1. How is acid produced and controlled within the gastrointestinal tract?
A: Acid is produced within the gastrointestinal tract through the gastric glands which are found
in the mucosa lining the fundus and the body of the stomach. The mucus cells secrete mucus that helps
to protect the stomach lining from mechanical and acid digestion; chief cells secrete the zymogen
pepsinogen and the enzyme gastric lipase. Parietal cells secrete hydrochloric acid and intrinsic factor.
Hydrochloric acid serves to activate pepsinogen, kill microorganisms, and denature proteins. Intrinsic
factor is a necessary aid in absorption of vitamin B12. Three substances found in the pylorus help in the
overall control and production of gastric juices; enterochromaffin (ECL) cells secrete histamine, G cells
secrete gastrin and D cells secrete somatostatin. Four major chemical messengers are involved in the
control of gastric secretions: acetylcholine, histamine, and gastrin which stimulate gastric secretions,
and somatostatin which inhibits gastric secretions. Acetylcholine stimulates parietal, chief, and ECL cells,
histamine acts on parietal cells to increase hydrochloric acid release, gastrrin stimulates chief and
parietal cells as well as ECL cells to release histamine, and somatostatin works as an inhibitory paracrine
by providing negative feedback to the stimulatory pathways. When gastric pH falls somatostatin acts on
each of the stimulatory mechanisms to slowly decrease gastric secretions.
Pg. 345
2. What role does lower esophageal sphincter (LES) pressure play in the etiology of gastroesophageal
reflux disease? What factors affect LES pressure?
A: The atmospheric pressure is greater in the esophagus than in the stomach under normal
conditions which assists in preventing stomach contents from refluxing back into the esophagus as well
as preventing large amounts of air from entering the stomach.
Pg. 344
3. What are the complications of gastroesophageal reflux disease?
A: If GERD is untreated complications like impaired swallowing, aspiration of gastric contents
into the lungs, ulceration, perforation or stricture of the esophagus, and Barrett’s Esophagus can arise.
Barrett’s Esophagus involves a change n the epithelial cells of the esophageal mucosa; the normal
squamous cell epithelium of the esophagus changes to metaplastic columnar cell epithelium.
Pg. 352, 353
4. What is H. pylori, and why did the physician want to biopsy the patient for H. pylori?
A: H. pylori is a bacteria that causes more than half of peptic ulcers worldwide. The bacterium
damages the mucous lining of the stomach and the duodenum which allows the hydrochloric acid to
come into contact with the underlying tissue. The physician wanted to biopsy for H. pylori because
some of the symptoms of GERD and peptic ulcer are the same; dull or burning pain, burping, vomiting,
weight loss, poor appetite, bloating, and nausea. In order to know how to treat she must be sure she
knows what to treat, so by testing for H. pylori she can either rule out peptic ulcer or start the
treatment for it.
http://digestive.niddk.nih.gov/ddiseases/pubs/hpylori/#3
5. Identify the patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal reflux
disease.
A: The patient’s signs and symptoms that suggest gastroesophageal reflux disease include
heartburn, chest pain, and belching.
6. Describe the diagnostic tests performed for this patient.
A: The diagnostic tests performed for this patient included ambulatory 24-hour pH monitoring,
Barium esophagram, and endoscopy with biopsy to rule out H. pylori infection. The twenty-four hour
ambulatory esophageal pH monitoring is a diagnostic procedure involving the placement of an
indwelling electrode into the lower esophagus of a patient for the purpose of determining the presence
of gastric reflux and measuring abnormal esophageal acid exposure (http://www.cms.gov/medicarecoverage-database/details/ncd-details.aspx?NCDId=108&ncdver=1). The Barium esophagram involves
the use of a liquid agent that when swallowed provide an X-Ray image of the inside of the intestine in
relation to the wall of the organ and surrounding structures. A barium esophagram may be ordered for
patients with difficult or painful swallowing, coughing, choking, a sensation of something stuck in the
throat, or chest pain (http://patients.gi.org/topics/gi-radiographic-tests/). Endoscopy with biopsy is a
procedure which allows a physician to look at the interior lining of the esophagus, stomach, and the
duodenum through a thin, flexible viewing instrument called an endoscope. The endoscope can detect
ulcers, inflammation, tumors, infection, or bleeding. Tissue samples can be biopsied, polyps can be
removed, and bleeding can be treated through the endoscope (http://www.webmd.com/digestivedisorders/upper-gastrointestinal-endoscopy)
7. What risk factors does the patient present with that might contribute to his diagnosis? (Be sure to
consider lifestyle, medical, and nutritional factors.)
