Jenna Paterno
KNH 413
Professor Matuszak
2-11-14
Case Study 14: Peptic Ulcer Resulting
In Gastrectomy
1. List all the food items that may contribute to GG’s condition and explain why.
Frozen dinners: frozen dinners are usually very high in sodium, which over time
has proven to damage the stomach lining
http://www.healthassist.net/food/side-effects/side-effects.shtml
Fried Foods: foods high in fat are sometimes hard on the stomach to digest. Fat
and cholesterol can also increase stomach acid causing the stomach lining to be
even more irritated
http://www.healthassist.net/food/side-effects/side-effects.shtml
Black Coffee, Chocolate Bars, and Coke: Caffeinated drinks and food trigger the
production of stomach acid. As the amount of stomach acid increases or is regular
at a higher level the more likely the lining of the stomach will be destroyed.
Rum: alcohol and ulcers may not necessarily be linked, but the association of
heavy drinking and ulcers have seen throughout research
http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm
Milk: Milk has been recommended to consume to help treat PUD, however, it has
been learned that the consumption of milk increases gastrin and pepsin secretion.
(Nelms, 363).
http://medicalcenter.osu.edu/patientcare/healthcare_services/digestive_disorders/p
eptic_ulcers/Pages/index.aspx
2. List any additional oral intake that may have contributed to GG’s condition and
explain why.
Tums/ Antacids: Antacids are commonly taken to help reduce heartburn and
indigestion, which is caused by stomach acid. GG sometimes feels relief after taking
Tums because at the moment it is reducing the amount of stomach acid being
produced by the digestive system.
Aspirin: GG is currently taking aspirin to reveal her headaches, however this is
causing more harm than good for her. Aspirin is known to relive pain, but it can cause
damage to the stomach lining. In GG’s case, this would cause her ulcer to worsen.
http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm
Smoking: Smoking increases the risk of getting an infection called H. Pylori,
which is considered a bacteria infection causing a peptic ulcer. However, GG already
has been considered to have a peptic ulcer, therefore, she should stop smoking
because it will slow down the healing processes of the sore in the lining of her
stomach.
http://medicalcenter.osu.edu/patientcare/healthcare_services/digestive_disorders/p
eptic_ulcers/Pages/index.aspx
3. List the non-oral stimulants that could contribute to GG’s condition and what she
could do to change them.
GG is currently very stressed with all the different life changes she is currently
going through. She is recently separated from her husband, but after being with him for
several years where he has supported her and their 4 year old son she has realized she
needs to go back to school to be able to get a job to currently support herself and her son.
After trying to balance her schoolwork and raising her son acting as both a mother and a
father, her son was recently diagnosed with ADHD, which can be emotional and physical
stress in the beginning when trying to learn how to overcome his difficulties. Some
changes that GG could consider to help her overcome her health problems is to make a
weekly schedule that works for her, her son, and her mother who is helping babysit GG’s
son while she is at school. GG should cut down on the amount of hours she is taking in
the beginning to have a smoother transition into school, while trying to balance her
family life also. Taking less credits will help her organize a schedule that will be easy to
follow and hopefully be less stressful for her.
4. List the symptoms of GG’s gastritis.
GG has mentioned that she gets easily upset and often has to take antacids for
burning stomach. However, in the last month the pain she has been experiencing has
been much worse and more often. The pain occurs 30 minutes after eating and is
taking antacids to deal with the pain. The other night she woke up from sever pain in
her right side that continued up into her chest. After taking TUMS and drinking some
milk the pain slowly went away, and she was able to go back to sleep. The next
morning she woke up with sever gastric pain again and tried taking TUMS and
drinking milk, but the pain never went away. This is when she decided to come to
urgent care center.
5. Was a bland diet necessary? Explain and list the principles of the diet plan that you
think GG should follow.
A bland diet is not necessary for GG. In her situation there are different foods and
beverages she should eliminate from her diet such as foods high in fat; for example
fired foods, caffeinated beverages; for example strong black coffee and coke, foods
that contain black and red pepper, and also eliminate the consumption of alcohol.
Some other foods GG should avoid are those that she feels bothers her after consumer,
or where she needs to take TUMS to help cope with her pain. She should consult with
a Registered Dietitian to help her create a large list of foods she can still consume and
different easy meal options she can prepare for her and her son on those busy days as
an alternative to frozen meals.
(Nelms, pg 363)
6. What is the mechanism of action of the following medications GG is receiving:
Carafate, Alternagel, and Pepcid?
