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LauraBussey

M.Fox
NUTR426
10/05/2015

CaseStudy#8:UlcerDisease:MedicalandSurgicalTreatment

I.UnderstandingtheDiseaseandPathophysiology
1.
Identifythepatientsriskfactorsforulcerdisease.
Mariasgreatestriskfactorforulcerdiseaseisprobablythefactthatsheusestobacco.Adietary
factorthatincreasesGERDsymptomsandirritatestheGItractisthefactthatsheconsumes
810cupsofcoffeeandsoftdrinksperday.HerfamilyhistoryofPUDputsherathighrisk,and
ofcoursethefactthatshehasbeenexperiencingGERDforaroundayear(possiblymore)isan
indicativefactorofherrisk.Inaddition,Mrs.Rodriguezhasexperiencedatragedysheisa
widow.Shealsohastwochildrenandisnowasinglemom.Thegrieffromthedeathofher
husband,alongwiththepressuresofraisingtwochildrenalone,mustbeincrediblydifficultand
stressful.Thisstresscancertainlyaggravateherulcerdisease.

2.
Howissmokingrelatedtoulcerdisease?
Thegastrointestinaleffectsofsmokingarewidespread.theyincludethelooseningofthelower
esophagealsphincterandthepyloricsphincter,leadingtoincreasedreflux.Also,thereisan
alterationofthenatureofthegastriccontents.Pancreaticbicarbonatesecretionisinhibitedas
well.GastricemptyingisspedupandthepHoftheduodenumislowered.Smokingimpairsthe
abilityofcertaindrugs,suchascimetidine,tolowertheacidsecretionthatoccursovernight(a
mechanismthatisthoughttobeamajorfactorinulcerogenesis).Smokingalsodecreases
salivationandcompromisestheintegrityofthegastrointestinaltract,includingitshealing
mechanisms,whichincreasesthelikelihoodthattheulcerwillperforateandrequiresurgeryto
repairitexactlywhathappenedtoMrs.Rodriguez.

3.
WhatroledoesH.pyloriplayinulcerdisease?
HelicobacterPylori
isagramnegativebacteriathatisresistanttotheacidicstateofthe
stomach.Itisresponsibleformostcasesofchronicinflammationofthegastricmucosaand
pepticulcer,gastriccancer,andatrophicgastritis.Theprimarycauseofpepticulcers,whichis
whatMrs.Rodriguezhas,is
H.Pylori
.

4.
FourdifferentmedicationswereprescribedfortreatmentofthispatientsH.pyloriinfection.
Identifythedrugfunctions/mechanisms.(Usetablebelow.)

Drug

Action

Metronidazole

antibacterial/antiprotozoalagentdecreasesGIdistress

Tetracycline

antibacterialagentproteinsynthesisinhibitor

Bismuthsubsalicylate

antacidandantidiarrhealtreatsstomachupsetandGIdiscomfort

Omeprazole

irreversibleprotonpumpinhibitorinhibitsacidsecretion

5.
WhatarethepossibledrugnutrientsideeffectsfromMrs.Rodriguezsprescribedregimen?
(Seetableabove.)Whichdrugnutrientsideeffectsaremostpertinenttohercurrentnutritional
status?

All
thesemedicationsshouldnotbetakenwithfood,asitcandecreasetheir
effectiveness.

Opremazole
inhibitionofacidsecretionmayinhibittheabsorptionofironandvitamin
b12.

Metronidazole
cancauseanorexia,GIupset,stomatitis,andametallictasteinmouth.

Bismuth

subsalicylate
bindswithprotein.ThismaybeproblematicforMrs.Rodriguez,
consideringherproteinlevelsarealreadyprettylow.

Tetracycline
maycauseanorexia.Also,itbindstoiron,magnesium,calcium,andzinc,
sotakingsupplementsalongwiththismedicationwillmakethemunabsorbable.This
medalsodecreasesbacterialproductionofvitaminKintheintestines.Itcancause
vitaminbdeficiencylongterm.CombinedwithvitaminA,tetracyclineincreasestherisk
ofbenignintracranialhypertension.Ontopofallofthat,itcancause
Clostridiumdifficile
pseudomembranouscolitis.

6.
Explainthesurgicalprocedurethepatientreceived.
MariareceivedaBillrothIIgastrojejunostomy.Inthisprocedure,upto75%ofthe
gastrinsecretingantrumisremovedfromthestomach.Theremainingstomachmaybeeither
reattachedtotheduodenum,inBillrothI,ortothesideofthejejunum,inBillrothII.
AnadvantageofBillrothIIisthattheduodenalstumpispreserved,allowingforthecontinued
flowofbileandpancreaticenzymesintotheintestines.


