Caitlin Mazurek
KNH 411
Case Study 2
Gastroesophageal Reflux Disease
1. How is acid produced and controlled within the gastrointestinal tract?
Acid is produced in the stomach where the gastric glands are located. The hydrochloric
acid is secreted from the parietal cells within the gastric gland. The hydrochloric acid
activates the pepsinogen, kills microorganisms, and denaturizes proteins. It is
produced and secreted during the first phase, called cephalic phase where the HCL and
pepsinogen are released when stimulated by tasting, smelling, or even seeing food.
2. What role does lower esophageal sphincter (LES) pressure play in the etiology of the
gastroesophageal reflux disease? What factors affect LES pressure?
Normally, the atmospheric pressure is greater in the esophagus than in the stomach,
and this prevents reflux of gastric contents. The LES stops serves as a barrier between
the esophagus and the stomach. The etiology of reflux is affected by many factors
including physical and lifestyle factors. Things that lower LES pressure include
increased hormones, other bodily conditions like a hernia, cigarette smoking,
medications, and foods high in fat among others.
3. What are the complications of gastroesophageal reflux disease?
Complications of untreated or unresponsive GERD may include impaired swallowing,
aspiration of gastric contents into the lungs, ulceration, and perforation or stricture of
the esophagus. Barrett’s Esophagus or Barrett’s metaplasia, has the cells change in the
esophagus going from normal squamous cell epithelium to metaplastic columnar cell
epithelium.
4. What is H. pylori and why did the physician want to biopsy the patient for H. pylori?
H. pylori or heliocobacter pylori is the bacteria responsible for most ulcers and stomach
inflammation. It can weaken the protective coating of the stomach. Many of the
symptoms of carrying H. pylori are similar to GERD. The physician wanted to biopsy the
patient just to cover all of the areas and make sure what he was working with.
5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease.
The patient has severe indigestion, and was afraid he was having a heart attack or
having some heartburn.
6. Describe the diagnostic tests performed for this patient.
Jack Nelson was admitted to the hospital and an intraesophageal pH monitoring and
barium esophagram support a diagnosis of gastroesophageal reflux disease. pH
monitoring is placing a capsule that has an acid sensing probe, battery and a transmitter
inside. The probe monitors the acid in the esophagus and transmits the information to a
recorder that is worn by the patient on a belt. The capsule transmits for two days and
then the battery dies. Within a week, the capsule is passed in the stool. Information is
taken and put into the computer to figure out the pH. A barium esophagram is a
procedure where Mr. Nelson drinks a mixture of barium sulfate, that is chalky and
white like a milk shake. The barium can be seen by fluoroscopy or b x-ray. It allows
swallowing to be seen and movement through the stomach into the duodenum.
7. What risk factors does the patient present with that might contribute to his diagnosis?
(Be sure to consider lifestyle, medical, and nutritional factors.)
Mr. Nelson is considered obese due to his high BMI. He has a very low activity rate due
to his past knee surgery and now his shoulder injury. He does not smoke but does take
many different pills each day such as atenolol, aspirin, and ibuprofen. His 24-hour
dietary recall contains many foods that are very high in fat such as fried chicken, potato
salad, French fries, and ice cream. He also has alcohol 3-4 times a week, which can
decrease LES pressure as well leading to GERD.
8. The MD has decreased this patient’s dose of daily aspirin and recommended
discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect gastroesophageal
disease?
Certain medications can control the gastric secretions certain ways, while others can
interfere with control of gastric secretions by blocking several of those control
pathways. Ibuprofen and aspirin can block these pathways. These drugs can provide
short-term relief, but over-the-counter drugs should not be used more than a few weeks
at a time, not every day. Aspirin and ibuprofen can weaken the LES causing GERD to
become more prevalent.
9. The MD has prescribed lansoprazole. What class of medication is this? What is the basic
mechanism of the drug? What other drugs are available in this class? What other groups
of medications are used to treat GERD?
Lansoprazole is a proton pump inhibitor that works by suppressing the molecules that
release the stomach acid. They block the H+, K+-ATPase ezyme, a component in HCL
production. Other proton pump inhibitors include omeprazole, pantoprazole,
rabeprazole, and esomeprazole which are all only available by prescription only. Overthe-counter strength Prilosec is also available. Other groups of medications that are
used to treat GERD include antacids, foaming agents, H2 antagonists, and prokinetics.
10. Are there specific foods that may contribute to GERD? Why or why not?
Specific foods that may contribute to GERD include foods high in fat, and also include
chocolate, spearmint, peppermint, alcohol, and caffeine. These all contribute to GERD
because they lower the LES pressre and thus contribute to LES incompetence.
11. Summarize the current recommendations for nutrition therapy in GERD.
The current recommendations for nutrition therapy include avoiding black and red
pepper, coffee, and alcohol as well as reducing the amount of food eaten at each meal.
Avoiding foods such as chocolate, mint, and high fat foods is also recommended.
Increasing calcium and iron may help as well. Reducing the amount of carbonated
beverages may also help.
12. Calculate this patient’s percent UBW and BMI. What does this assessment of weight tell
you? In what ways does this contribute to his diagnosis?