Carafate (Sucralfate): The mechanism of action is not 100 % understood, but the
actions are considered to be important for its beneficial effects.
- It binds to the surface of the ulcers and coats it to protect the ulcer from
further injury
- It directly inhibits pepsin, which is an enzyme that breaks apart proteins, in the
presence of stomach acid.
-
It binds bile salts coming from the liver protecting the stomach lining from
injury, which can be caused by the bile acids
It may increase prostaglandin production, which are known to protect the
lining of the stomach
http://www.medicinenet.com/sucralfate/article.htm
Alternagel: used to treat symptoms of too much stomach acid.
http://www.medicinenet.com/aluminum_hydroxide_suspension-oral/article.htm
Pepcid: Pepcid is an oral drug that blocks the production of acid by acid-producing
cells in the stomach. H2- blockers inhibit the action of histamine on the cells, which
reduces the production of acid.
http://www.medicinenet.com/famotidine/article.htm
7. List the nutrient-drug interactions that are associated with these medications.
Carafate: avoid taking other medications within two hours of taking Carafate. Avoid
using antacids unless recommended by your doctor, some antacids make it harder for
Carafate to work within your system.
http://www.medicinenet.com/sucralfate/article.htm
Alternagel: avoid citrate due to dangerous results. Consume larger amounts of
phosphorus, folic acid, and calcium because absorbing these nutrients can be difficult
http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf)
Pepcid: possibl risk for certain difficienies such as iron, zinc, folic acid, and vitamin
B12.
http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf
8. What are GG’s IBW and percent IBW?
Hight: 5 feet 2 inches
Weight: 98 lbs
IBW: 5 ft= 100 lbs + 5 lbs for every inch after
=100 lbs + 5 (2 inches)
= 110 pounds
% IBW: (ABW/ IBW) x 100
= (98 lbs/ 110 lbs) x 100
= (.891) x 100
= 89 %
9. Estimate her daily energy needs using the Harris-Benedict equation and appropriate
stress factor.
Harris-Benedict equation: 655+ (9.56 x W (kg)) + (1.85 x h (cm))– (4.68 x age)
= 655+ (9.56 x 44.5kg) + (1.85 x 157.48cm) – (4.68x27)
= 655 + (425.42) + (291.34) – (126. 36)
= 1245 kcals
= 1245 X 1.0
= 1245 kcals
= 1245 X 1.5
= 1868 kcals
I used a range for GG’s stress level of 1.0 to 1.4 because of her infection and her
activity level. A range of calories she should consume would be 1250- 1900. I would
recommend her to consume more toward the higher amount of calories considering
she is slightly under her IBW. Her body also needs the extra calories to help her body
adequately heal her ulcer.
10 What might be the cause of LUQ pain along with her usual pain? (Hint: consider
the enzymes that are elevated.)
GG’s left upper quadrant pain can come from a variety of different factors.
However, it did mention that she started to heavily drink again which would cause
elevated liver enzymes in her system. This could be a reason as to why GG is feeling
pain in the LUQ.
11. In the second 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 were drawn,
A drop in lab values can indicate that she is over hydrated due to her pervious labs
indicating she needed an IV.
12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This
probably means that:
a. Enezymes 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
The first time GG’s labs were taken were within 24 hours of her drinking.
This could have caused these values to be elevated due to the fact that the kidney
was working to clean out toxins. When the labs were taken a second time GG
hadn’t consumed alcohol in a longer span of time allowing for those different
values to drop.
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 enezymes are not affected by alcohol or hydration
b. Her medications caused them to drop
c. Dehydration 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) indicates that GG has an ulcer?
GG had an esophagogastroduodenoscopy, which is a test to examine the
lining of the esophagus, stomach, and first part of the small intestine. In GG’s
situation this revealed the gastric superior to the pyloric sphincter with an ulcer on
the dorsal wall of the duodenum. GG’s stool also tested positive for blood.
http://www.nlm.nih.gov/medlineplus/ency/article/003888.htm
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
16. Define:
H2 Antagonist: a drug that reduces or inhibits the secretion of gastric acid by
binding competitively with histamine to H2 receptors on cell membranes.
http://www.merriam-webster.com/medical/h2%20antagonist
Proton Pump Inhibitor: a group of drugs that reduce the secretion of gastric acid.
