Erin Baas
KNH 413
PUD Case Study
Questions:
1. List all the food items that may contribute to GG’s condition and explain why.
a. GG’s diet consisted of a lot of fast food, fried food, frozen dinners, coffee, chocolate,
and alcohol. Frequently consuming an excessive amount of alcohol causes the lining of
the stomach wall to not be able to properly breathe from the irritating effects of the
alcohol. Overtime this can lead to gastritis. The caffeine found in coffee and chocolate
can increase the stomach acid, which can lead to gastritis. Fast foods contain a lot of
salt, which can irritate the stomach lining and also cause gastritis.
(http://www.peacehealth.org/xhtml/content/cam/hn-1217004.html#hn-1217004- eatingright)
(http://www.the-alcoholism-guide.org/alcoholic-gastritis.html)
2. List any additional oral intake that may have contributed to GG’s condition and explain why.
a. GG’s oral intake of tums, aspirin, and chemicals found in the cigarette smoke may
have contributed to her condition. The chemical irritants found in cigarettes can
damage the lining of the stomach. Taking aspirin frequently like GG does can also
cause damage to the lining of the stomach. Tums reduce stomach acidity to relieve any
burning symptoms a person might have. However, reducing stomach acidity too often
can make it easier for an individual to get an infection.
(http://www.healthcentral.com/acid-reflux/guide-154319-75.html?ic=506048)
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.
a. Trying to balance being a single parent, working, going to school, and having to
maintain good grades could all be contributing to GG’s condition. Being a single
parent isn’t something she can change. However, maybe she could create a better
routine with her mother and babysitting. She could also take fewer credit hours in
school. This way she isn’t so stressed out with homework, will have more time to
spend with her son, and would hopefully not feel the need to drink so often. This would
also allow her time to possibly add physical activity into her daily or weekly routine,
which could definitely help relieve some of her overall stress.
4. List the symptoms of GG’s gastritis.
a. Abdominal pain, burning stomach pain after meals, and indigestion.
5. Was a bland diet necessary? Explain and list the principles of the diet plan that you think GG
should follow.
a. A bland diet was not necessary, but GG should be educated through nutrition therapy
on how she eat more healthfully and what foods she should stay away from so she
won’t worsen her condition. She should definitely stay away from any foods or drinks
that may increase acid production/irritate the stomach. Foods containing high
antioxidant and flavonoid content such as bell peppers, blueberries, cherries, green tea,
squash, apples, cranberries, garlic, and onions would serve her body well in not
worsening her condition. Foods high in flavonoids can potentially help eliminate H.
pylori in the system. Probiotic foods would also serve GG well in that they contain live
bacteria cultures that can help to reduce the number of harmful bacteria in the stomach.
(http://healthyeating.sfgate.com/ulcer-friendly-foods-3909.html)
6. What is the mechanism of action of the following medications GG is receiving: Carafate,
AlternaGel, and Pepcid?
a. Carafate: The mechanism is unknown, but is thought to form an ulcer-adherent
complex with proteinaceous exudate, such as albumin and fibrinogen, at the ulcer site,
protecting it against further acid attack.
b. AlternaGel: It is used to treat symptoms of increased stomach acid, such as heartburn,
upset stomach, sour stomach, or acid indigestion.
c. Pepcid: It decreases the amount of acid the stomach produces.
(www.drugs.com)
7. List the nutrient-drug interactions that are associated with these medications.
a. Carafate: May reduce the absorption of other drugs. Therefore, other drugs should be
taken two hours prior to taking Carafate.
b. AlternaGel: Can interfere with the absorption of many other drugs. Shouldn’t take at
meal time.
c. Pepcid: May interfere with the absorption of other drugs that require acid for adequate
absorption.
(www.medicinenet.com)
8. What are GG’s IBW and percent of IBW (Appendix A, Tables 7 and 8)?
a. IBW = For women 100 lbs for the first 5 feet of height, then add 5 lbs for every inch
over 5 feet, or subtract 5 lbs for every inch under 5 feet.