7.
Howmaythenormaldigestiveprocesschangewiththisprocedure?
Sincethegastriccontentsnolongeremptyintotheduodenum,itisdifficulttogetbileand
enzymaticproductstothechymeasitentersthejejunum.Thefactthattheduodenalstumpis
thereisagoodthing,becausethebileandenzymescanstillbeproducedandflowintothe
jejunum,buttheremaybesomeinefficiencysinceitwillnotgettothejejunuminstantaneously.
SincetheGItractcannolongerdigestlipidsandcarbsintheduodenum,andsincetheentire
smallintestineisnowshortened,therewillbesomedifficultywithabsorptionofmacronutrients
justbecauseoflesssurfacearea.Also,highsugarfoodsmaytriggerdumpingsyndrome.

II.UnderstandingtheNutritionTherapy
8.
Themostcommonphysicalsideeffectsfromthissurgeryaredevelopmentofearlyorlate
dumpingsyndrome.Describeeachofthesesyndromes,includingsymptomsthepatientmight
experience,etiologyofthesymptoms,andstandardinterventionsforpreventing/treatingthe
symptoms.

Earlydumpingsyndrome
ischaracterizedbyabdominalfullnessandnauseawithin
103minutesafterameal.Thisisduetoacceleratedgastricemptyingintothesmall
bowel,andthereforefluidshiftstofollowthecirculationintothebowel.

Latedumpingsyndrome
,whichoccursfrom1to3hoursafterameal,createsvascular
symptoms.Reactivehypoglycemiaoccurs,wheretheinsulinresponseissogreatthat
thepersonsbloodsugarisdrivendownintohypoglycemiclevels.Thepersonmay
experienceflushing,rapidheartbeat,faintness,andperspiration.Theymightwanttosit
orliedown,andmayfeelshaky,nervous,hungry,andlightheaded.

Dietarychanges
arethetypicalinitialmedicalintervention.Usuallythesechangesare
veryeffective!Theguidelinesfortheantidumpingdietincludesmaller,morefrequent
meals,lesssolidfoodsandmorecrushedfoods,lowfluidintakeduringmeals,fewer
simplesugars,morecomplexcarbohydrates,especiallyfoodswithsolublefiber,
increasedfatintake,andlactosefreefoodsifthepatientisexperiencingdumping
syndromeinpartduetolactoseintolerance.

9.
Whatotherpotentialnutritionaldeficienciesmayoccurafterthissurgicalprocedure?Why
mightMrs.Rodriguezbeatriskforirondeficiencyanemia,perniciousanemia,and/or
megaloblasticanemia?
Afterremovingapartoftheduodenum,Mariamaystillexperienceissueswith
malabsorption.Gastricacidnormallyreducesironcompoundssotheycanbeabsorbedonce
theyreachthesmallintestine,butsincelessacidisbeingsecretedinthenowsmallerstomach,
thereisalossofacidsecretion.Coupledwithashortertransittimefromstomachtojejunum,
Mariawillbeatriskforirondeficiencyanemia.Sincethegastricmucosaarereduced,theriskof
VitaminB12deficiencyalsogoesup.Intrinsicfactorisproducedbythegastriccells,soitmay
notbeproducedinsufficientenoughquantitiestofacilitateB12absorption.Thiscaninduce
perniciousanemia.SincebacterialovergrowthisanotherlikelysideeffectofBillrothII
gastrectomies,bacteriacanalsocompetefortheuseofthatB12anditmayneverbeabsorbed.
Thismaycauseamegaloblasticanemia.
Anadditionalriskfactorforanemiaisrelatedtorecurrence.Ifsheexperiencesanother
ulceranditleadstointernalbleeding,shewillbeasriskofdeficienciestothenutrientsfoundin
blood,suchasirondeficiencyanemia.
10.
ShouldMrs.Rodriguezbeonanytypeofvitamin/mineralsupplementationathomewhen
sheisdischarged?Wouldyoumakeanyrecommendationsforspecifictypes?Explain.
Mariamaybenefitfromprophylacticvitaminb12injectionsorsublingual
supplementation.Inaddition,agoodmultivitaminmaybebeneficial,especiallyonewithhigher
thannormallevelsofiron(oranironsupplementalone).

