Claire Millonig
KNH 413
10 February 2015
PUD Case Study
1. List all the food items that may contribute to GG’s condition and explain why.
The foods that may be contributing to GG’s condition include microwave meals, fried
foods, alcohol, fast foods with high fat content, chocolate, black coffee. All of these
foods contain relatively high fat content, the alcohol is acidic along with the coffee.
These factors cause an imbalance in the gastric juices and allow the Helicobacter pylori
(H. pylori) bacteria to grow and cause ulcers.
http://www.webmd.com/digestive-disorders/digestive-diseases-peptic-ulcer-disease
2. List any additional oral intake that may have contributed to GG’s condition and explain
why.
The consumption of aspirin daily could have also contributed to her diagnosis of peptic
ulcer disease. It has been commonly found that taking aspirin contributes to the
development of stomach ulcers.
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.
Some contributing factors to her development of stomach ulcer include her high stress
level due to her recent divorce, financial situation, going back to school, and taking care
of her 4-year-old son. Also, her son was recently diagnosed with ADHD, which requires
more attention. Although these are everyday stressors that she must deal with, she
could try taking an hour out of each day to relax and do something for herself. This
could be reading a book or watching an episode of her favorite TV show.
4. List the symptoms of GG’s gastritis.
The symptoms GG is experiencing include severe pain in her stomach and right lower
quadrant 30 minutes after eating and after drinking alcohol or coffee.
She has also woken up with severe pain in her stomach stretching up into her chest.
5. Was a bland diet necessary? Explain and list the principles of the diet plan that you think
GG should follow.
A bland diet may not be necessary but is advised. People react differently to diet
therapy but are generally advised to avoid foods that contain pepper, caffeine, coffee
and alcohol and any other foods that an individual finds to irritate their stomach. These
may be different based on the client. I think GG should follow these guidelines and
quitting smoking. I also advise her to smaller, more frequent meals and not eat a large
meal close to bedtime. It is also important to avoid laying down after a meal.
6. What is the mechanism of action of the following medications GG is receiving: Carafate,
AlternaGel, and Pepcid?
Carafate is not absorbed into the digestive tract but rather adheres to the stomach
lining where ulcers are present to protect them from acids, enzymes and salts.
AlternaGel, also known as aluminum hydroxide, is used to treat symptoms of increased
stomach acid. These include heart burn, upset stomach or acid indigestion. Pepcid is a
histamine blocker that works to decrease the production of acid in the stomach. All of
these medications are commonly used to treat peptic ulcers.
http://www.drugs.com/carafate.html
http://www.drugs.com/mtm/alternagel.html
http://www.drugs.com/pepcid.html
7. List the nutrient-drug interactions that are associated with these medications.
The intake of magnesium can decrease the absorption of AlternaGel and Pepsid.
8. What are GG’s IBW and percent of IBW (Appendix A, Tables 7 and 8)?
IBW = 100 lbs. + 10 lbs = 110 lbs.
% IBW = 98/110 x 100% = 89%
9. Estimate her daily energy needs using the Harris-Benedict equation and appropriate
stress factor (Appendix A, Table 17).
655 + (9.56 x 44.5 kg) + (1.85 x 157.5 cm) – ( 4.68 x 27) =1245 kcals
1245 x 1.6 (stress factor) = 1993 kcals = approx. 2,000 kcals per day
10. What might be the cause of the LUQ pain along with her usual pain? (Hint: Consider the
enzymes that are elevated.)
The cause of her LUQ pain is most likely from her binge drinking. Alcohol irritates the
lining of the stomach and makes it more likely to develop peptic ulcers or delay the
healing of existing ulcers. The consumption of alcohol also increases enzyme production
in the stomach. These factors resulted from her binge drinking and therefore caused the
pain she was feeling.
http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/risk-factors/con20028643
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. Bleeding
b. Eating poorly in the hospital
c. Dehydrated when the first labs were drawn
d. Over hydrated when the second set of labs was drawn
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 alcohol
b. Her medications caused them to drop
c. GG was dehydrated when the first labs were drawn
d. GG was over hydrated when the second set of labs was drawn
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 hydration
b. Her medications caused them to drop
c. Dehydrated when the first labs were drawn
d. 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?
The tests that indicate GG has an ulcer include the blood test that was positive for H.
pylori, stool test, and esophagogastroduodenoscopy.
