Carly RichterMatuszakKNH 4137 February 2016

Case Study: Peptic Ulcer Disease Resulting in Gastrectomy

Part I:

1. List all the food items that may contribute to GG’s condition and explain why.

GG’s consumption of fast foods with high fat content, fried foods, and frozen meals may have contributed to her condition. Poor nutrition and poor health have been suggested to contribute to the severity of symptoms that GG may be experiencing, and also may slow the healing process (Krause, 2017, pg 516).

2. List any additional oral intake that may have contributed to GG’s condition and explain why.

Alcohol and her caffeinated coffee beverages could have contributed to GG’s condition (Nelms, 2016, pg 366). Her alcohol and NSAIDs consumption are known to inhibit prostaglandin synthesis, which is necessary for protecting the bicarbonate and mucus barrier that lines the stomach. Therefore, these substances could have compromised her mucosal integrity and thus, contributed to her gastritis (Krause, 2017, pg 516). Additionally, smoking can also decrease mucosal integrity, similarly to NSAIDS.

3. List the non-oral stimulants (physical or psychological stress) that could contribute to GG’s condition and what she could do to change them.

The stress that GG is dealing with involving her son’s ADHD and working part-time while also going back to school to support her son could be contributing to GG’s condition (Krause, 2017, pg 517). In order to reduce or manage her stress, GG can meet with a counselor or psychiatrist in order to work through her issues.

4. List the symptoms of GG’s gastritis.Common symptoms of gastritis include the following: bleeding, abdominal

pain, belching, vomiting, and anorexia (Nelms, 2016, pg. 366). Symptoms that GG experienced due to her gastritis were stomach pain following meals, pain in her RLQ, burning sensation, and stress headaches.

5. Was a bland diet necessary? Explain and list the principles of the diet plan that you think GG should follow.

I do not think that the bland diet was necessary for GG’s condition. There is very little evidence that demonstrates how dietary factors may exacerbate PUD. However, some patients may have discomfort after consuming acidic foods, but these foods are not likely to interfere with healing or cause ulcers. It is important that these patients consume a nutritionally complete, high-quality diet with a wide

variety that can, in turn, promote healing. GG should be advised to avoid foods that worsen her symptoms (Krause, 2017, pg 519).

6. What is the mechanism of action of the following medications GG is receiving: Carafate, AlternaGel, and Pepcid?

Carafate is a medication that works to prevent the return of ulcers by attaching itself to damaged ulcer tissue and protects from acid damage in order for healing to take place. AlternaGel is used in order to relieve pain due to peptic ulcers or heartburn, and to promote healing of those ulcers. Pepcid can be taken in order to prevent and treat heartburn by decreasing the amount of acid produced in the stomach. Pepcid falls under a category of medications known as H2 blockers (MedlinePlus, 2017).

7. List the nutrient-drug interactions that are associated with these medications.

If taking an antacid in addition to Carafate, antacids should be taken 30 minutes before or after Carafate is taken. Aside from that, a normal diet can be continued while taking Carafate. AlternaGel may interfere with other medications, but those are not specified (Medlineplus, 2017). Finally, Pepcid has the ability to decrease absorption of iron and vitamin B12, and a supplement may need to be taken (Krause, 2012, pg. 1105).

Part II:

8. What are GG’s IBW and percent IBW?IBW= 100 + (5 X 2) = 110 lb

% IBW = (98 / 110) X 100% IBW = 89%

Based off of her height and gender, GG’s IBW is 110 lb. GG is currently 89% of her ideal body weight.

9. Estimate her daily energy needs using the Harris-Benedict equation and appropriate stress factor.

REE= 655 + (9.56 X wt (kg)) + (1.85 X ht (cm)) – (4.68 X age)REE=655 + (9.56 X 44.5 kg) + (1.85 X 157.5 cm) – (4.68 X 27)

REE = 1245 kcal X PAEnergy needs 1245 kcal X 1.2

Energy needs = 1495 kcal/dayUsing the Harris-Benedict equation, GG’s estimated energy needs are 1450-

1500 kcal/day.

Part III:

10. What might be the cause of the LUQ pain along with her usual pain? (Consider the enzymes that are elevated)

According to her laboratory results, her aspartate aminotransferase (ALP) levels were elevated at 122 U/L where the normal range is 25-100 U/L. This elevated level could be indicative of poor liver function. Due to GG’s recent heavy drinking habits, her liver is most likely overworked which is why her ALP levels are elevated. Therefore, GG’s heavy drinking might be the main cause of the LUQ pain that she has been experiencing (Krause, 2012, pg. 1096).

