ANDREWS UNIVERSITY DIETETIC INTERNSHIP
Major Case Study
Gastrointestinal Diseases and Nutrition Support
Rebekah Vukovich
4/14/2015
Introduction:
N.P. is a 63 years old female with multiple abdominal surgeries and
complications. On 1/8/15 she weighed 44kg and on re-admission on 3/24/15 she
weighed 49kg. Her height is 152.4 cm with a BMI of 18.9. This patient was chosen for
the case study due to her history of abdominal surgeries, nutrition support, and
significant weight loss due to illness. The study began in January and ended April 4,
2015. The focus of this study is gastrointestinal diseases and their impact on nutrient
intake. This span of this case study followed N.P. during two of her recent admissions,
though I also completed a nutrition assessment for her earlier in December. Admission
1 will refer to the admission date of 1/8/15. Admission 2 will refer to her readmission on
3/24/15.
Social History:
N.P is married and previously worked as a housekeeper, though she is retired
now. She has been living in an extended care facility from October 2014 to January
2015. After discharge in January, she lived at home and received home health care
visits. Following discharge in April, the patient was admitted to a short-term rehab
facility. She smoked 2 packs a day for 48 years, but quit smoking in June 2014. Patient
is self-pay.
Normal Anatomy and Physiology of Applicable Body Functions:
The gastrointestinal tract is responsible for digesting and absorbing nutrients and
expelling waste and it includes all the structures between the mouth and anus. The
stomach has five regions, the cardia and gastroesophageal junction, fundus, corpus,
antrum, and pylorus.1 The fundus and corpus regions include acid-secreting glands, the
HCL-secreting parietal cells, and the pepsinogen-secreting chief cells. Acid secretion is
stimulated by acetylcholine (released by the vagus nerve), histamine (released locally
by enterochromaffin-like cells), and gastrin.1 The antrum includes the alkaline-secreting
cells and the G-cells which secrete gastrin.
The stomach contributes to the digestion of food by mixing chyme with acid and
pepsin. Pepsinogen, activated to pepsin in the presence of luminal acid, helps to break
down protein into peptides. Parietal cells secrete intrinsic factor, which is essential in
the absorption of vitamin B12 further down in the terminal ileum. Gastric acid aids in the
absorption of calcium, iron, and other trace minerals.1 The stomach has an important
role in regulating food intake and satiety. Ghrelin, released by gastric mucosal cells, is
an appetite stimulating hormone that is released to the portal circulation and on to the
central circulation. Following bariatric surgery, the baseline and pre-meal peaks of
ghrelin are suppressed, which may lead to the suppression of appetite following this
surgery.1
The small intestine is comprised of the duodenum, jejunum, and ileum. The
small intestine further breaks down chyme into nutrients that can be absorbed across
the epithelium. The jejunum starts at the ligament of Treitz. In some instances, tube
feedings may be place after this ligament in order to reduce risk of aspiration.
Pancreatic enzymes and bile, which enter the small intestine, break down the
molecules. The small intestine also has a critical role in water and acid-base balance. A
key mechanism in absorption is establishing an electrochemical gradient of sodium
across the epithelial cell boundary of the lumen.2 Carbohydrates are broken down by
intra luminal amylase and amylopectin.2 The majority of protein is absorbed in the
jejunum after being broken down by pancreatic trypsinogen and endopeptidases.2 Bile
works to break down fat globules into smaller sizes and then micelles are formed, which
diffuse into the interior of the cell. Calcium is absorbed in the duodenum and jejunum
and iron is absorbed in the duodenum.2
Past Medical History:
N.P has a history of: partial gastrectomy, gastrointestinal bleed, hypertension,
tracheostomy, myocardial infarction, colostomy, ulcers, chronic obstructive pulmonary
disease, depression, coronary disease, transient ischemic attack, cardiac stents, and
rheumatoid arthritis.