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
(See extra page)
16. Define:
H2 antagonist: “a class of drugs used to block the action of histamine on parietal cells
(specifically the histamine H2 receptors) in the stomach, decreasing the production of
acid by these cells.”
Proton pump inhibitor: “reduce the production of acid by blocking the enzyme in the
wall of the stomach that produces acid.”
http://en.wikipedia.org/wiki/H2_antagonist
http://www.medicinenet.com/proton-pump_inhibitors/article.htm
17. What is the mechanism of action of the following medications GG is receiving: Nexium,
amoxicillin, and clarithromycin?
Nexium works to decrease the amount of acid produced by your stomach. Amoxicillin
and clarithromycin are both used to treat bacteria infections. In this case they work to
eliminate the H. pylori bacteria.
http://www.webmd.com/drugs/2/drug-20536/nexium-oral/details
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a685001.html
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a692005.html
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.
In this situation I would listen to GG’s complaints and assess her diet. I would have felt
comfortable in giving her diet instructions to provide healthier snacks and meals while
she is on the go. This seems to be a major contributor to her ulcer along with the alcohol
and smoking. For this I would have referred her to a specialist to help her stop drinking
and smoking. The Oxford Drug and Alcohol Rehab center has a 24-hour hotline that she
would be able to call and talk to someone.
19. What is the significance of the dark stools?
The dark stools indicate that she began bleeding rapidly from her ulcers. It is typically
dark red or maroon blood in the stool. This was an indicator that her ulcers have
returned and are now bleeding and becoming very serious.
http://patients.gi.org/topics/peptic-ulcer-disease/
20. Give the pathophysiology for the cause of the following abnormal values: BUN, NH3,
and WBC.
BUN: indicate internal bleeding and impaired kidney function
NH3: high values indicate internal bleeding and possible liver failure
WBC: high levels indicate severe stress and inflammatory disease.
http://www.mayomedicallaboratories.com/articles/criticalvalues/view.php?name=Critic
al+Values%2FCritical+Results+List
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.
22. After admission GG received packed cells and IV fluids. How would that affect the next
set of lab values?
Through the use of IV fluids and packed cells her next lab values will indicate that she
has been rehydrated and stabilize her BUN, hemoglobin and glucose levels.
23. Define the following terms:
Packed cells: “a preparation of blood cells separated from the liquid plasma”
Abdominal tap: “a procedure used to remove fluid from the area between the belly wall
and the spine.”
Perforated ulcer: “serious condition where an untreated ulcer can burn through the wall
of the stomach (or other areas of the gastrointestinal tract), allowing digestive juices
and food to leach into the abdominal cavity.”
Fistula: “abnormal connection between an organ, vessel, or intestine and another
structure.”
Exploratory Laparotomy: “he standard of care in various blunt and penetrating trauma
situations in which there may be multiple life-threatening injuries, and in many
diagnostic situations in which the operation is undertaken in search of a unifying cause
for multiple signs and symptoms of disease.”
Billroth I: “an operation in which the pylorus is removed and the proximal stomach is
anastomosed directly to the duodenum.”
Vagotomy: “a surgical procedure that involves removing part of or resection of the
vagus nerve.”
24. Sketch the Billroth I.
(See attached)
25. Compare a Billroth I to a Billroth II as to anatomical changes as well as to dietary
changes, if any.
In Billroth I the proximal stomach is attached directly to the duodenum, in Billroth II the
curvature of the stomach is connected to the first part of the jejunum, in a side-by-side
manner. Both are similar procedure that would result in possible malabsorption of
nutrients and changes in gastric emptying.
http://en.wikipedia.org/wiki/Billroth_I
http://en.wikipedia.org/wiki/Billroth_II
26. Calculate GG’s energy and protein needs.
655 + (9.56 x 44.5 kg) + (1.85 x 157.5 cm) – ( 4.68 x 27) =1245 kcals
1245 x 1.6 (stress factor) = 1993 kcals = approx. 2,000 kcals per day
44.5 kg x 1.5 g/kg = 66.8 g of protein
27. List the principles of a postgastrectomy diet and briefly describe the scientific basis for
each principle.