11. In the second set of lab values, glu, BUN, Cr, ser alb, Na, K, Cl, hgb, and hct all dropped. This probably means that GG was:

a) Bleedingb) Eating poorly in the hospitalc) Dehydrated when the first labs were drawnd) Over hydrated when the second set of labs was drawn

Low hct and low hgb levels indicate bleeding (Nelms, 2016, pg. 364).

12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This probably means that:

a) Enzymes were elevated due to alcoholb) Her medications caused them to dropc) GG was dehydrated when the first labs were drawnd) GG was over hydrated when the second set of labs was drawn

These enzyme values have been shown to be affected by alcohol and increased levels can be attributed to large amounts of alcohol consumption (Krause, 2012, pg. 1096)

13. Refer to the two lab tables again, and note that two days after admission, GG’s Alk, Phos, and CPK remained essentially unchanged. Why?

a) These enzymes are not affected by alcohol or hydrationb) Her medications caused them to dropc) Dehydrated when the first labs were drawnd) Over hydrated when the second set of labs was drawn

14. What diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?An endoscopy and biopsy are diagnostic tests that can confirm the presence

of H. pylori. Other diagnostic tests include urea breath test (BUT) and ELISA, which were both positive and indicated H. pylori (Nelms, 2016, pg. 366)

15. Briefly sketch the anatomical position where GG’s ulcer can be found.

16. Define:a) H2 antagonist: Medications that reduce stomach acid secretion by glands in the stomach lining (Medline, 2017).b) Proton pump inhibitor: A proton pump inhibitor is a type of medication that functions to inhibit acid secretion by blocking the H+, K+ -ATPase enzyme (Nelms, 2016, pg 218). Some common names of proton pump inhibitors include the following: esomeprazole, pantoprazole, and omeprazole (Krause, 2017, pg. 512).

17. What is the mechanism of action of the following medications GG is receiving: Nexium, amoxicillin, and clarithromycin?

Nexium treats GERD , works to prevent the development of ulcers, and also treats the return of ulcers. Nexium is a proton pump inhibitor that decreases the amount of stomach acid produced. Amoxicillin works by inhibiting the bacterial growth, and can be used with other medications to rid patient of H. pylori. Clarithromycin works similarly and is taken to stop the growth of bacteria. Clarithromycin falls in a class of medications known as macrolide antibiotics (Medline, 2017).

Part IV:

18. GG was not receiving counsel at the time the major bleeding started. If you had the opportunity to counsel GG just before the bleeding, in what areas would you feel competent to counsel her and in what areas would you refer her to someone else? Investigate the agencies in your area that are available to provide assistance to someone like GG.

If I had the opportunity to counsel GG before her bleeding occurred, I would feel competent in to help GG determine which foods she tolerates and which foods may exacerbate her symptoms, educating the patient on foods that may irritate the gastric mucosa, timing of meals, how to interpret laboratory results, and also educate her on medication nutrient interactions. I would refer GG to a counselor or psychiatrist to help manage her stress and relationship/financial problems.

19. What is the significance of the dark stools?Dark stools, also known as melena, can be a sign of a serious health problem

such as GI bleeding (Krause, 2017, pg. 517).

20. Give the pathophysiology for the cause of the following abnormal values: BUN, NH3, and WBC.

BUN is a measurement of urea nitrogen present in the blood. Thus, GG’s high BUN levels may be due to the patient’s dehydration. Her high ammonia levels could be due to impaired liver function, which could be attributed to the patient’s alcoholism. Her high WBC levels could be attributed to the fact that GG is fighting an infection.

21. GG was probably dehydrated on admission since she had been drinking. This means that some of her lab values were probably higher/lower (circle one) than indicated.

When dehydrated, there is a deficit of water in the body, and therefore, the concentration of electrolytes is greater.

22. After admission GG received packed cells and IV fluids. How would that affect the next set of lab values?

After GG received packed cells and IV fluids, she should become rehydrated and her next laboratory values that were high due to dehydration will return into the normal range. Additionally, her low Hgb and Hct levels will increase due to the packed cells.