http://medical-dictionary.thefreedictionary.com/proton+pump+inhibitors
17. What is the mechanism of action of the following medications GG is receiving:
Nexium: Esomeprazole is a proton pump inhibiort that suppresses gastric acid
secretion by inhibition of H+/K+- ATPase in the gastric parietal cell. The proton
pump blocks the final step in acid production, which reduces the gastric acidity.
http://www.rxlist.com/nexium-drug/clinical-pharmacology.htm
Amoxicillin: amoxicillin acts by inhbiting the synthesis of bacterial cell walls. It
inhibits the cross-link between the linear peptidoglycan polymer chains that make
up a major component of the cell walls of gram-positive and gram-negative
bacteria.
https://www.princeton.edu/~achaney/tmve/wiki100k/docs/Amoxicillin.html
Clarithromycin: prevents the growth of bacteria by interfiering with the synthesis
of the protein.
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.
I would feel comfortable counseling GG in areas of her life that relate to
her diet and her health. Since her ulcer is a major concern I would help her with a
list of foods that she felt she should can could consumer and also help her think of
healthy and fun meals for her and her son to make. I would help her think of a list
of foods high in protein to help her bulk up her calories and get the right nutrition
to help her ulcer to correctly heal and continue leading a healthy life. However, in
regards to talking to someone about her life struggles and overcoming working
while taking care of her son and going through her divorce I would recommend a
therapist to her so she is able to talk and get some advice on how to go about these
different life changes. I would also recommend her going to a physician that she
feels comfortable meeting with and reaching out to when she starts to feel ill.
19. What is the significance of the dark stools?
The dark stool signifies that there is blood in her stool. This is showing
that there is bleeding in the upper gastrointestional tract, such as the stomach.
This indicates that there is most likely another ulcer.
http://www.mayoclinic.org/stool-color/expert-answers/faq-20058080
20. Give the pathophysiology for the cause of the following abnormal values: BUN,
NH3, and WBC.
BUN: blood, urine, and nitrogen test are done to reveal important information
about a patients kidneys and how well they are working. It does this by measuring
the amount of nitrogen in your blood. Higher levels of nitrogen may indicate that
your kidneys are not working properly, which can lead to other health
altercations. In GG’s situation, her BUN levels are elevated, indicating that her
kidneys might not be working as well as they should be.
http://www.mayoclinic.org/tests-procedures/blood-ureanitrogen/basics/definition/prc-20020239
WBC: white blood cells are considered disease-fighting cells. In GG’s situation
she has an elevated level of WBC, which indicates that she currently has an
illness that her body is working to fight off.
http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/whento-see-doctor/sym-20050611
21. GG was probably dehydrated on admission since she had been drinking. This
means that some of her values were probably higher/lower (circle one) than
indicated.
Since GG was drinking she was most likely dehydrated, which would alter
her lab values. This indicates that some of her values were probably higher than
indicated.
22. After admission GG received packed cells and IV fluids. How would that affect
the next set of lab values?
Since GG received packed cells and IV fluid, her next set of lab values
should be more normal than before. Since she is dehydrated her lab values may be
higher than normal and if she is over hydrated her lab values may be lower than
the normal amount.
23. Define the follow:
Packed Cells: a blood product consisting of concentrated cells, most of the
plasma having been removed. Given to a patient who needs red blood cells
without increased fluid volume.
http://medical-dictionary.thefreedictionary.com/packed+cells
Abdominal Tap: a procedure used to remove the fluid from the area
between the stomach wall an the spine (abdominal cavity).
http://www.nlm.nih.gov/medlineplus/ency/article/003896.htm
Perforated Ulcer: an ulcer that bursts through the stomach wall and leaks
food and gastric juices into the abdominal cavity.
http://www.collinsdictionary.com/dictionary/english/perforated-ulcer
Fistula: an abnormal connection between an organ, vessel, or intestine and
another structure. Usually the result of injury or surgery.
http://www.nlm.nih.gov/medlineplus/ency/article/002365.htm
Exploratory Laparotomy: an operation into the peritoneal cavity where the
surgeon examines all surfaces for a lesion
Billroth II: the surgical resection of the pylorus to the stomach, followed
by closure of the cut ends of the duodenum and gastrojejunostomy.
http://medical-dictionary.thefreedictionary.com/Billroth's+operation+II
Vagotomy: severing of the vagus; often a component of gastric surgery
(Nelms, pg G-26)
24. Sketch Billroth I.
25. Compare Billroth I to Billroth II as to anatomical changes as well as to dietary
changes, if any.