Previous admissions to the hospital:
12/28/14 Hyperkalemia, weakness, dehydration, acute kidney injury
12/1/14 Septic shock, acute renal failure
10/23/14 Acute abdominal pain; jejunal resection; duodenostomy; hernia repair;
chronic antral ulcer; gangrene of the gallbladder, colon, ileum, duodenum, and
abdominal wall. A second surgery during admission for resection of portion of ileum,
gastrostomy tube placement, debridement of abdominal wall, subtotal abdominal
colectomy (removing the colon and leaving the rectum), and end ileostomy.
7/22/14 Upper GI bleed, peptic ulcer, anemia, COPD, partial gastrectomy for
recurrent upper GI bleed (gastrostomy w/ RNY gastrojejunostromy), G-tube placed
5/22/14 GI bleed, AKI, dehydration, upper GI endoscopy showed hiatus hernia
and gastric ulcer in pre-pyloric region
3/18/14 Hematemesis, reflux esophagitis, hiatal hernia, chronic gastritis, gastric
ulcer
7/27/12 Exploratory laparotomy, small bowel obstruction
6/8/12 Perforated duodenal ulcer with peritonitis, exploratory laparotomy with
graham patch placement over ulcer
6/6/12 Acute abdominal wall strain
3/24/12 Cardiac stents placed
3/7/11 Cardiac arrest, myocardial infarction, ventricle fibrillation
6/6/07 Right total knee replacement
3/7/07 Acute right knee injury with ligation tear
In May and July of last year, N.P. presented to the hospital with a
gastrointestinal (GI) bleed. A GI bleed refers to any bleeding that starts in the
gastrointestinal tract and signs include dark, tarry stool; large amounts of blood passed
from the rectum; small amounts of blood in the toilet, or in streaks of stool; and
vomiting blood.3 A GI bleed may be caused by abnormal blood vessels in the lining of
the intestines, diverticulosis, ulcerative colitis, esophageal varices, esophagitis, gastric
ulcer, intussusception, Mallory-Weiss tear, Meckel’s diverticulum, or GI cancer.3
Also in July, N.P. underwent a gastrectomy, a total resection of the stomach, due
to recurrent GI bleeds. The patient’s diagnosis stated that she had a chronic antral ulcer
refractory to medication with recurrent GI bleeding. Clinical symptoms of a peptic ulcer
are epigastric discomfort, burning pain which tends to be more severe at night, nausea,
vomiting, flatulence, and weight loss.4 Other complications of peptic ulcers are
perforation, the ulcer eats a hole in the wall of the stomach in which partially digested
food can spill, or obstruction, swelling and scarring which may narrow the intestinal
opening.5 Medical management of an ulcer depends on its primary cause, which may
include H. Pylori infection, stress, gastritis, or chronic NSAID use.4 H.Pylori is the major
cause of stomach ulcer and this bacteria produces substances that weaken the
stomach’s protective mucus barrier and therefore make it more susceptible to the
damaging effects of acid and pepsin.5
In a partial gastrectomy, up to 75% of the distal stomach is removed.6 This
includes the antrum, which secretes gastrin. Per operative records, N.P. had a
laparoscopic antrectomy and gastrostomy w/ RNY gastrojejunostomy. In an
antrectomy, the portion of the stomach distal to the antrum is removed. A
gastrojejunostomy involves reattaching the remaining part of the stomach to the side of
the jejunum. The duodenum is kept to allow for the continued flow of bile and
pancreatic enzymes into the intestines.6 The definition of the roux-en-Y procedure is
very similar; it connects the remaining part of the stomach with the jejunum.
During an ileostomy, an opening is made from the small intestine to the abdominal wall
where waste will now leave the body. The waste produced is a watery stool because
fluid is not as effectively reabsorbed without the colon. Since the amount, frequency,
and consistency of stool is influenced by the diet, it is necessary to following ostomy
diet recommendations. Jejunal resections may have nutritional complications due the
jejunal enterohormones that have important roles in digestions and absorption.
