Jang, Helen
DFM 485
2/17/15
Case Study #1: Case 7 (GERD)
Answer the following questions:
1. How is acid produced and controlled within the gastrointestinal tract?
Gastric acid secretion contains three phases: the cephalic phase, the gastric phase,
and the intestinal phase. The cephalic phase occurs when there is the anticipation
of eating food thus sending signals to the brain to release HCl and pepsinogen.
The gastric phase is activated when there is food in the stomach producing HCl.
Gastric acid is produced by parietal cells in the lumen and maintained by the
proton H+/K+ pump. The pump releases H+ ions for K+ ions, then secreting both
K+ and Cl-, therefore ultimately producing HCl. Both cephalic and gastric are
stimulatory phases in which they produce secretions. The intestinal phase slows
down gastric secretions and prepares chyme in the small intestines. The
accumulation of acid, presence of fat, and distension of the stomach increases the
osmolality of the food resulting in the release of two hormones which are used to
slow down gastric motility: cholecystokinin and secretin. These hormones inhibit
the action of the chief and parietal cells, reducing the overall amount of gastric
juices.
This is all controlled through the nervous and endocrine system with four
chemical messengers: acetylcholine, histamine, gastrin, and somatostatin.
Acetylcholine is a neurotransmitter that stimulates parietal, chief, and ECL cells.
Gastrin stimulates parietal and ECL cells to release histamine. Histamine tells
parietal cells to increase HCl release. Lastly, somatostatin works by negative
feedback to slowly decrease gastric secretions when pH drops and becomes too
acidic.
2. What role does lower esophageal sphincter (LES) pressure play in the etiology of
gastroesophageal reflux disease (GERD)? What factors affect LES pressure?
The LES is a small ring muscle that works as a shut off barrier between the
esophagus and the stomach. Under normal conditions, the atmospheric pressure in
the esophagus is greater than that in the stomach, preventing the return of stomach
contents back up the esophagus. GERD is a digestive disorder that occurs when
the LES is weak or relaxes inappropriately causing the chronic reflux of stomach
contents. Foods that relax LES pressure include peppermint, spearmint, chocolate,
coffee, alcohol, and foods high in fat. Foods that may increase gastric acid
secretions, therefore contributing to GERD, include both regular and decaf
coffees, alcohol, and pepper.
Avoiding high fats and large meals, losing weight, smoking, and decreasing
esophagus irritants such as citrusy foods, spicy foods, and tomato products are
some ways to help manage GERD.
3. What are the complications of GERD?
Symptoms from GERD are dysphagia, heartburn, increased salivation, and
belching. In some cases, GERD can lead to severe pain in the back, neck, or jaw,
which can worsen when lying down. Untreated GERD can lead to complications
such as impaired swallowing, aspiration of gastric content into the lungs,
ulcerations, and constriction of the esophagus. A serious complication from long
term or refractory GERD is Barrett’s esophagus, where the tissue lining of the
esophagus changes to intestinal tissue. This occurs in approximately 10% of all
GERD patients. Having Barrett’s esophagus puts you at a higher risk for
adenocarcinoma of the esophagus.
4. The physician biopsied for H. pylori. What is this?
H. Pylori, helicobacter pylori, is a type of bacteria that can live in the mucosal
layer of the stomach. This bacterium has the ability to break down urea to produce
ammonia, which neutralizes acid around the area. It can also cause persistent
inflammation and ultimately damage the mucosal lining of the stomach.
5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
GERD.
The patient is showing symptoms of indigestion and continues to consume high
fat meals, which stays in the stomach longer and lowers LES pressure,
exacerbating the symptoms of GERD. His recent weight gain and BMI also
concludes that he is obese which is highly linked to worsen GERD symptoms.
6. What risk factors does the patient present with that might contribute to his
diagnosis? (Be sure to consider lifestyle, medical, and nutritional factors.)
The patient does not do much physical activity except play with his children on
the weekends. He continues to eat and drink more even after a 35-pound weight
gain after his knee surgery a few years ago. His diet recall shows he regularly
consumes high fatty meals, which exacerbates his GERD. Overall, his risk factors
include complaints of constant indigestion, his weight gain, his overconsumption
of foods and alcohol, and his family history of heart disease, which has led to
increased distress.
7. Summarize the current nutrition and lifestyle recommendations for nutrition
therapy for GERD.
To decrease the frequency and volume of the reflux, it is recommended to elevate
the head by 30 degrees while laying down, being upright for three to four hours
after eating, eating small and frequent meals, losing weight if overweight,
separating liquids from meals, and avoiding foods or activities that can cause pain.
There are also pharmacological treatments of GERD such as proton pump
inhibitors, antacids, histamine receptor antagonists, and prokinetics. Proton pump
inhibitors work by inhibiting the proton pump in the parietal cells; therefore,
decreasing acid production in the stomach. Antacids work by increasing stomach
pH, decreasing acidity. Histamine receptor antagonists also decrease acid
secretions. Lastly, prokinetics help control GERD by strengthening the LES,
increasing the stomach motility and gastric emptying allowing less time for acid
to occur.
8. Calculate the patient’s %UBW and BMI. What does this assessment of weight tell
you? In what ways may this contribute to his diagnosis?
