Gastric Cancer
description
Transcript of Gastric Cancer
GASTRIC CANCERBy Heidi Thomason, RD Intern
POSSIBLE GASTROINTESTINAL BLEED
Mr. Anderson91 year old patient admitted with
intermittent epigastric pain for previous 6 months
Weight loss of 40 lbs. CT showed thickening of gastric
wall Stool positive for occult blood Pre-op labs revealed anemia (8.5
Hgb), requiring blood transfusion
Anthropometrics: Wt: 133#/60.6kg (10/30/13 – bed scale) Ht: 65” (stated by pt.) IBW: 136#/62kg %IBW: 98% UBW: 173#/79kg, 77% UBW 23% loss in body wt. in 6 mos. = Severe wt. loss
Lab results 10/30/2013: Alb: 2.7 – Critically Low H/H: 8.1/24.9 – Critically Low BUN/Cr: 28/1.26 - High Na/K: 140/4.1 - Normal Cl: 108 – High
PHYSICAL ANTHROPOMETRICS & BIOCHEMICAL RESULTS
MEDICAL HX. OF MR. ANDERSON Medical History:
Atrial fibrillation Hypertension Hypogonadism Hypothyroidism Benign prostatic
hyperplasia Hx. Of pericarditis
Surgical History: Pacemaker Appendectomy Craniotomy Various ortho. surgeries
Current Medications Sotalol (Beta-blocker)
40mg 2x/d Niferex (Fe) 150mg
2x/d MVI 1/d Testosterone 100mg/d
Social Hx: Nonsmoker No drug or EtOH use Lives independently 2 sons who are MDs
FOOD - MEDICATION INTERACTIONS Sotalol (beta-blocker) decreases food
absorption by 20%, must be taken separately from Mg, Ca, and Al.Can cause wt. changesCan cause N/V/D, abdominal pain,
flatulence In DM pts, can cause a prolonged
hypoglycemia response Niferex (Ferrous salts – elemental iron)
Can cause stomach upset, N/V/D, occult fecal blood, anorexia
High doses may decrease Zinc absorption
NORMAL INTAKE & NEEDS Usual intake:
Unable to assess usual intake or preferences due to delerium and altered mental status until RD consult was done four days after admission.
Needs:Using IBW of 136 lbs./62kg
Calories: 62kg x 25-30kcals = 1550-1860kcals/day
Protein: 62kg x 1.2-1.5g (GIB, anemia, low Alb) = 75-93g protein/day
Fluids: 62kg x 25+ml (cardiac pt.) = 1550ml H2O/day
FIGURING OUT THE PROBLEM
2 units RPBC transfusion done, PET scan scheduled
Esophagogastroduodenoscopy (EGD) & CT done Showed an ulcerated mass lesion on the
anterior wall of the gastric antrum Biopsy revealed adenocarcinoma of the distal
stomach Hemi-gastrectomy scheduled
Adenocarcinoma cells
PRE-OP NUTRITION DIAGNOSIS 10/30 Unintended wt. loss (NC-3.2) related to
GIB AEB reported loss of 40 lbs./23% loss of body weight.
Altered nutrition-related laboratory values related to gastrointestinal bleeding, anemia AEB low albumin and low H/H.
PROGRESS NOTE Hemi-gasrectomy done; S/P resection of
adenocarcinoma of the distal stomach Postop delerium Tachycardic – uncontrolled atrial fibrillation Renal function improved (BUN: 6 – Low) WBC high (13.4) H/H improved but still low (34.3/11.4)
G-tube placed when partial gastrectomy done
RESECTION OF THE DISTAL STOMACH NPO status initially for 3 days – in the
ICUNo BM for 4 days, hypo BS, flatus absent
Tube feed ordered, RD consult orderedTF of Fibersource HN @ 20ml/hr initiated to
provide: 576kcal, 26g protein, 389ml free H2O per MD order
ADAT to goal rate of 60ml/hr to provide: 1728kcals, 78g protein, 1166ml free H2O
RD CONSULT
RD consult provided: No known food allergiesNo food intolerancesNo difficulty chewing or swallowingNo food preferencesRegular diet followed at homeUsual appetite is goodSkin integrity: abdominal wound, shoulder
contusion, no edema
NEW DIAGNOSIS POSTOP 11/3 Altered GI function related to gastric
cancer AEB NPO since 11/1/13, no BM since 10/31, and TF ordered.
Altered nutrition-related laboratory values related to gastric adenocarcinoma, GIB AEB low Alb, low H/H.Future Topics to Discuss
Postop gastrectomy diet
NUTRITION REASSESSMENT 11/4 TF stopped and TPN ordered.
TPN of Clinamix E 5/15 with standard daily lipids ordered @ goal rate of 80ml/hr to provide: 1776kcals, 80g protein
Recommend: Monitor closely for signs of refeeding syndrome due to
severe wt. loss Labs daily per TPN order Daily wts. per TPN order Clear liquid to regular diet when medically possible
Goals: Meet nutritional needs, no GI distress, PO>75%, adv. diet, gradual wt. gain, wound healing, bowel regularity, incr. Alb/Prealb., BG <160mg/dL on TPN.
M/E: Will monitor I&O’s, labs, PO intake, tx. plan, skin.