III.NutritionAssessment
11.
PriortobeingdiagnosedwithGERD,Mrs.Rodriguezweighed145lbs.Calculate%UBW
andBMI.Whichoftheseisthemostpertinentinidentifyingthepatientsnutritionrisk?Why?
Mrs.RodriguezspercentUBWis75.9%.Thismeanssheslost24.1%ofherbodyweightwithin
11months,averaging2%permonth.Thisputsherweightlossintheseverecategory,which
greatlyincreaseshernutritionalrisk.However,herBMIis20.2,whichputsherinahealthy
weightcategory.Ibelievethat%UBWisthemostpertinentanthropometricmeasurein

determininghernutritionalrisk,becauseitgivesusherchangeinweightovertime,notsimply
anassessmentofhercurrentweight.
12.
Whatotheranthropometricmeasurescouldbeusedtofurtherconfirmhernutritionalstatus?
IBWand%IBWmayalsobeusedtoconfirmhernutritionalstatus,aswellasbodyfatandlean
masspercentages.Itispossiblethatshehasexperiencedsomemusclewastingasapartofher
unintendedweightloss.
13.CalculateenergyandproteinrequirementsforMrs.Rodriguez.
Energy:
Accordingtheanempiricalformulaof2530kcalsperkilogramofbodyweight,Mrs.
Rodriguezsenergyneedshavearangeof12501500kcalsperday.
AccordingtothemoreaccurateMifflinSt.JeorEquation,withanactivityfactorof1.2accounting
forhersedentaryjob,thekcalssheneedstomaintainhercurrentweightareabout1360per
day.
Protein
:Mrs.Rodriguezsnormalneedsof.81.0g/kgwouldbearound4050gperday.
However,sincesheiscurrentlyincriticalcarerecoveringfromasurgery,ASPENguidelines
indicatethataproteinlevelof1.22.0g/kgwillbemoreappropriate.Basedonthatguideline,
Mariawouldneed60100gofproteinperday.
14.
Thispatientwasstartedonanenteralfeedingpostoperatively.Whattypeofenteralformula
isPeptamenAF?Usingthecurrentguidelinesforinitiationofnutritionsupport,statewhether
youagreewiththischoiceandprovidearationaleforyourresponse.
PeptamenAFisanenteralnutritionformuladesignedformalabsorptiveconditions.Mrs.
Rodriguezfitsrightinthisspotinhercurrentcondition.Shehashadanulcerinherduodenum
(partoftheabsorptivesmallintestine)forquitesometime,andhernutritionalintakehas
sufferedgreatlybecauseofthesymptomsassociatedwithit.Withan
H.pylori
infectionaffecting
theduodenumandcreatingulcerativelesions,theabsorptivecapacityoftheduodenalmucosa
hasbeendecreased.Forthosereasons,PeptamenAFhasenzymehydrolyzedwheyprotein
andMCToils,helpingabsorptiontofacilitateeasier.Anotherqualityworthnotingisits
lactosefreenaturesincegastricsurgerycansometimesimpairenzymefunctionforlactase,it
willbehelpfultohelpheravoidunnecessarysymptomsoflactoseintolerance.
15.
Whywastheenteralformulastartedat25mL/hr?

Mrs.Rodriguezneedsaround50mLofPeptamenAFperhourtoreachherneedsovera
24hourperiod.However,shehashadprolongedgastricdistressandhashadalowcaloric
intakeforthepastseveralmonthsasevidencedbya24%weightlossinlessthanayear.The
likelihoodthatshewillexperiencerefeedingsyndromeisfairlyhigh.Refeedingsyndromeis
potentiallylethal,soavoidingitisabsolutelynecessary.Therefore,ASPENrecommendations
aretobeginwith2550%ofthegoalfeedingconcentration,andmoveupslowlyfromthere,
guidingtheprogressionbasedonthepatientsreactionstothefeedings.ThisiswhyMrs.
RodriguezsENwasbeganat25mL,around50%ofhergoalfeeding.

16.
Isthecurrententeralprescriptionmeetingthispatientsnutritionalneeds?Compareher
energyandproteinrequirementstowhatisprovidedbytheformula.Ifherneedsarenotbeing
met,whatshouldbethegoalforherenteralsupport?
Thisformulameetsherenergyneedsthroughtheamountof50mL/hour.Hernormalprotein
requirementsare4050gdaily,buthercurrentproteinneedsaremuchhigher.Therefore,the
91gofproteinthatthecurrentENprescriptionprovidesfallswithintherecommendedintake,
thoughitisonthehigherside.TheadvantageofENproteinbeingonthehigherside,though,is
thatintheearlystagesoffeeding,whenwestartat25mLandifMrs.Rodriguezhasdifficulty
toleratingtheformula,herproteinintakewillbeclosertoadequate,evenifsheisonlytakingin
halfofwhatsheneeds.
17.
WhatwouldtheRDassesstomonitortolerancetotheenteralfeeding?
InordertomonitorMariastolerancetothefeedingformulaandschedule,itwouldbeimportant
toanswerthefollowingquestions:

Isherabdomendistendedorissheexperiencingdiscomfort?