This patient’s percent UBW is 148% and his BMI is 31.7. He is considered obese due to
his high BMI. His percent UBW is 148% meaning, is usual body weight should be around
145 pounds or a little more. Being obese does contribute to an increase chance of
getting GERD and since he is obese, this lowers the LES pressure.
13. Calculate energy and protein requirements for Mr. Nelson. Identify the
formula/calculation method you used, and explain the rationale for using it.
The calculated energy requirements for Mr. Nelson is 2970. His protein requirement is
111 g/day. The formula I used to calculate this out is as follows:
662 – 9.53 x age + physical activity x (15.91 x weight + 539.6 x height)
662 - 9.53 x 48 + 1.11 x (15.91 x 97.7 + 539.6 x 1.75)
This formula was used because it can be controlled using the amount of physical
activity which was only a 1.11.
14. Complete a computerized nutrient analysis for this patient’s usual intake and 24-hour
recall. How does his caloric intake compare to your calculated requirements?
After calculating out his nutrient analysis, it is evident that the patient eats around
4,500 calories each day, or at least in the past 24-hours. His caloric intake is far higher
than what he should be eating daily. Since he should be eating around 2970 calories a
day, he is eating close to 1,530 more than he should.
15. From the information gathered within the intake domain, list possible nutrition
problems using the diagnostic term.
Mr. Nelson’s diet includes a lot of carbonated beverages as well as plenty of high fat
foods due to his dining out at fast food places. Although his diet is only about 30% of his
nutrient intake, he should be eating less due to his obesity. Since he is less capable of
getting exercise because of his knee and now shoulder injuries, he needs to be eating
healthier to minimize his chances of GERD.
16. Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s
overall cardiac health? Explain.
Mr. Nelsons’s cholesterol is very off. His LDH is very high and his HDL is very low. This
is throwing off his overall cholesterol as extremely high at 220 when normal is between
120-199. Improving his cholesterol by lowering his weight can improve his overall
health including his cardiovascular health.
17. From the information gathered within the clinical domain, list possible nutrition
problems using the diagnostic term.
HTN, or hypertension can be a problem from high blood pressure. He also has high
cholesterol, which can lead to many more problems in the future. His triglycerides are
also above normal.
18. What other components of lifestyle modification would you address in order to help in
treating his disorder?
I would try to break down his meals into smaller snacks almost. He should be eating five
smaller meals instead of three large meals and two snacks. I would also try to lessen the
amount of soda that he drinks. Drinking 5-6 cans of diet soda will increase sodium
intake and decrease the water intake. Water is important to drink, because it
normalizes most of the things in the body.
19. From the information gathered within the behavior-environmental domain, list possible
nutrition problems using the diagnostic term.
Possible nutrition problems include a high-fat diet, as well as excess sodium intake.
There is very little, if any water intake.
20. Select two high-priority nutrition problems and complete the PES statement for each.
Inadequate food intake related to excessive fat intake as evidenced by 24 hour dietary
recall.
Inadequate beverage intake related to excessive carbonated beverage intake, decreased
water intake, as evidenced by 24 hour dietary recall and difficulty swallowing.
21. For each of the PES statements that you have written, establish an ideal goal (based on
the signs and symptoms) and an appropriate intervention (based on the etiology).
An ideal goal to lessen the amount of fat eaten would be to switch to a grilled chicken
sandwich instead of a fried chicken sandwich and to try to pack a lunch instead of
eating out for both lunch and dinner.
An ideal goal would be to try to cut out one soda a day and replace it with water and try
to gradually decrease the amount of soda drank. These are both realistic goals that can
eventually lessen Mr. Nelson’s weight as well as help with his GERD.
22. Outline necessary modifications for him within his 24-hour recall that you could use as
a teaching tool.
Food item
Modification
Rationale
Crispix
none
n/a
Skim milk
none
n/a
Orange juice
Switch to a water based juice This will lessen the acidity in
that is flavored with orange
the juice and will help with
the LES and GERD/acidity in
the stomach
Diet Pepsi
Lessen the amount that is
Carbonated beverages can
drank daily as much as
increase gastric acid
possible
secretion
Fried chicken sandwich
Switch to a grilled chicken
Aid in the lessening of fat in
sandwich
the diet aspect
French fries
Switch to apples or yogurt
Fries are fat loaded, and a
parfait at McDonalds
fruit side would have less
calories and more nutrients
Iced Tea
Chips
Avoid tea to see if it is
symptomatic and causes
irritation
Switch to apple chips
Beer
Avoid for a while
Fried chicken
Switch to grilled chicken
Potato Salad
Switch to a baked potato
Green Bean Casserole
Switch to just green beans
Fruit salad
Baked beans
None
Avoid if it causes irritation
Milkshake
Switch to a smoothie
If the tea causes irritation,
then he should try to avoid it
He would get the chip feel of
the apple chips, but it would
be less fat
If the alcohol causes
irritation, then it should be
avoided, it may increase the
gastric acid secretion
Lessen the amount of fat
eaten
Lessen the amount of fat
eaten and possibly increase
vegetables and nutrients
eaten
Lessen the amount of fat
within the casserole and
increase the nutrient value
n/a
If it causes irritation, then
try different foods.
Increase the amount of fruits
eaten and lessens the
amount of fat