Esclerosis sist&#233;mica y tracto gastrointestinal&#46; Abordaje diagn&#243;stico y terap&#233;utico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "O&#46;L&#46; Vera-Lastra"
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                    0 => array:2 [
                      "doi" => "10.1016/S1699-258X(06)73104-7"
                      "Revista" => array:7 [
                        "tituloSerie" => "Reumatol Clin"
                        "fecha" => "2006"
                        "volumen" => "2"
                        "numero" => "Suppl&#46; 3"
                        "paginaInicial" => "S24"
                        "paginaFinal" => "S30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21794384"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0010"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Malnutrition is common in systemic sclerosis&#58; results from the Canadian scleroderma research group database"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46; Baron"
                            1 => "M&#46; Hudson"
                            2 => "R&#46; Steele"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3899/jrheum.090694"
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                        "tituloSerie" => "J Rheumatol"
                        "fecha" => "2009"
                        "volumen" => "36"
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                        "paginaFinal" => "2743"
                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19833750"
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                0 => array:2 [
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                      "titulo" => "Gastrointestinal complications&#58; the most frequent internal complications of systemic sclerosis"
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                          "etal" => false
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                            0 => "A&#46; Forbes"
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                    0 => array:2 [
                      "doi" => "10.1093/rheumatology/ken485"
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                        "tituloSerie" => "Rheumatology"
                        "fecha" => "2008"
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                      "doi" => "10.1007/s10620-007-0018-8"
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                        "tituloSerie" => "Dig Dis Sci"
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                  "contribucion" => array:1 [
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                      "titulo" => "Disfagia orofaringea"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "P&#46; Clav&#233;"
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                            2 => "I&#46; Ferrero"
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Review Article
Nutrition in Systemic Sclerosis
Nutrición en la esclerosis sistémica
M.a Asunción Recasensa, Celia Puiga, Vera Ortiz-Santamariab,
Corresponding author
33144vos@comb.cat

Corresponding author.
a Unidad de Endocrinología, Hospital General de Granollers, Spain
b Unidad de Reumatología, Hospital General de Granollers, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In systemic sclerosis &#40;SS&#41;&#44; the second most frequently affected organ is the gastrointestinal tract &#40;GIT&#41; and particularly the esophagus&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The clinical manifestations associated with the alteration of the GIT have malnutrition as a common denominator&#46; A recent study by the Task Force of the Canadian Scleroderma &#40;CSRG&#41; Group showed that about 30&#37; of an unselected sample of patients with SS had a moderate or high risk for malnutrition&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Recently&#44; a panel of U&#46;S&#46; experts has published a consensus on how to detect and manage malnutrition and GI disorders in SS&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> These are the leading cause of death in 5&#37;&#8211;10&#37; of patients with SS and GI involvement is associated with increased morbidity&#44; mortality and reduced quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The main pathological changes consist of GI smooth muscle atrophy and intestinal wall fibrosis&#44; with dysphagia and gastroesophageal reflux being the most common digestive manifestations in SS&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4</span></a></p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Oropharyngeal Dysphagia</span><p id="par0015" class="elsevierStylePara elsevierViewall">It is due to oropharyngeal dysmotility&#44; hindering the passage of the bolus from the mouth to the oropharynx&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Patients may have skin involvement of the face and tongue&#44; but these changes rarely affect oral<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> intake&#46; However&#44; 20&#37; of patients with SS have a associated Sj&#246;gren&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In this case&#44; the reduction in saliva production is associated with oropharyngeal dysphagia due to the inability to properly lubricate the food bolus before being transferred into the esophagus&#46; In addition&#44; impairment of salivary secretion increases the risk of developing periodontal disease and accelerates tooth decay&#44; making mastication difficult&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> so the evaluation of the oral cavity should be included routinely in the physical examination of such patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Oropharyngeal dysphagia is characterized by occurring a few seconds after initiating the act of swallowing&#44; and the