In November, N.P. had a gastrostomy tube placement. With a percutaneous
endoscopic gastrostomy (PEG), a tube is place directly into the stomach through the
abdominal wall. This type of feeding method may be performed when the need for
enteral feedings is expected for more than 3-4 weeks. Gastrostomy feedings also
reduce the complications and discomfort associated with nasogastric and oral gastric
tubes. During this non-surgical procedure, a tube is endoscopically guided from the
mouth into the stomach or the jejunum and then brought through the abdominal wall.
PEG’s have a short piece of tubing that can be used to inject feeding with a syringe or
connect to a feeding bag.
Present Medical Status and Treatment
Admission 1
Date: 1/8/15 - 1/16/15
Impression:
 Severe sepsis due to abdominal abscess, complicated by septic shock
 Advanced COPD
 Right lower quadrant fluid collection
 Acute abdominal pain related to mesenteric edema
 Possible abscess
 Peritonitis
 Leukocytosis
 Hypertension
Sepsis is a response of the immune system to a bacterial infection and it may be
called systemic inflammatory response syndrome.5 In N.P. the sepsis began in the
abdomen, caused by an abdominal abscess and peritonitis. The sepsis worsened which
lead to septic shock and low blood pressure. The usual treatment for sepsis is
intravenous antibiotics, IV fluids, oxygen, and medications to increase blood pressure.5
N.P developed hypotension, which was treated by giving a fluid bolus.
Intra-abdominal abscess is a collection of pus or infected fluid that is surrounded
by inflamed tissue inside the abdomen and can be caused by bacterial infection.7 Blood
tests (WBC), imaging tests, and a physical exam are used to diagnose an intraabdominal abscess. N.P. had elevated WBC and well as a CT scan, which revealed fluid
collection in the right lower quadrant and mesenteric edema. In most cases, the site
needs to be drained of fluid in order to heal. Antibiotics are typically given as well. The
physician notes that for N.P. the abscess was due to the recent removal of the
duodenostomy tube. N.P. had a CT-guided drainage to remove the fluid. The patient
also received somatostatin to decrease the stoma and drain with bilious fluid
production. Somatostatin is a peptide hormone that is prescribed for gastrointestinal
hemorrhage. It also decreases the release of most gastrointestinal hormones and
reduces gastric acid and pancreatic secretion.5
Peritonitis is inflammation of the peritoneum; caused a collection of blood, body
fluids, or pus.5 The peritoneum is a membrane that lines the inner abdominal wall and
abdominal organs. Symptoms may include abdominal pain, fever, excessive fatigue,
nausea, vomiting, passing little or no stool or gas, and shortness of breath.
Leukocytosis is an increase in the total number of white blood cells due to any
cause. Leukocytosis occurs in response to various infections, inflammation, and
physiologic processes such as stress. The usual treatment is based off of the initial
cause of the altered white blood cells. Treatments may include IV fluids, antibiotics,
steroids, antacids, and blood transfusions.
Admission 2
Re-admission: 3/24/15 – 4/4/15
Impression:
-Polymicrobial septicemia (likely from original UTI)
-Fungal septicemia
-Hyponatremia
-Weakness
-Leukocytosis
-Anemia of chronic illness and malnutrition
N.P. presented to the hospital with complaints of weakness, fatigue, low back
pain, and cough for the past two weeks. The dehydration may be related to the
patient’s ostomy. When diarrhea occurs with an ostomy, it is very easy to lose large
amounts of water, minerals, and vitamins which can lead to dehydration.8 Prior to
admission, she was residing at home, mostly homebound. She has been receiving TPN
and lipids since previous discharge in January with some oral intake reported.