A: The patient has a sedentary lifestyle and doesn’t get much exercise which he attributes to his
recent knee surgery. He is overweight and according to his 24-hour recall his diet is high in fatty, fried
foods.
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?
A: The MD has decreased the patient’s dose of daily aspirin and recommended the
discontinuation of ibuprofen because evidence suggests that NSAIDs exert their anti-inflammatory
activity by inhibiting the activity of pro-inflammatory cyclooxygenase (COX) enzymes. However, the COX1 enzyme is also important for promoting the formation of the protective mucus lining of the stomach.
Since people who are suffering with GERD already have trouble with acid refluxing into their esophagus
the mucus lining becomes more important
(http://www.lef.org/protocols/gastrointestinal/gastroesophageal_reflux_07.htm#dietary).
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?
A: Lansoprazole is a proton pump inhibitor. The mechanism of lansoprazole is to block the H+,
K+-ATPase enzyme which is a component in HCL production. Another group of medication used to treat
GERD is antacids which use different combinations of three basic salts; magnesium, calcium, and
aluminum, with hydroxide or bicarbonate ions to neutralize HCL. Foaming agents are another group of
medicine used to treat GERD. They reduce the symptoms associated with reflux by combining
aluminum, magnesium, and sodium bicarbonate. H₂ antagonists work by blocking histamine receptors
that are a component of one of the stimulatory paths for acid secretion. Finally, prokinetics work to help
strengthen the pyloric sphincter and also increase speed of gastric emptying.
Pg. 353
10. Are there specific foods that may contribute to GERD? Why or why not?
A: There are specific foods that can contribute to GERD. Foods that are high in fat, chocolate,
spearmint, peppermint, alcohol, and caffeine can all decrease LES pressure which can cause an increase
in reflux. There are also personal sensitivities to certain foods and each patient should identify the foods
that make their symptoms worse and decrease the intake of those foods. Beverages to avoid if
symptoms are present include carbonated beverages, carreinated and decaffeinated coffee and tea,
cocoa, alcohol. Mild products to avoid include 2% nd whole milk, cream, high-fat yogurts, and chocolate
milk. Eggs should be avoided if they are fried or scrambled using high-fat cooking methods. Pastries
should also be avoided. Protein sources should not include fried meats, bacon, sausage, pepperoni,
salami, bologna, and frankfurters/hot dogs. Fruits and vegetables that aggravate individuals should be
avoided, but only those that aggravate. Desserts that are considered high in fat or fried should be
avoided. Also, finally if individuals find pepper an aggravator of symptoms it should also be avoided.
Pg. 352, 353
11. Summarize the current recommendations for nutrition therapy in GERD.
A: The current recommendations for nutrition therapy in GERD include a trial of food restriction
excluding those foods that may lower LES pressure and to reduce gastric acidity. Exclusion of black and
red pepper, alcohol, and coffee; caffeinated and decaf from the diet is one of the first steps in nutrition
therapy for GERD. Smaller, more frequent meals are also prescribed. Also any foods known to lower the
LES pressure and any foods that create problems for individuals should be avoided. Weight loss is also
encouraged if the patient is obese.
Pg. 354
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?
A: Percent UBW = current weight
X 100
usual body weight
Percent UBW for Mr. Nelson =
215 X 100 = 119.4%
180
BMI = 96.75kg = 32.51kg/m^2
2.97 m^2
The assessment of weight tells me that Mr. Nelson is obese as a BMI of 30 or more indicates.
Research indicates that obesity satisfies several criteria for a causal association with GERD and some of
its complications.
http://www.ncbi.nlm.nih.gov/pubmed/18651221
13. Calculate energy and protein requirements for Mr. Nelson. Identify the formula/calculation method
you used, and explain the rationale for using it.
A: Using the Harris-Benedict equation; the energy and protein requirements for Mr. Nelson can
be calculated as follows:
66.5 + 13.8(96.75kg) + 5.0(172.5) – 6.8(48) = 1,938 calories per day
Protein needs vary depending upon body weight and the frequency, intensity, duration and types of
activities. For an individual with a sedentary lifestyle like Mr. Nelson the protein needs would equal
Protein needs in grams x body weight in pounds = recommended protein intake
0.36 x 215 = 77.4 grams per day.
http://cals.arizona.edu/pubs/health/az1388.pdf
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?