feeling is manifested by retention of food in the throat and the need to swallow repeatedly&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is often accompanied by regurgitation of the bolus into the nasopharynx&#44; which may expel food through the nose or larynx&#46; Dysfunction of the constrictor muscles of the pharynx can cause dysarthria&#44; nasal voice and pharyngonasal regurgitation&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a> In more severe cases&#44; the patient cannot swallow saliva and drools&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Esophageal Dysphagia</span><p id="par0025" class="elsevierStylePara elsevierViewall">The difficulty in swallowing arises once the bolus has passed through the pharynx and upper esophageal sphincter&#46; This type of dysphagia may be due to a motor or sensitive mechanical disturbance&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In SS&#44; the overproduction of collagen leads to thickening and fibrosis&#46; Muscles weaken and cause dysmotility&#44; a mechanism that involves esophagea<span class="elsevierStyleSup">l</span> dysphagia&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> This alteration can range from a lack of coordination of esophageal motility to the existence of complete paralysis of the esophagus&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Esophageal dysfunction in SS mainly occurs in the lower two-thirds of the esophagus&#44; causing esophageal sphincter weakness and profound loss of peristaltic<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> action&#46; This dysfunction leads to reflux of stomach contents into the esophagus&#46; Esophageal damage may manifest as a peptic ulcer or erosive esophagitis progressing to hemorrhage and ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The ulcer may scar or progress to an esophageal stricture&#44; fistula&#44; achalasia and Barrett&#39;s esophagus with the risk of neoplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Dietary interventions not only depend on the degree of impairment but also must ensure adequate nutritional support&#44; and are intended to modify the texture of foods&#44; attaining adequate lubrication of food and a smooth consistency for each type of dysphagia&#44; as well as reducing and&#47;or preventing problems associated with itself&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;10&#8211;12</span></a> Dietary recommendations in cases of oropharyngeal dysphagia are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;8&#44;11&#44;12</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Gastroesophageal Reflux</span><p id="par0045" class="elsevierStylePara elsevierViewall">Gastroesophageal reflux is defined as the regurgitation of gastric contents into the esophagus and duodenum mainly due to loss of lower esophageal sphincter pressure 13&#46; Recommendations are based on dietary changes and avoiding foods that promote reflux as well as reflux-inducing positions &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Esophageal Stricture</span><p id="par0050" class="elsevierStylePara elsevierViewall">Esophageal stricture is a narrowing of the esophagus causing difficulty for swallowing&#46; It is characterized by the appearance of a feeling of difficulty passing food or retrosternal pain right after swallowing&#44; chest pain during eating and regurgitation of undigested food&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a> Most patients are able to pinpoint the zone where this occurs&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In this case&#44; liquids are easier to swallow than solids&#46; Virtually all foods can be liquefied&#44; although for some of them it may be necessary to add a liquid &#40;e&#46;g&#46; milk for grain&#44; broth for meat&#44; vegetables or fish&#41;&#46; Dietary recommendations are presented in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Sometimes&#44; despite performing a dietary intervention with conventional diet components&#44; one may need to resort to commercial preparations or enteral<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> nutrition&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Delayed Gastric Emptying or Gastroparesis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Gastroparesis is a gastric motility disorder characterized by delayed emptying of solids and&#47;or fluids from the stomach without any mechanical obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Gastroparesis can worsen gastroesophageal reflux&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Vascular ectasia is a cause of chronic gastrointestinal bleeding in patients with SS&#44; who may experience a frank hemorrhage or bleeding causing microcytic or ferropenic anemia micro&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although no controlled trials evaluating the efficacy of dietary modification in the treatment of gastroparesis exist&#44; and the clinical benefits are modest&#44; some dietary recommendations may be useful in patients with milder forms of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Nutritional intervention is based on dietary measures to encourage gastric emptying such as correct mastication&#44; eliminating alcohol because it slows gastric emptying&#44; fractionating a diet characterized by low but frequent volumes of food &#40;5&#8211;6 meals a day&#41;&#44; which may be low-fat and low in fiber to prevent bezoar formation&#46; The soft consistency food or liquid is better tolerated&#46; Fluid intake during a meal may promote gastric emptying&#46; Orthostatic position or simply walking after eating in addition to other measures may facilitate gastric emptying&#46; Nutritional therapy should be tailored to the severity of the disease&#46; When weight loss occurs&#44; the patient should be evaluated for the use of oral supplementation