Whatisherfluidintakeandoutput?

Doesshehavesignsorsymptomsofedemaordehydration?

Whatisherstooloutputandconsistency?Doesshehavemelenastool?

Labvaluestokeeptrackof:

Serumelectrolytes

BUN

Creatinine

Serumglucose,calcium,magnesium,andphosphorus

18.
Usingtheintake/outputrecordforpostoperativeday3,howmuchenteralnutritiondidthe
patientreceive?Howdoesthiscomparetowhatwasprescribed?
Mariareceived450mLofformulaonpostoperativeday3.Thisismuchlessthanwhatis
prescribedashergoalvolumeforfeedings,butbecauseherprescriptionwastobeginwith
smallerfeedingsof~25mL/hour,sheisclosetotarget.
19.
Asthepatientisadvancedtosolidfood,whatmodificationsindietwouldtheRDaddress?
Why?Whatwouldbeatypicalfirstmealforthispatient?
ForMariastransitionalfeeding,sheshouldgothroughastepwisedecrease.Itwillbeagood
ideatomovefroma24hrfeedingtoa12hourfeeding,thenan8hourformulaadministration,
onlyduringthenight.Doingnocturnalfeedingwillreestablishhungerandsatietycuesforduring
thedaytime.
Asafirstmeal,somethingisotonicandwithablandflavorwillbeeasilytolerated.Soupsor
cookedcerealssuchasoatmeal,creamofwheatorcreamofricearesuitableoptions.Sweetor
highfatfoodsshouldbeavoided.
Later,smallsolidmealsmadeoutoffoodsthatcaneasilybecutandchewedthoroughlyare
satisfactoryintroductorymeals,andwouldincludemeats,starches,andcookedvegetables.

20.
WhatotheradvicewouldyougivetoMrs.Rodrigueztomaximizehertoleranceofsolid
food?
Itisimportantthatshereintroducefoodsslowlyandwithcaution.Thefoodsthataggravatedand
contributedtoherulcerdiseaseshouldbeavoided,asshecanstillgetanotherulcer.Highly
spiced,fatty,highsugarfoodsmaynotbewelltoleratedinitially.Highprotein,moderatefat
foodsarewelltoleratedandrecommended.Smallmealsthroughoutthedaywithadequatefiber
intakewillhelpherpreventdumpingsyndrome.
21.
Mrs.Rodriguezaskstospeakwithyoubecausesheisconcernedabouthavingtofollowa
specialdietforever.Whatmightyoutellher?
Iwouldsaysomethingalongtheselines:
Youwillbeabletoeatregularmealssoon,andyouwillnotbeontubefeedforever!Thereare
manypeoplewhohaveexperiencedexactlywhatyouareexperiencingrightnow.Infact,

around1in10peoplestrugglewithH.Pyloriinfectionatsomepointintheirlives.Beingscared
aboutthefutureoutcomeisnormal.WhatIcantellyouisthatsinceH.pyloriisthecauseof
theseulcers,wearenowdoingeverythingtoeradicatethebacteria.Thetreatmentmeasures
thedoctorshaveprescribedtoyou,andthedietaryguidelineIwillgiveyou,havehadalotof
successwithmanyotherpatients.Forthatreason,weuseitasourstandardprocedure.Yes,
youwillneedtochangeyoureatingpatternsforsomethings,butmuchofyournormaldietcan
remainthesameandyoucandefinitelyeatyourfavoritefoodsagain.Moderationwillhelpyou
enjoyfood,preventfurtherulcers,andfeelhealthier.
22.
Usingheradmissionchemistryandhematologyvalues,whichbiochemicalmeasuresare
abnormal?Explain.

BUNandBUNtoCreatinineratio(bothhigh)

Bilirubin,totalanddirect(bothhigh)

Totalprotein,albuminandprealbumin(alllow)

WBCcount(high)

Hemoglobinandhematocrit(bothlow)

Meancellhemoglobinandmeancellhemoglobincontent(bothlow)

Lymphocytes(low)

Segs(high)

a.Whichvaluescanbeusedtofurtherassesshernutritionalstatus?Explain.
Totalprotein,albuminandprealbumincanbeusedtohelpassesshernutritionstatus.Thefact
thatthesearelowtellusshemaybeundernourishedfromthemanymonthsofinadequate
intake.Hemoglobinandhematocritarealsorelatedtomalabsorptionandmalnutrition.
b.Whichlaboratorymeasures(seelabresults,pages8485)arerelatedtoherdiagnosisofa
duodenalulcer?Whywouldtheybeabnormal?
HerWBCcountisup,possiblyduetoher
H.pylori
infection,butdefinitelyasaresponsetoher
surgery.Segsareelevated,probablyduetoinflammation.Bilirubinishighbecauseitisstaying
incirculationinsteadofbeingexcreted.Also,ifherulcerwasbleedingalotshemayhavelost
albuminandprealbuminifherulcerisbleeding.