IBW = 110 lbs
%IBW = actual body weight / usual body weight x 100
= 98 lbs / 110 lbs x 100
%IBW = 89%
9. Estimate her daily energy needs using the harris-benedict equation and appropriate stress
factor (Appendix A, Table 17).
a. Harris-Benedict Equation
= 655 + (9.56 x weight in kg) + (1.85 x height in cm) - (4.68 x age)
= 655 + 425.4 + 291.3 - 126.4
= 1,245 kcals
Stress factor = 1.5 (active; has ulcer)
=1,245 x 1.5
= 1,867 kcals
10. What might be the cause of the LUQ pain along with her usual pain? (Hint: consider the
enzymes that are elevated).
a. Pain in the left upper quadrant is often seen in individuals with gastritis. Elevated liver
enzymes can be caused by GG’s alcohol consumption, which can cause pain.
(https://docs.google.com/a/muohio.edu/viewer?a=v&q=cache:gPLRFmOEKCoJ:mededc
onnect.com/samplechapters/9781455707720/9781455707720.pdf+&hl=en&gl=us&pid=bl&srci
d=ADGEEShXK123BpXE9JfMPjAUTSxtRkvHX0SJBICVURX_pK9_l0AyE12mzx9Cnx7iB8b3TZ
kZfmOtAUghye0DvcjCakQ2eVQE_7XcRx6u65srx78w9Y4FD1RLAp69CNuPvPlyT6t0snn6&sig
=AHIEtbQO-xP6y-ls_dYM_AOr7DMmMDQefg)
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 were 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 with the first labs were drawn
d. GG was over hydrated when the second set of labs were 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 were drawn
14. What diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?
a. GG had an esophagogastroduodenoscopy, which showed she had blood in her stool,
gastritis, and an ulcer. She was also tested positive for H. pylori through an endoscopy.
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
16. Define:
H2 antagonist: An agent that blocks the action of histamine by competitive binding to the
H2 receptor; used to inhibit acid secretion in the treatment of peptic ulcer.
Proton pump inhibitor: A group of drugs that reduce the secretion of stomach acid. They
act by binding with the enzyme H+, K(+)-ATPase, hydrogen/potassium adenosine
triphosphate, which is sometimes referred to as the proton pump. This enzyme
causes parietal cells of the stomach lining to produce acid.
(http://medical-dictionary.thefreedictionary.com)
17. What is the mechnism of action of the following medications GG is receiving: Nexium,
amoxicillin, and clarithromycin?
a. Nexium: A proton pump inhibitor that suppresses gastric acid by specific inhibition of H+,
K(+)-ATPase in the gastric parietal cell.
b. Amoxicillin: Belongs to a class of antibiotics called penicillins. These antibiotics don’t kill
bacteria, but they stop bacteria from multiplying by preventing bacteria from forming the walls
that surround them.
c. Clarithromycin: Prevents bacteria from growing by interfering with their protein synthesis.
(www.medilexicon.com)
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.
a. I would definitely want to counsel GG on how she could reduce her symptoms by
improving her diet and educating her on what foods/drinks will aggravate her the most
and the least. However, I would not feel comfortable aiding her on which medications
would be best for her to take. I would recommend she see a physician/doctor when it
comes to medications.
19. What is the significance of the dark stools?
a. Blood in the stool can come from anywhere along the digestive tract. Dark/black stools
usually mean the blood is coming from the upper part of the GI tract. This includes the
esophagus, stomach, and the first part of the small intestine.
(http://www.nlm.nih.gov/medlineplus/ency/article/003130.htm)
20. Give the pathophysiology for the cause of the following abnormal values: BUN, NH3, and
WBC.
a. BUN: High BUN levels mean your kidneys aren’t working well. It can also be caused
by urinary tract obstruction, congestive heart failure, or gastrointestinal bleeding.
b. NH3: Abnormal values of NH3 can be caused by congestive heart failure, GI bleeding,
genetic diseases of the urea cycle, hyperthermia, and liver failure.
c. WBC: High WBC count is called leukocytosis. This can be caused by anemia, bone
marrow tumors, infectious diseases, inflammatory disease, leukemia, severe emotional
or physical stress, or tissue damage.
(http://www.nlm.nih.gov/medlineplus/)
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.
a. This would cause the next set of lab values to be decreased.
23. Define the following terms:
Packed cells: A preparation of blood cells separated from liquid plasma, often
administered in severe anemia to restore adequate levels of hemoglobin and red
blood cells without overloading the vascular system with excess fluids.
Abdominal tap: A procedure used to remove fluid from the area between the belly wall
and the spine, otherwise known as the abdominal cavity.