with enteral diets &#40;complete diets in liquid form which need not be masticated or require stomach emptying&#41;&#46; In later stages&#44; when the stomach cannot empty liquids&#44; enteral nutrition via a jejunostomy tube may be required&#44; but parenteral nutrition while should be restricted to patients with severe gastric dysmotility of the small intenstine&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;15</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Bowel Involvement</span><p id="par0085" class="elsevierStylePara elsevierViewall">SS may affect both the small and large intestine&#44; including the rectum and anus&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In the small intestine&#44; dysmotility involves the immobilization of intraluminal contents&#44; which promotes bacterial growth and consequent diarrhea&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;4</span></a> Pharmacological treatment with antacids also can support and&#47;or aggravate bacterial<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> overgrowth&#46; All this contributes to impaired absorption of nutrients&#44; causing malabsorption&#44; which together with pseudoobstructions may lead to severe malnutrition&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4&#44;7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Complications including the colon are&#58; luminal dilatation or pneumatosis&#44; pseudo-obstruction&#44; constipation&#44; diarrhea&#44; fecal incontinence and bleeding&#44; often hidden by telangiectasia<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> bleeding&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In patients with severe manifestations of the small intestine and loss of response to antibiotics&#44; one must consider artificial nutrition&#46; An alternative may be nocturnal enteral nutrition&#44; although in most cases it is more convenient and acceptable for the patient to undergo a percutaneous<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> gastrostomy&#46; The natural history of the disease may require parenteral<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> nutrition&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;1&#41;</span><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Constipation</span>&#58; due to intestinal<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> dysmotility&#46; In the early stages there appears to be effective constipation<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> that can be initially treated with laxatives and soluble dietary fiber&#44; which can also help improve fecal incontinence&#46; Avoidance of non-absorbable carbohydrates such as sorbitol or lactulose is recommended as they may worsen the symptoms of bloating and discomfort&#44; also favoring bacterial overgrowth&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;2&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diarrhea</span>&#58; dietary advice in this case has a limited effect&#44; with the main objective being the reduction of clinical symptoms such as postprandial discomfort&#44; bloating and loss of weight&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The first step is to prescribe a diet low in fiber which may be easily digested and absorbed&#46;</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">Restricting carbohydrates from the diet may reduce intestinal fermentation&#44; as they are the main energy source of bacteria&#44; and helps reduce symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For this reason&#44; the dietitian-nutritionist&#39;s diet should be tailored individually&#44; based on progression&#44; patient tolerance and habits&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Sometimes lactose intolerance appears&#44; forcing its removal from the diet plan&#46; Some studies have detected the anomalous presence of Lactobacillus or other probiotics in the small intestine&#44; so their usefulness is questionable in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In any case&#44; patients with advanced stages of the disease may be candidates for artificial nutrition&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods for Screening for Malnutrition</span><p id="par0125" class="elsevierStylePara elsevierViewall">To optimize resources and improve health care efficiency&#44; questionnaires have been considered useful in clinical practice as a systematic way of screening to detect the involvement of different portions of the GIT&#46; There are validated questionnaires developed by the CSRG<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; To assess the risk of malnutrition&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> the Malnutrition Universal Screening Test &#40;MUST&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> has already been used in this disease<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and is considered a practical tool for use in outpatient settings &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Proposal for a Nutritional Intervention Protocol in Patients With Systemic Sclerosis</span><p id="par0130" class="elsevierStylePara elsevierViewall">The overall assessment of the nutritional status of patients with SS should include a survey on the food habits of the patient&#44; ruling out any GI symptoms due to GI involvement &#40;such as dysphagia&#44; gastroparesis&#44; nausea&#44; vomiting&#44; heartburn&#44; rhythm disturbances&#8230;&#41; through a validated questionnaire developed by the CSRG&#44; and consider intercurrent disease&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">On physical examination one must determine the weight&#44; height&#44; body mass index&#44; and a complete inspection of the oropharyngeal cavity &#40;teeth&#44; chewing ability and salivation&#44; the presence of infection&#41;&#44; assessing the