The hyponatremia may be related to dehydration and normal saline was given as
a treatment. Normal saline is sterile, nonpyrogenic solution for fluid and electrolyte
replacement. It contains 154 mEq sodium and chloride and is used as a source of water
and electrolytes.9
Short bowel syndrome is defined as nutrient malabsorption that can occur after
surgical resection, congenital defect, or disease of the bowel.10 Short bowel syndrome
(SBS) is a concern after surgery when 40% or more of the small intestine is removed,
particularly the ileum and ileocecal valve.11 Per the physician notes in March 2015, N.P.
has short bowel syndrome and will require long-term TPN due to malabsorption. The
location of the resection and the adaptability of the remaining intestine are key factors
for the degree of nutritional problems.11 Short bowel syndrome often results in
diarrhea, steatorrhea, weight loss, muscle wasting, bone disease, and malabsorption of
several nutrients.11 N.P. has shown signs of diarrhea, weight loss, and anemia, though
additional vitamin/mineral deficiencies may also be present.
Managing symptoms and improving intestinal absorption are the main focuses of
treatment for short bowel syndrome. The remaining section of the small intestine is
able to adapt by growing in length, diameter, and thickness and thus increase the
absorptive area and somewhat compensate for the removed section.10,11 Newer
research indicates that minimal stimulating with early feedings is actually good for
recovery and adaption of the gut.11 In cases of severe SBS, consuming up to two times
basal energy expenditure may be needed to absorb enough calories.12 However, in
some cases, parenteral nutrition may be necessary to preserve nutritional status.
Parenteral nutrition may be maintained until intestinal rehabilitation is complete and
oral intake meets nutritional needs.12
In SBS, medications that slow gastric emptying and intestinal motility and
manage symptoms of diarrhea, steatorrhea, and bacterial overgrowth may be
prescribed.11 These medications may also increase nutrient absorption.13 Intestinal
adaptation has had some success with the use of growth hormone, glutamine, fiber,
and epidermal growth factors.11
N.P. was discharged to a short-term nursing facility on IV anti-fungal and TPN.
Labs (1/11/15)14
Name
Value
Normal Range
Hemoglobin (Hgb)
10.4 g/dL
11.6-14.8 g/dL
Hematocrit (Hct)
35.4%
35-49.0%
White Blood Cells
(WBC)
Glucose
15.6 K/mm3
3.8-10.4 K/mm3
172 mg/dL
60-110 mg/dL
BUN
14.0 mg/dL
BUN/Creatinine ratio 24.1
7-17
8-20
Sodium
132 mmol/L
137-145 mmol/L
Potassium
Phosphorus
4.0 mmol/L
3.1 mg/dL
3.4-5.1 mmol/L
3.6-5.0 mg/dL
Free
Triiodothyronine
2.26 pg/mL
2.77-5.27 pg/mL
Possible
Indication(s)
Anemia, nutritional
deficiency
Anemia,
malnutrition,
hemolytic reaction
Infection, stress,
inflammation
Uncontrolled BG,
acute stress
response, diuretic
therapy,
corticosteroid
therapy
WNL
Reduced renal
perfusion, GI bleed,
trauma
Diuretic
administration,
excessive IV water
intake, peripheral
edema, intraluminal
bowel loss
WNL
Inadequate dietary
ingestion of
phosphorus, Vit. D
deficiency, chronic
antacid ingestion
Hypothyroidism
Medications
Medication
Use/purpose
Sodium
chloride (IV)
Fluid and sodium
chloride
replacement
Provides M/V when
NPO
Antiasthma,
bronchodilator
Sleep aid
MV injection
in TPN
Albuterol
Ambien
Aspirin
Analgesic,
antipyretic,
antiarthritic, NSAID
Sucralfate
Antiulcer
Sandostatin
Antidiarrheal
(parental only)
Norco 10/325
Analgesic,
antitussive
Sodium
bicarbonate
tab
Antacid, alkalinizing
agent
Drug/food interactions
Relevant side
effects
Fluid wt. gain
Limit caffeine/xanthine
Increase appetite, anorexia
Do not take immediately
after a meal as food
decreases absorption and
delays onset of drug action.