%UBW: current body weight/ usual body weight x 100
215 / 180 x 100 = 119%
BMI: lbs / (in x in) x 703
215 / 4761 x 703 = 31.75 BMI (Obese)
Mr. Nelson is 119% of his usual body weight and is currently obese with a BMI
of 31.75. People that are obese are more likely to develop GERD and experience
worse reflux symptoms. Mr. Nelson’s exacerbation of GERD symptoms can be
due to his recent weight gain because BMI is strongly linked to GERD.
9. Calculate energy and protein requirements for Mr. Nelson. How would this
recommendation be modified to support a gradual weight loss? Use Mr. Nelson
actual current weight and the Mifflin St. Jeor Equation to calculate his energy
needs.
(Mifflin-St. Jeor = 10W + 6.25H – 5A + 5)
Basal Metabolic Rate: 10 (97.7kg) + 6.25 (175.26cm) – 5(48) + 5 = 1837 kcal
Total Daily Energy Expenditure: 1937.38 kcal x 1.2 activity factor = 2205 kcal
Protein: 0.8g/ kg = 78.17g = 78g protein
If the patient tries to do a gradual weight loss of reduction of 250kcals a day, to
around 1955kcal, he can lose half a lb a week. If he wants to take it further, he can
do a reduction of 500kcals to 1705kcal a day, he can lose one lb a week. Since his
usual weight before the 35lb weight gain is 180lbs. He can reach his usual 180 lbs
again in 35 weeks, about 9 months, if he reduces his normal calorie intake by
500kcals a day. He can also reach 180 lbs in 75 weeks, about 18 months, if
reducing his normal calorie intake by 250kcals a day.
10. Identify pertinent nutrition problems and corresponding nutrition diagnoses and
write at least two PES statements for them.
Elevated triglycerides levels related to lack of nutrition knowledge and proper diet
as evidenced by high cholesterol, low HDL, high LDL, and high triglycerides in
laboratory results.
Inappropriate weight gain and excessive calorie intake related to physical
inactivity and increased calories consumption as evidenced by patient’s 35-pound
weight gain and BMI of 31.75.
11. Determine the appropriate intervention for each nutritional diagnosis.
Provide and educate patient with proper nutrition knowledge so he can make
healthy decisions. Also, educate patient on foods that exacerbates GERD, foods
that lessen GERD symptoms, and provide helpful eating strategies to combat
reflux.
Inform patient the benefits of appropriate weight loss with consideration for his
knees and how it will help with GERD symptoms.
12. Using Mr. Nelson’s 24-hour recall, outline any necessary modifications and the
rationale for these modifications. Please make sure that all recommendations are
appropriate for a patient with GERD.
Food Item
Crispix
Modification
Whole grain toast,
oatmeal, whole grain
cereals
Skim milk
Good
Orange juice
Water
Rationale
Try avoiding processed foods as
it stays in the stomach longer; opt
for whole grains because it
decreases acid secretions
Skim milk is a good option for
dairy because it is low in fat
Avoiding citrus juices can
decrease the irritation of the
esophagus
Food Item
Diet Pepsi
Modification
Water
Fried chicken
sandwich
Grilled chicken with
whole grain bread
French fries
Baked sweet potato
Iced tea
Water
Chips
Low sodium crackers
Beer
Water
Fried chicken
Lean fish
Potato salad
Cottage cheese
Rationale
Try a beverage without
carbonation and high acidity
because it can cause the stomach
to distend from the excess air in
sodas
High fat foods stay in the
stomach longer which can
promote more acid production,
avoiding them can also help with
GERD symptoms; try a leaner
protein such as grilled meats
High fat foods stay in the
stomach longer which can
promote more acid production,
avoiding them can also help with
GERD symptoms; try a starchy
vegetable like a baked potato
instead
Try a beverage without caffeine
because it is a major trigger for
heartburn
High fat foods stay in the
stomach longer which can
promote more acid production,
avoiding them can also help with
GERD symptoms; opt for some
low sodium crackers
Try to avoid alcohol as it lowers
LES pressure
High fat foods stay in the
stomach longer which can
promote more acid production,
avoiding them can also help with
GERD symptoms, try a leaner
protein such as fish
Potato salads are usually high in
fat because of the mayonnaise,
they usually contain onions as
well which both are triggers of
GERD symptoms; try opting for
cottage cheese which has similar
texture but lower in fat
Food Item
Green bean casserole
Fruit salad
Baked beans
Milkshake
Modification
Steamed vegetables
medley
Rationale
Usually, casseroles contains both
peppers and onions which can
increase acid secretions; try
opting for some steamed
vegetables instead
Try fruits that are not
Avoid acidic foods such as
citrusy like berries,
citrusy fruits as they are a trigger
melons, bananas, peaches for heartburn; try some noncitrusy fruits instead
Green Beans, Edamame
Try to avoid foods that promote
gas as it creates more air in the
stomach promoting acid reflux;
try some starchy vegetables
instead
Low fat yogurt, Greek
Usually, milkshakes are high in
yogurt
fat, so try to avoid fatty foods as
it stays in the stomach longer; try
a low fat yogurt instead