condition of the skin and mucosa to rule out nutritional deficiencies and the existence of edema&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">One may assess the risk of malnutrition by MUST and consider the evaluation of laboratory parameters&#46; The basic analytical determinations established by the U&#46;S&#46; expert panel include&#58; blood count&#44; hemoglobin&#44; vitamin A&#44; folic acid&#44; ferritin&#44; vitamin B<span class="elsevierStyleInf">12</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In the absence of folic acid supplementation&#44; the detection of elevated plasma levels of this component may suggest the presence of bacterial overgrowth in the intestine&#46; Low levels of vitamin A may be indicative of the existence of intestinal malabsorption&#44; for which determination of zinc&#44; 25-OH vitamin D and vitamin K levels and prothrombin<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> time are recommended&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although these patients generally have normal plasma albumin levels&#44; and malnutrition is mostly caloric &#40;marasmus&#41;&#44; its determination in plasma may be useful for the diagnosis of mixed or protein-energy malnutrition &#40;marasmus-kwashiorkor&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Depending on the symptoms and test results&#44; one must consider assessing the need for additional tests &#40;endoscopy&#44; radiology tests&#44; breath test&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;14</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Dietary advice in writing should be provided and related to the pathology in question &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1&#8211;3</a>&#41;&#44; and the need to refer the patient to the dietitian-nutritionist assessed&#44; providing a food registry form to the patient &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The involvement of multiple parts of the digestive tract and the development of highly personalized dietary recommendations are fundamental&#46; In case the oral intake is insufficient with conventional foods&#44; nutritional supplements are indicated orally&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The indications for oral nutritional supplements and artificial nutrition do not differ from other chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;18</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Follow-up is done by weighing the patient&#44; as it constitutes the best indicator of malnutrition&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and normalization of laboratory parameters in case of alterations&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0170" class="elsevierStylePara elsevierViewall">Alterations of the GIT in patients with SS are very common&#46; Throughout the entire gastrointestinal tract&#44; manifestations are observed in relation to the concerned section&#46; The common denominator of the GIT&#39;s condition is malnutrition&#46; Malnutrition is associated with increased morbidity&#44; mortality and reduced quality of life&#46; Screening&#44; detecting and early intervention by a multidisciplinary team&#44; including nutritional intervention&#44; are priorities in patients with SS&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of Interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:10 [
        0 => array:2 [
          "identificador" => "xres125776"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec113062"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres125775"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec113063"
          "titulo" => "Palabras clave"
        ]
        4 => array:3 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0010"
              "titulo" => "Oropharyngeal Dysphagia"
            ]
            1 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Esophageal Dysphagia"
            ]
            2 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Gastroesophageal Reflux"
            ]
            3 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Esophageal Stricture"
            ]
            4 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Delayed Gastric Emptying or Gastroparesis"
            ]
            5 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Bowel Involvement"
            ]
          ]
        ]
        5 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Methods for Screening for Malnutrition"
        ]
        6 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Proposal for a Nutritional Intervention Protocol in Patients With Systemic Sclerosis"
        ]
        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conclusions"
        ]
        8 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflict of Interest"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-06-16"
    "fechaAceptado" => "2011-09-09"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec113062"
          "palabras" => array:6 [
            0 => "Systemic sclerosis"
            1 => "Nutrition"
            2 => "Diet"
            3 => "Malnutrition"
            4 => "Gastrointestinal system"
            5 => "Therapeutic approach"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec113063"
          "palabras" => array:7 [
            0 => "Esclerosis sist&#233;mica"
            1 => "Nutrici&#243;n"
            2 => "Dietista"
            3 => "Desnutrici&#243;n"
            4 => "Tracto gastrointestinal"
            5 => "Abordaje terap&#233;utico"