Billroth I: is also considered gastroduodenostomy, a partial gastrectomy or
pyloroplasty is performed with a reconstruction that consists of an anastomosis of
the proximal end of the duodenum to the distal end of the stomach.
Billroth II: also considered gastrojejunostomy is a partial gastrectomy with a
reconstruction that consists of an anastomosis of the proximal end of the jejunum
to the distal end of the stomach.
With both of these surgeries nutrient absorption is a concern due to the
fact that parts of the stomach are being removed that are responsible for absorbing
certain nutrients.
(Nelms, pg 364)
26. Calculate GG’s energy and protein needs.
Weight: 98 lbs / 2.2 kg= 44.5 kg
Height: 5 ft. 2 in =(5 feet x 12 in = 60 in + 2 in = 62 in/ .3937 cm = 157.48 cm
EER= 10 X w(kg) + 6.25 (H cm) - 5 (age)- 161
= 10 x ( 44.5 kg) + 6.25 (157.48 cm) – 5 (27)-161
= 445 + 984.25 – 135 -161
= 1133.25
= 1133.25 x 1.2
=1,359.9
GG has a stress factor of 1.2 because she currently had surgery and she is going to
have to learn how to adapt to a new diet. I would recommend trying to get a max
of 1,400 kcals a day to allow her to get an adequate start to a healthy recovery.
Protein: 1.0-1.5 g protein/kg
1.0 g protein X 44.5 kg= 44.5 grams of protein per day
1.5 g protein X 44.5 kg= 66.8 grams of protein per day
45-70 grams of protein
The adequate amount of protein for an individual is 1.0-1.5 g protein/ kg.
The range for GG is 45 grams to 70 grams of protein. Since she is currently
recovering from surgery I would recommend for her to have a greater bulk of
protein to help her properly recover.
(Nelms, pg 61)
27. List the principles of a postgastrectomy diet and briefly describe the scientific
basis for each principle.
- Adequate energy and protein intake to ensure appropriate healing and
recovery postop
o If progression to solid foods does not proceed successfully appropriate
nutrient support may recommended
- Slow progression of solid food to prevent onset of early and late dumping
syndrome.
o Avoid all simple sugars in the beginning
- Lactose intolerant and dairy products should be avoided
- Slowly progress to 5-6 small meals each day
- Consume liquids 30 minutes to 1 hour after solid food
- Lie down after eating
- Addition of functional fibers to delay gastric emptying and assist with
treatment of diarrhea.
- Prevent the development of nutrient deficiencies
o Liquid multivitamins and mineral supplements should be initiated to
meet DRI
o Vitamin B12 injections are initiated if extent of gastric surgery warents
this intervention
- Provide nutrition education that will promote optimal nutritional intake and
minimize symptoms of malabsorption.
(Nelms, 366)
28. Is it possible that GG’s diet will ever change or do you believe she will be on a
postgastrectomy diet for the rest of her life? Explain your answer.
I feel that if GG is currently on a postgastrectomy diet and continues
following an adequate plan she will hopefully be able to change her diet to what
she would prefer. She still needs to continue with the small portioned meals
throughout the day and monitor her fluid intake. I would not recommend her to go
back to her old habits and would make a list of foods she should continue to avoid
to prevent future complications.
Work Cited
Eisner MD, T. (n.d.). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/003888.htm
Glover. (n.d.). Retrieved from http://www.healthassist.net/food/side-effects/sideeffects.shtml
High white blood cell count. (n.d.). Retrieved from
http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/whento-see-doctor/sym-20050611
Longstreth, G. (n.d.). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm
Medline plus: Abdominal tap. (n.d.). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/003896.htm
Medline plus: Fistula . (n.d.). Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/002365.htm
(n.d.). Retrieved from http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf
(n.d.). Retrieved from
http://medicalcenter.osu.edu/patientcare/healthcare_services/digestive_disorders/p
eptic_ulcers/Pages/index.aspx
(n.d.). Retrieved from http://medical-dictionary.thefreedictionary.com/Proton Pump
Inhibitors
Ogbru, O. (n.d.). Retrieved from http://www.medicinenet.com/sucralfate/article.htm
Packed cells. (n.d.). Retrieved from http://medicaldictionary.thefreedictionary.com/packed cells
Picco, MD, M. (n.d.). Stool color: When to worry. Retrieved from
http://www.mayoclinic.org/stool-color/expert-answers/faq-20058080
Sucraflate, carafate. (n.d.). Retrieved from
http://www.medicinenet.com/sucralfate/article.htm