NUTRITION REASSESSMENT 11/7 TPN running @ goal (Clinamix E 5/15 @ 80
ml/hr) Wt: 59kg (standing scale 11/6), I&O’s
variable, 3+ edema. LBM 11/5, hypo BS, flatus absent
Skin: surg. wound improving, no further breakdown
Meds: Pain meds, Biaxin & Flagyl (abx.), Nitro, Protonix, Sotalol. PRN Zofran, MOM
Labs: 11/6 – Alb/Prealb:1.7/105L, BG:122H, BUN:22H, K:3.3L, CR/NA/CL/P/MG/WBC/TRIG: WNL
NUTRITION REASSESSMENT 11/7
Recommend: Monitor closely for signs of refeeding syndrome
due to severe wt. loss Labs daily per TPN order Daily wts. per TPN order Clear liquid to regular diet when medically
possibleGoals: Meet nutritional needs, no GI
distress, PO>75%, adv. diet, gradual wt. gain, wound healing, bowel regularity, incr. Alb/Prealb., BG <160mg/dL on TPN.
M/E: Will monitor I&O’s, labs, PO intake, tx. plan, skin.
NUTRITION REASSESSMENT 11/11 Full liquid diet & supplement of Ensure
ordered in addition to TPN; PO Intake = 0-25%, Suppl. Intake = 25-50%. Labs: 11/11 – Alb:1.9L, BG:138H, BUN:31H,
Na:130L, H/H:27.5/9L Accuchecks 11/9-11/11: 111-152mg/dL
Diagnosis: Altered GI function related to gastric cancer
AEB TPN and full liquid diet ordered. Altered nutrition-related laboratory values
related to GIB, metabolic stress, TPN Rx AEB low Alb., low Prealb, low H/H, high BG at times
NUTRITION REASSESSMENT 11/11 Recommend:
Continue current diet orders, consider decreasing to 40ml/hr to increase PO intake; adv. diet as able.
Daily labs per TPN order Daily wts. per TPN order
Goals: Meet nutritional needs, no GI distress, PO>75%, adv. diet, gradual wt. gain, wound healing, bowel regularity, incr. Alb/Prealb., BG <160mg/dL on TPN.
M/E: Will monitor I&O’s, labs, PO intake, tx. plan, skin.
NUTRITION NOTE 11/16 Pt. transferred to Vibra LTAC
TPN continued and PO order setsHelicobacter pylori infectionAnemiaFunctional Decline
Nutritional Level: High
NUTRITION ASSESSMENT 11/17 Admitting Diagnosis: Gastric cancer Nutrition screen consult: TPN
PES: Altered nutrition-related laboratory values related to gastric cancer, anemia, GIB AEB low Alb, low H/H.
Intervention: TF not tolerated well since initiation, currently on
hold. Current TPN of Clinamix E 5/15 meets 100% of estimated needs (1776kcals, 80g protein). Alb/Prealb remains low and significant wt. loss since admission was d/w MD.
RD ASSESSMENT 11/17 Recommend:
Continue TPN order; adv. diet as medically possible when pt. can tolerate TF @ goal rate
Daily wts. and labs per TPN order Advance TF of Fibersource HN to goal rate of 60ml/hr as
medically possible Prealbumin labs q week on TF once TPN DC’d SLP to follow for possible diet advancement If PO diet possible, recommend regular diet (texture per
SLP) Diet Education: N/A due to confusion. Will monitor for
education needs PRN. Expected outcome/goals:
Support nutrition needs, utilize GI as able, incr. Alb/Prealb to wnl, post-op wound healing, no significant wt. loss/gradual wt. gain
REASSESSMENTS & FINAL RESULTS Pt. continued to have N/V and never
tolerated PO diet well. He stayed at Vibra for two weeks and multiple attempts to use a TF formula were never met.
On 11/30, he went to SRMC to get a PEG tube placement, but did not do well S/P. He failed a swallow eval. done on 12/4 and was never able to tolerate a TF. He eventually was changed to comfort care and DNR code status. His TPN was DC’d on 12/10 and he expired on 12/19.
MAINTAINING NUTRITIN IN POST GASTRIC CANCER PATIENTS According to journal articles, critically ill
patients are hypermetabolic and maintaining nutrition is difficult and necessary for their survival1&2. Mr. Anderson’s complications with his h.
pylori infection made it nearly impossible to feed him. If an PEJ tube had been placed earlier, he may have tolerated a TF better.
The number of successful patients fed post-pyloric TF’s after a gastric resection are high.
REFERENCES Boulton-Jones J.R., Lewis J., Jobling J.C., Teahon K.
(2004). Experience of post-pyloric feeding in seriously ill patients in clinical practice. Clinical Nutrition. 23, pp.35-41.
Nelms M, et al, (2011). 'HIV and AIDS'. In: (ed), Nutrition Therapy and Pathophysiology. 2nd ed. : Wadsworth Cengage Learning. pp.735-770
Pagana K., Pagana T. (2010). Mosby’s Manual of Diagnostic and Laboratory Tests.4th ed.: Elsevier Inc.
Zhu X., Wu Y., Qiu Y., Jiang C., Ding Y. (2013). Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy. World Journal of Gastroenterology. 19(35), pp.5889-5896.