A: Mr. Nelson’s calculated energy requirements were 1,938 cal/day. His usual intake of calories
was around 2,600 which is well above his required intake. His 24-hour intake of calories was 3,937,
almost exactly 2,000 more calories than he needs. Mr. Nelson’s protein needs were calculated at 77.4
grams per day. From his 24-hour recall he took in 146 grams, which is about two times the amount that
is needed. His usual diet also consists of more protein than is needed; he consumes around 111 grams
per day when following his typical diet. So, even if Mr. Nelson was having a “bad diet day” when he gave
his 24-hour recall, his typical diet is still too high in calories.
Typical Diet
Food
Item
Potassium
(minimum
4,700mg/120
mEq)
400.2 mg
Sodium(maxim
um
2,400mg/100
mEq)
420.0 mg
Magnesium
(500 mg)
Calcium
(minimum
1,240mg)
Total
Fat
(g)
Saturated
fat (g)
Cholest
erol
(mg)
Fiber
(g)
20%
20%
3.6g
0.76g
0.0mg
5.6g
286.7mg
77.2mg
5%
23%
0.15g
0.094g
3.7mg
0.0g
1,441.2mg
22.4mg
19%
8%
0.45g
0.051g
0.0mg
1.7g
124.7mg
198.9mg
526.8mg
535.2mg
2%
13%
0%
2%
3.5g
1.5g
1.1g
0.22g
22.3mg
0.0mg
0.0g
4.6g
147.7mg
525.4mg
82.5mg
1.4mg
168.0mg
340.8mg
2%
6%
5%
1%
1%
9%
0.23g
12.0g
0.0g
0.039g
3.5g
0.0g
0.0mg
0.0mg
0.0mg
3.3g
1.4g
0.0g
21.1mg
194.4mg
767.6mg
153.6mg
28.8mg
127.6mg
0%
11%
14%
1%
3%
1%
3.1g
0.0g
16.3g
0.71g
0.0g
5.9g
0.36g
0.0g
0.0g
Pasta
Fruit
Salad
Bread
167.5mg
265.4mg
159.9mg
30.0mg
516.8mg
2.9mg
16.2mg
204.3mg
6%
4%
4%
2%
2%
1%
3%
5%
8.4g
0.26g
0.13g
0.99g
1.8g
0.065g
0.021g
0.22g
3.8mg
0.0mg
161.6m
g
31.2mg
0.0mg
0.0mg
0.0mg
Iced tea
Popcorn
22.7mg
30.5mg
4,866.4mg
9.1mg
45.3mg
3,196.4mg
1%
3%
461.8mg
1%
0%
800.2mg
0.0g
3.6g
54.21
g
0.0g
2.1g
16.58g
Cheerio
s
Skim
milk
Orange
Juice
Ham
Whole
wheat
bagel
Apple
Chips
Diet
Soda (6)
Cookies
Beer
Meat
TOTAL
0.0mg
8.5mg
231.1m
g
1.2g
2.7g
1.1g
0.72m
g
0.0g
1.3g
23.98
g
Food
Item
Crispix
Skim
milk
Orange
juice
Diet
soda (3)
McDon
ald’s
fried
chicken
sandwic
h
Small
fries
Chips
Beer
KFC
chicken
breast
Potato
salad
Green
bean
casserol
e
Fruit
salad
Baked
beans
Iced tea
Ice
cream
Skim
milk
TOTAL
Potassium
(minimum
4,700mg/120
mEq)
98.4mg
382.2mg
Sodium(maxim
um
2,400mg/100
mEq)
478.4mg
102.9mg
Magnesium
(500 mg)
Calcium
(minimum
1,240mg)
Total
Fat
(g)
Saturated
fat (g)
Cholest
erol
(mg)
Fiber
(g)
4%
7%
2%
31%
3.0g
0.2g
0.4g
0.12g
0.0mg
4.9mg
0.4g
0.0g
961.6mg
14.9mg
3%
6%
0.3g
0.034g
0.0mg
1.1g
42.6mg
170.4mg
3%
4%
0.0g
0.0g
0.0mg
0.0g
526.6mg
1,373.4mg
16%
8%
17.7g
3.2g
58.0mg
3.2g
414.4mg
143.6mg
6%
1%
13.2g
2.6g
0.0g
3.0g
1,050.9mg
97.2mg
493.6mg
336.0mg
14.4mg
651.3mg
11%
5%
14%
2%
1%
4%
24.0g
0.0g
30.5g
7.0g
0.0g
7.9g
0.0mg
0.0mg
167.5m
g
2.8g
0.0g
0.76g
914.3mg
1,031.5mg
14%
3%
19.3g
2.9g
9.1mg
4.7g
66.2mg
161.3mg
2%
2%
1.6g
0.42g
0.44mg
0.79g
132.6mg
23.3mg
2%
2%
3.8g
1.0g
1.5mg
1.7g
907.8mg
1,128.3mg
27%
16%
7.6g
2.6g
15.3mg
10.0g
700.9mg
537.9mg
56.8mg
197.9mg
14%
10%
0%
34%
0.0g
28.5g
0.038g
17.6g
0.0g
1.9g
382.2mg
102.9mg
7%
31%
0.2g
0.12g
0.0mg
107.4m
g
4.9mg
7,709.4mg
5,987.3mg
7,709.4mg
1,472.3mg
149.9
g
45.93g
369g
30.35
g
0.0g
15. From the information gathered within the intake domain, list possible nutrition problems using the
diagnostic term.