Part V:

23. Define the following terms:a) Packed cells: Concentrated red blood cells separated for blood transfusion.b) Abdominal tap: A procedure involving the removal of fluid from the abdominal cavity.c) Perforated ulcer: An ulcer that protrudes through an organ wall.

d) Fistula: a passage connecting an organ to another organ, wound, or skin (Nelms, 2016, pg G-9).e) Exploratory Laparotomy: A surgical procedure to view the organs within the abdominal area.f) Billroth I: Billroth I, or a gastroduodenostomy, is the removal of the pylorus and/or antrum, along with an anastomosis of the end of the duodenum to the distal end of the stomach (Krause, 2017, pg 520).g) Vagotomy: surgical procedure that involves severing of the vagus nerve (Nelms, 2016, G-23).

24. Sketch a Billroth I.

25. Compare a Billroth I to a Billroth II as to anatomical changes as well as to dietary changes, if any.

Billroth I, also known as gastroduodenostomy, is a partical gastrectomy procedure that involves an anastomosis of the proximal end of the duodenum to the distal end of the stomach. In contrast, Billroth II or a gastrojejunostomy, is a partial gastrectomy that involves an anastomosis between the proximal end of the jejunum to the distal end of the stomach. In the Billroth II, a blind loop of the duodenum is made (Nelms, 2016, pg. 368). Both procedures will require the patient to adhere to a post gastrectomy diet.

26. Calculate GG’s energy and protein needs.

Protein needs: 1.5 gm per kg body weightProtein needs = 1.4 gm X 44.5 kg

Protein needs = 62 gmEnergy needs = 1245 kcal X 1.4

Energy needs = 1743 kcal

GG should consume 62 grams of protein per day in order to help with recovery from surgery. GG’s energy needs should increase since she is postoperative so a stress factor of 1.4 was used to determine that she should consume 1700-1800 kcal/day. Although it may be difficult for GG to consume this amount postoperatively, she should aim to consume this level of calories as her diet progresses back to normal. Also, it is important that she tries to consume as close to this value of calories per day as possible through small meals in order to support her energy needs postoperatively. 27. List the principles of a post-gastrectomy diet and briefly describe the scientific basis for each principle.

Resection of the stomach can put the patient at nutritional risk due to malabsorption, maldigestion, and decreased oral intake. The post-gastrectomy diet is also known as the “antidumping” diet and encourages a diet slightly higher in protein and fat than what the U.S. Dietary Guidelines recommend. It is important to avoid simple sugars in order to prevent hyperosmolality and hypoglycemia, which are both associated with dumping syndrome. Additionally, lactose is not tolerated in many cases, so calcium and vitamin D supplements can be recommended. Liquids are to be consumed in between meals since they promote quick movement through the small intestine. The patient should consume 6 small meals per day (Nelms, 2016, pg. 369).

28. Is it possible that GG’s diet will ever change or do you believe she will be on a post-gastrectomy diet for the rest of her life? Explain.

GG must begin consuming liquids and progress to consuming semi-solids and eventually solid foods. It is crucial that she begins with small feedings and progresses slowly to avoid dumping syndrome. If she slowly adds back in foods in small increments, she will be able to eventually return to her normal diet (Nelms, 2016, pg. 369).

Additional Questions:

29. If GG were to be hospitalized for an extended period of time and required a tube feeding via duodenum or jejunum, what characteristics would be appropriate for the tube feeding you would use?

GG’s tube feeding diet should be similar to her suggested oral diet. Her tube feeding should be a hydrolyzed formula that includes a high protein, low carbohydrate, lactose-free diet that is energy dense. Additionally, feedings should be small to ensure the patient is able to tolerate the tube feedings (Nelms, 2016, pg. 92).

30. Using the table below, compare several of the enteral nutritional supplements that would be appropriate for GG.

Product Producer

Form Cal/ mL

Pro (g/ L)

CHO (g/ L)

Fat (g/ L)

Na mg

K mg

mOsm / kg water

Vol to meet RDA in ml

G of fiber / L

Free H2O /L in mL

Promote

Abbott liquid 1 62 130 25 340 1000 838

Crucial Nestle liquid 1.5 93 136 68 510

480 490 1000 774

References:

Drugs, Herbs, and Supplements. (2017). Medline Plus. Retrieve from https://medlineplus.gov/druginfo/meds

Krause, Mahan, K., Escort-Stump, S., & Raymond, J. (2017). Krause's Food and the Nutrition Care Process (14th ed.). St. Louis, MO: Elsevier.

Nelms, M., Sucher, K., & Lacey, K. (2016). Nutrition Therapy and Pathophysiology (3rd ed.). Boston, MA: Cengage Learning.