Perforated ulcer: An ulcer extending through the wall of an organ.
Fistula: An abnormal or surgically made passage between a hollow or tubular organ and
the body surface, or between two hollow or tubular organs.
Exploratory Laparotomy: An incision through any part of the abdominal wall for the
purpose of physically examining the contents of the peritoneal cavity.
Billroth I: Excision of the pylorus with end to end anastomosis of the upper portion of the
stomach and the duodenum.
Vagotomy: The surgical cutting of the vagus nerve to reduce acid secretion in the
stomach.
(http://medical-dictionary.thefreedictionary.com/packed)
24. Sketch Billroth I.
25. Compare a Billroth I to a Billroth II as to anatomical changes as well as dietary changes, if
any.
a. Billroth I, a partial gastrectomy, is the surgical removal of a section of the stomach,
and then reconnects the top half of the stomach to the duodenum. Billroth II, a
gastrojejunostomy, removes part of the stomach, and then the top half of the stomach is
reconnected to the small bowl. After either of these surgeries, patients will need to eat
smaller, more frequent meals while decreasing their oral intake.
(Nutrition Therapy & Pathophysiology, page 364)
26. Calculate GG’s energy and protein needs.
a. Energy Needs:
EER = 354 - 6.91 x age + PA x (9.36 x weight + 726 x height)
= 354 - (6.91 x 27) + 1.45 x (9.36 x 44.55) + (726 x 1.57)
= 1,911 kcals
= 1,900-2,000 kclas/day
Protein Needs:
= Around 15%
= 1950 x .15
= 293 kcals/day from protein
27. List the principles of a postgastrectomy diet and briefly describe the scientific basis for each
principle.
a. Eat calorie dense foods to maintain body weight. Eat a variety of foods by gradually
adding foods to your diet, such as fruits, vegetables, whole grains, protein rich foods,
dairy products, etc. Eat small frequent meals to make sure you’re getting the proper
nutrition. Therefore, always carry snacks with you and don’t go more than 2-3 hours
without eating something. Add more calories whenever possible to, once again, make
sure you are maintaining your body weight. Drink nutrient rich beverages that provide
a lot of calories. These can be easier to get down than solid foods. Even though you
may not be hungry, make sure you eat, because the food and nutrients are what are
going to help excel the healing process.
(http://www.nostomachforcancer.org/gastric-cancer/life-without-a-stomach/basicprinciples-of-nutrition-after-gastrectomy)
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?
a. Following a postgastrectomy diet at first will be important for GG to help her recover.
However, as long as she starts gradually adding in a more healthful range of foods over
time, and steers clear from the foods and drinks that were causing her symptoms in the
first place, I think she will be able to eat more than just what is recommended.
Optional Questions:
29. If GG were 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?
a. Characteristics: Small frequent feedings, calorie dense foods, variety of foods, high
protein, high fat, low CHO, and liquid between meals.
30. Using the table below, compare several of the enteral nutritional supplements that would be
appropriate for GG.
Prod
uct
Prod
ucer
Form
Ensur
e high
protei
n
Ensur
e
vanill
a
ready
to
drink
Ensur
e high
protei
n
shake
Ensur
e
Crea
my
milk
choc.
ready
to
drink
Cal/
mL
0.97
Nonpro
cal/g
N
Pro
(g/L)
CHO
(g/L)
Fat
(g/L)
Na
mg
K
mg
93:1
12
31
6
290
500
25
23
2.5
280
440
mOs
m /kg
water
Vol to
meet
RDA
in ml
g of
fiber
/L
610
237
0
414
3
Free
H2O
/L in
ml
Prod
uct
Prod
ucer
Form
Ensur
e plus
Ensur
e
Butter
pecan
ready
to
drink
Ensur
e
Ensur
e
Ensur
e
Enliv
e
Ensur
e
Cal/
mL
Nonpro
cal/g
N
Pro
(g/L)
CHO
(g/L)
Fat
(g/L)
Na
mg
1.5
146:1
13
50
11
220
Straw
berry
ready
to
drink
1.06
149:1
9
40
6
Apple
ready
to
drink
1.01
7
43
0
K
mg
mOs
m /kg
water
Vol to
meet
RDA
in ml
g of
fiber
/L
400
680
237
0
200
370
620
237
0
35
35
796
198
0
Free
H2O
/L in
ml