A: Nutrition problems that may occur due to Mr. Nelson’s diet include the development of
hypertension because of the amount of salt he consumes, excess energy intake, excessive or
inappropriate intake of fats, excessive sodium intake, inadequate fiber intake, inadequate Vitamin A,
Vitamin D, and Vitamin E intake along with possible inadequate calcium intake, increasing obesity, food
and nutrition-related knowledge deficit, and physical inactivity. (Inadequate food/oral beverage intake,
excessive fat intake, swallowing difficulty, food-medication interaction, overweight/obesity, inadequate
iron and calcium intake, impaired nutrient utilization, food and nutrition-related knowledge deficit, and
undesirable food choices)
16. Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s overall cardiac
health? Explain.
A: Mr. Nelson’s labs looked okay, many of his numbers were on the upper end of the normal
limits, but his cholesterol levels are an area of concern. His total cholesterol is high, LDL levels are high
and HDL levels are low which puts him in danger of cardiovascular disease.
17. From the information gathered within the clinical domain, list possible nutrition problems using
the diagnostic term.
A: Possible nutrition problems from the clinical domain include hypertension, cardiovascular
disease, Barrett’s Esophagus, cancer of the esophagus, impaired swallowing, aspiration of gastric
contents into the lungs, ulceration, and perforation or stricture of the esophagus.
18. What other components of lifestyle modification would you address in order to help in treating his
disorder?
A: Lifestyle modifications that I would address would be
o Establish a regular exercise route
o Reduce intake of fried foods, fatty foods, and alcohol
o Reduce calorie intake
o Prescribe a meal plan that involves smaller meals more frequently
o Limit intake of foods that have been identified by Mr. Nelson as aggravators of GERD
o Limit intake of tea
o Limit intake of carbonated beverages
19. From the information gathered within the behavior–environmental domain, list possible nutrition
problems using the diagnostic term.
A:
20. Select two high-priority nutrition problems and complete the PES statement for each.
One high-priority nutrition problem is Mr. Nelson’s weight.
P: Excessive weight
E: As related to excessive fatty foods in the diet
S: As evidenced by current state of obesity
A second high-priority nutrition problem is Mr. Nelson’s
P:
E:
S:
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).
22. Outline necessary modifications for him within his 24-hour recall that you could use as a teaching
tool.
Food Item
Crispix
Skim milk
Modification
Eat 1 cup of cereal
Use less
Orange juice
Discontinue if aggravates
symptoms
Limit intake
Diet Pepsi
Fried chicken sandwich
Grilled chicken sandwich, salad
with grilled chicken
French fries
Baked potato, garden salad
Iced tea
Drink water
Chips
Baked chips
Beer
Exclude alcohol from diet
Fried chicken
Grilled chicken, grilled fish
Potato salad
Green bean casserole
Fruit salad
Baked beans
Eat less, or eat a little at a later
time
Eat fresh steamed green beans
Try fresh fruit without mayo
Exclude
Milkshake
Try fresh fruit or sherbet
Rationale
Smaller meals
Milk products may aggravate
GERD
Some fruits can aggravate.
Carbonated beverages decrease
LES pressure
Fried foods/foods high in fat can
aggravate symptoms, decrease
LES pressure, and less fat if
grilled
Fried food can aggravate
symptoms
Caffeine can decrease LES
pressure
Less fat which decreases LES
pressure
Alcohol may aggravate
symptoms
Fried foods are high in fat which
decreases LES pressure and
causes symptoms to exacerbate
Smaller more frequent meals can
help to reduce symptoms
Less sodium
Less fat, less cholesterol
Less sodium, smaller meals more
frequently can help reduce
symptoms
Milk products can aggravate
GERD