            6 => "Malnutrici&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Systemic sclerosis is a connective tissue disease characterized by inflammation and fibrosis of multiple organs &#40;skin&#44; gastrointestinal tract&#44; lung&#44; kidney and heart&#41;&#46; After the skin&#44; the organ most affected with a frequency of 75&#37;&#8211;90&#37;&#44; the gastrointestinal tract is more often involved&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Gastrointestinal tract involvement is manifested by the appearance of oropharyngeal dysphagia&#44; esophageal dysphagia&#44; gastroesophageal reflux&#44; gastroparesis&#44; pseudo-obstruction&#44; bacterial overgrowth and intestinal malabsorption&#44; constipation&#44; diarrhea and&#47;or fecal incontinence&#46; These effects influence food intake and intestinal absorption leading to the gradual emergence of nutritional deficiencies&#46; About 30&#37; of patients with systemic sclerosis are at risk of malnutrition&#46; In 5&#37;&#8211;10&#37;&#44; gastrointestinal disorders are the leading cause of death&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Therapeutic strategies currently available are limited and aimed at reducing clinical symptoms&#46; The multidisciplinary management of these patients&#44; including nutritional intervention&#44; helps improve gastrointestinal symptoms&#44; and avoid malnutrition&#44; morbidity and improve quality of life&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La esclerosis sist&#233;mica es una enfermedad del tejido conectivo caracterizada por inflamaci&#243;n y fibrosis de m&#250;ltiples &#243;rganos &#40;piel&#44; aparato digestivo&#44; pulm&#243;n&#44; ri&#241;&#243;n y coraz&#243;n&#41;&#46; Despu&#233;s de la piel&#44; el &#243;rgano m&#225;s afectado&#44; con una frecuencia del 75 al 90&#37;&#44; es el tracto gastrointestinal&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La afectaci&#243;n del tracto gastrointestinal se manifiesta por la aparici&#243;n de disfagia orofar&#237;ngea&#44; disfagia esof&#225;gica&#44; reflujo gastroesof&#225;gico&#44; gastroparesia&#44; seudoobstrucci&#243;n&#44; sobrecrecimiento bacteriano y malabsorci&#243;n intestinal&#44; estre&#241;imiento&#44; diarrea y&#47;o incontinencia fecal&#46; Estas afectaciones condicionan la ingesta alimentaria y la absorci&#243;n intestinal y conducen a la aparici&#243;n progresiva de deficiencias nutricionales&#46; Alrededor de un 30&#37; de los pacientes con esclerosis sist&#233;mica presentan un riesgo de malnutrici&#243;n&#46; En el 5-10&#37;&#44; los trastornos gastrointestinales son la principal causa de muerte&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las estrategias terap&#233;uticas existentes en la actualidad son limitadas y est&#225;n dirigidas a reducir la sintomatolog&#237;a cl&#237;nica&#46; El manejo multidisciplinar de dichos pacientes&#44; que incluya la intervenci&#243;n nutricional&#44; contribuye a mejorar la sintomatolog&#237;a gastrointestinal&#44; adem&#225;s de evitar la malnutrici&#243;n&#44; la morbilidad y aumentar la calidad de vida&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please&#44; cite this article as&#58; Recasens MA&#44; et al&#46; Nutrici&#243;n en la esclerosis sist&#233;mica&#46; Reumatol Clin&#46; 2012&#59;<span class="elsevierStyleBold">8</span>&#58;135&#8211;40&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1519
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Adapted Malnutrition Universal Screening Test &#40;MUST&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Food Registry Sheet&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eat and chew slowly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eat small amounts of food and often &#40;5&#8211;6 meals a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">To facilitate swallowing it is recommended that food to be consumed slightly cold</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drink water or other liquids between bites to aid swallowing</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Carry a water bottle and drink in small sips of water throughout the day &#40;6&#8211;8 glasses of water a day total&#41; to ensure all bodily functions as well as production and quality of saliva</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">The consumption of sugar-free gum may help in some cases to stimulate the production of saliva and prevention of dental cavities</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Soften food with oil&#44; butter&#44; margarine or sauces&#44; especially meat and vegetables</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Moisten dry foods like bread or crackers in liquid</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Get the desired consistency by adding water&#44; milk or broth or thickeners &#40;cornstarch&#44; flour&#44; commercial infant cereal or prepared specific&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Recommended foods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Milk&#44; yogurt&#44; puddings&#44; custards&#44; cream&#44; cheese&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ice creams&#44; sorbets&#44; puddings&#44; mousses&#44; souffl&#233;s&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Gelatin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Food with soft texture or can be crushed&#44; pureed vegetables&#44; pureed vegetables&#44; omelets&#44; scrambled eggs&#44; fruit compote&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Foods to avoid</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sticky foods such as boiled rice&#44; sliced bread&#44; mashed potatoes&#44; banana&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Foods such as grilled meat&#44; artichokes&#44; asparagus&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dry foods such as nuts&#44; toast&#44; potato &#8220;chip&#8221;&#44; cookies&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fish with bones and meat with small bones &#40;rabbit&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Dietary Recommendations in Case of Swallowing Problems&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drink plenty of fluids &#40;6&#8211;8 glasses a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Make small volume but frequent meals &#40;5&#8211;6 a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eat and chew slowly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Eat soft consistency or pureed foods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid extremes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid fat &#40;butter&#44; cream&#8230;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Use simple cooking &#40;grilled&#44; baked&#44; steamed&#44; boiled&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sit for 1&#8211;2<span class="elsevierStyleHsp" style=""></span>h after meals&#44; because gravity will aid peristalsis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Elevate the head of the bed and eat 2&#8211;3<span class="elsevierStyleHsp" style=""></span>hours before bedtime</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid the following food</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcohol&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Carbonated beverages&#58; glusoft drinks&#44; cola&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chocolate and derivatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Caffeine &#40;coffee&#44; tea&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Wine&#44; vinegar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Spices &#40;pepper&#44; mustard&#44; cloves&#44; oregano&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Citrus fruits &#40;orange&#44; tangerine&#44; lemon&#44; grapefruit&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fermented cheeses &#40;Manchego&#44; Cabrales&#44; Roquefort&#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Whole grains bread&#44; brown rice&#44; whole wheat pasta&#44; whole grains&#44; bran&#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Garlic and onion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>According to tolerance&#58; cucumber&#44; peppers and melons&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab212247.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dietary Recommendations in Cases of Gastroesophageal Reflux&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Liquid foods are easier to swallow than solids&#46; Virtually any food or food can be liquefied&#46; Grind or blend all possible foods to get a semi-solid or soft texture&#44; adding any liquid or food support such as&#58; cereal with milk&#44; beef broth&#44; vegetable broth with rice or vegetables&#44; milk or water with fruit&#44; cake and ice cream or sorbet &#8230; smoothie crushed texture should be smooth</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Chew food thoroughly</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drink fluids to stay well hydrated &#40;6&#8211;8 glasses a day&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid dry foods like toast or biscuits&#44; cookies&#44; French fries or &#8220;chips&#8221;&#44; snacks&#44; nuts&#8230;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid sticky foods like textured white bread&#44; dried fruit&#44; mashed potatoes&#44; soft candy&#8230;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid foods high in fiber or chips &#40;bread&#44; artichokes&#44; asparagus&#8230;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Avoid spicy foods spice and vinegar&#44; and do not eat salty foods</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Recommended semisolid food</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Porridge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8220;Baby jars&#8221; or commercial purees&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Meals baked egg souffle type&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cakes vegetables&#44; meat or fish&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pudding&#44; mousse&#44; jello&#44; pudding&#44; custard&#44; ice cream&#44; sorbet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fruit Compote&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab212246.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Dietary Recommendations in Cases of Esophageal Stenosis&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Baron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46; I have &#40;or had&#41; a lack of appetite almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; I have &#40;or had&#41; difficulty swallowing&#59; food or liquid sometimes sticks in my chest when I swallow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46; I have &#40;or had&#41; food or a sour taste returning to my nose and mouth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46; I wake up &#40;or have done so&#41; with a breathless sensation at night&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46; I have &#40;or had&#41; a burning sensation in my stomach or lower chest that ascends to my throat almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46; I have &#40;or had&#41; a sensation of fullness shortly after starting to eat on most days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46; I have &#40;or had&#41; visible abdominal swelling or the sensation of abdominal swelling &#40;making me loosen my clothes&#41; almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46; I have &#40;or had&#41; nausea and&#47;or vomiting almost every day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t">9&#46; I have &#40;or had&#41; constipation almost every day&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">12&#46; I have &#40;or had&#41; greasy&#44; foul smelling stools&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13&#46; I have &#40;or had&#41; fecal incontinence &#40;soiling my clothing&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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