23.
Doyouthinkthispatientismalnourished?Ifso,whatcriteriacanbeusedtosupporta
diagnosisofmalnutrition?UsingtheguidelinesproposedbyASPENandAND,whattypeof
malnutritioncanbesuggestedasthediagnosisforthispatient?
IbelievethatMrs.Rodriguezismalnourished.Shehashadinsufficientenergyintakeformonths
duetoherdifficultieswitheatingassociatedwithGERDandulcerdisease.Someofthatweight
losshaslikelycomefrommusclemass.Ithinkitisappropriatetocategorizeherasmoderate
malnutrition.
IV.NutritionDiagnosis
24.
SelecttwonutritionproblemsandcompletethePESstatementforeach.
#1)Insufficientenergyintakerelatedtodifficultyeatingsecondarytoulcerdisease,and
malabsorptionprimarytoulcerdisease,asevidencedbyunintendedbodyweightlossof24%
within11months.
#2)AlteredGIfunctionrelatedpostoperativeconditionasevidencedbycompleted
gastrojejunostomysurgery.
V.NutritionIntervention
25.
ForeachofthePESstatementsthatyouhavewritten,establishanidealgoal(basedon
thesignsandsymptoms)andanappropriateintervention(basedontheetiology).
#1)
Goal:
MaintaincurrentbodyweightatIBW(110lbs).
Intervention:

EnteralNutritionRate,Volume,andSchedule(ND2.1.35):
Gradually
increaseENformulafeedaccordingtoprescribedrateof50mL/hourtoprovide1450
kcalsand91gprotein.
CompositionofMealsandSnacks(ND1.2):
WhenweanedoffofEN,solidfoodmeals
shouldprovideroughlythesameamountofkcalsperday,thoughproteinneedswill
decreaseslightly.
#2)
Goal:
FollowingnutritionrestorationviaENandupondischarge,preventmalnutrition
recurrenceasaconsequenceofgastrectomy.
Intervention:

NutritionEducationContent:Nutritionrelationshiptohealth/disease

(E1.4):
Providenutritioneducationsothatpatientunderstandswhichnutrientssheisat
riskofdeficienciesofandwhichfoodstheobtainthosenutrientsfrom.

26.
Whatnutritioneducationshouldthispatientreceivepriortodischarge?
Asstatedabove,Mrs.Rodriguezshouldreceiveeducationonwhichnutrientssheisatriskof
deficienciesof,andthefoodsshecaneatthathavethosenutrients.Sheshouldalsobe
educatedonthefoodsthatcantriggeroraggravateGERDandulcersandincreasethe
likelihoodofarecurrentH.pyloriinfection.Providingsometakehomereferences,alongwitha
samplemealplanbasedonfoodsshestatesshelikes,maybenefitherlongtermadherence.
27.
Doanylifestyleissuesneedtobeaddressedwiththispatient?Explain.
Mrs.RodriguezhasafewlifestylefactorsthatcontributetoGERDandherdevelopmentof
ulcers.HercoffeeandsodaintakeislikelytocontinuetoirritateherGItractandtriggerGERD
symptoms.Therefore,itisvitalthatsheworkonreducingherconsumptionofthesebeverages.
Secondly,stressisalargecontributingfactortothedevelopmentofulcers,sosheneedsto
workoncopingwiththestressorsinherlife.Thelossofalovedonecanbeextremelytraumatic,
soIbelievethatapsychologicalconsulttodiscussheroptionsformentalhealthcaremay
benefither.Iwouldcoordinatecaretoreferhertoapsychologist.Thirdly,shewillneedtotweak
hereatingpatternsandtimingtobettersuitheralteredGItract.Smaller,morefrequentmeals
andadietrichinfruitsandvegetableswillhelpmaximizenutrientintakeandabsorption,aswell
asdecreasethelikelihoodofexperiencinganyunpleasantsideeffectssuchasdumping
syndrome.Lastly,Mrs.RodriguezsuseoftobaccoishurtingheroverallhealthandherGItract.
Itisvitalthatshequitsmoking.Iwouldreferhertoasmokingcessationprogram.