A post-gastrectomy diet consists of 5-6 small meals with snacks throughout the day
because of the decreased size of the stomach. High calorie and high protein snacks are
recommended. For example, peanut butter and crackers, cheese or yogurt with no
added sugars. Adding extra protein when it’s available is important for repair and
recovery of the body. Avoiding high fiber foods and drinking with meals is a main
component of a post-gastrectomy patient. This is due to the decreased ability of
absorption and digestion of the fiber. A patient should wait about 30 minutes after a
meal to drink fluids.
http://www.upmc.com/patients-visitors/education/nutrition/pages/post-gastrectomydiet.aspx
28. Is it possible that GG’s diet will ever change or do you believe she will be on the
postgastrectomy diet for the rest of her life? Explain your answer.
GG will not be on this limited diet for the rest of her life. Starting with small meals, she
can increase the size of her meals as she feels necessary until returning to a normal diet
again.
http://www.upmc.com/patients-visitors/education/nutrition/pages/post-gastrectomydiet.aspx
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?
If tube feeding became necessary it would require high calorie, high fat and high protein
content along with a lower carbohydrates. The high protein and fat will help to provide
adequate calories while tube feeding. The carbohydrates will help to avoid dumping
syndrome.
30. Using the table below, compare several of the enteral nutritional supplements that
would be appropriate for GG.
53%
22%
NA
Free
H20/ L in
mL
25%
g fiber/L
80:1
Fat
mOsm/
kg water
1.0
CHO
K (mg)
Pro
Na (mg)
Boost- Nestle
High
Protein
Vital
Abbott
1.5 Cal
Non-pro
kcal/g N
Producer
kcal/mL
Product
g/L
NA
650
*
85%
595
6g
610
1.50 139:1 67.5g 187g 57.1g 1500 2000
http://abbottnutrition.com/brands/products/vital-1_5-cal
http://www.nestlehealthscience.us/products/boost®-high-protein
References
Peptic Ulcer Disease (Stomach Ulcers) Cause, Symptoms, Treatments. (n.d.). Retrieved
February 10, 2015, from http://www.webmd.com/digestive-disorders/digestivediseases-peptic-ulcer-disease
Carafate: Uses, Dosage, Side Effects - Drugs.com. (n.d.). Retrieved February 10, 2015,
from http://www.drugs.com/carafate.html
Alternagel medical facts from Drugs.com. (n.d.). Retrieved February 10, 2015, from
http://www.drugs.com/mtm/alternagel.html
Pepcid: Uses, Dosage, Side Effects - Drugs.com. (n.d.). Retrieved February 10, 2015, from
http://www.drugs.com/pepcid.html
Peptic ulcer. (n.d.). Retrieved February 10, 2015, from
http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/riskfactors/con-20028643
H2 antagonist. (n.d.). Retrieved February 10, 2015, from
http://en.wikipedia.org/wiki/H2_antagonist
Proton Pump Inhibitors (PPIs): Drug Facts, Side Effects and Dosing. (n.d.). Retrieved
February 10, 2015, from http://www.medicinenet.com/protonpump_inhibitors/article.htm
Nexium oral : Uses, Side Effects, Interactions, Pictures, Warnings & Dosing - WebMD.
(n.d.). Retrieved February 10, 2015, from
http://www.webmd.com/drugs/2/drug-20536/nexium-oral/details
Amoxicillin: MedlinePlus Drug Information. (n.d.). Retrieved February 10, 2015, from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a685001.html
Clarithromycin: MedlinePlus Drug Information. (n.d.). Retrieved February 10, 2015, from
http://www.nlm.nih.gov/medlineplus/druginfo/meds/a692005.html
Peptic Ulcer Disease. (n.d.). Retrieved February 10, 2015, from
http://patients.gi.org/topics/peptic-ulcer-disease/
DLMP Critical Values / Critical Results List. (n.d.). Retrieved February 10, 2015, from
http://www.mayomedicallaboratories.com/articles/criticalvalues/view.php?nam
e=Critical Values/Critical Results List
Billroth I. (n.d.). Retrieved February 10, 2015, from
http://en.wikipedia.org/wiki/Billroth_I
Billroth II. (n.d.). Retrieved February 10, 2015, from
http://en.wikipedia.org/wiki/Billroth_II
Post-Gastrectomy Diet. (n.d.). Retrieved February 10, 2015, from
http://www.upmc.com/patients-visitors/education/nutrition/pages/postgastrectomy-diet.aspx
Vital® 1.5 Cal. (n.d.). Retrieved February 10, 2015, from
http://abbottnutrition.com/brands/products/vital-1_5-cal
BOOST® HIGH PROTEIN. (n.d.). Retrieved February 10, 2015, from
http://www.nestlehealthscience.us/products/boost®-high-protein