Insure adequate fluid
intake/hydration. Increase
foods high in Vit. C and
Folate with long-term high
dose. Avoid or limit natural
products which affect
coagulation (garlic, ginger,
gingko, ginseng, or horse
chestnut)
Bland diet may be
recommended. Take
calcium or Mg supplement
separately by >30 min.
Low-fat diet may decrease
GI side effects. May cause
fat and fat soluble vitamin
malabsorption and delay
gallbladder emptying. Alters
insulin, growth hormone,
thyroid hormone, and
glucagon levels.
Consider the Na content
with low-sodium content.
Take Fe supplement
N/V, dyspepsia,
black tarry stools
Decreases pepsin
activity by 32%
N/V, abdominal
pain, bloating,
diarrhea, flatulence
Prolonged use may
produce
constipation
Increase thirst,
increase wt.
(edema), belching.
separately. Caution with Ca
sup or high milk intake with
long-term use- may cause
milk-alkali syndrome.
Lasix
Diuretic,
antihypertensive
Zosyn
(parental
only)
Novolog
Antibiotic
Lactated
Ringers
Fluid and
electrolyte
replenishment ,
alkalinizing agent
Analgesic
Fentanyl
Diabetic meal plan to
balance carb w/ insulin.
Lipitor
(atorvastatin)
Antihyperlipidemic
Questran
Light
Antihyperlipidemic
FiberCon
Laxative for
constipation/bulking
agent, used to firm
the stool for an
ileostomy or
colostomy
Antitussive,
analgesic
Codeine
Sulfate
Caution w/ K sup
Anorexia, increase
thirst, decreased
blood pressure.
Fluid/electrolyte
imbalances.
Anorexia, n/v,
epigastric distress
May increase wt.
May interact with
corticosteroids or
corticotrophin
Anorexia, dry
mouth, dyspepsia,
N/V, abdominal
pain, constipation,
diarrhea
To help reduce chol.,
reduce dietary fat and
cholesterol. Limit
grapefruit and related
citrus.
May also include dietary
changes to reduce
cholesterol.
High fiber w/ 1500-2000
mL fluid/day to prevent
constipation. Take Fe, Zn,
Ca, or F supp separately by
1-2 hr.
May decrease
absorption of fat
and some
vit/minerals.
Belchig, N/V,
dyspepsia,
constipation.
Ca is about 30%
absorbed, provides
significant dietary
Ca.
Anorexia, delays
digestion,
constipation, dry
Lomotil
Antidiarrheal
Metronidazole Antibiotic,
amebicide,
antitrichomonal
Diarrhea may increase fluid
and electrolyte needs.
Consider Na content w/ low
Na diet
Prozac
Antidepressant,
SSRI
Avoid tryptophan sup (will
increase drug side effects)
Imodium
Antidiarrheal (also
indicated to reduce
volume of
discharge from
ileostomies)
Antihypertensive
Antigerd,
antisecretory
Diarrhea may increase fluid
and electrolyte needs.
Insure adequate fluid
intake/hydration.
Lopressor
Protonix
Zofran
Antiemetic,
antinauseant
Morphine
Sulfate
Analgesic
Porcine
(Heparin)
Anticoagulant
Albumin
(human)
Hypovolemia,
hypoalbuminemia
Avoid natural licorice
May decrease absorption of
Fe. And Vit. B12.
mouth, constipation
Anorexia, dry
mouth, constipation
Anorexia, metallic
taste, N/V,
epigastric distress,
diarrhea
Anorexia, dry
mouth, dyspepsia,
nausea, diarrhea
Diarrhea
Decrease gastric
acid secretion,
increase gastric pH,
diarrhea
Abdominal pain,
constipation,
diarrhea
Anorexia, decrease
wt., increase thirst,
dehydration,
decrease gastric
motility, N/V
Abdominal pain, GI
bleeding,
constipation, black
tarry stools
N/V
Medical Nutrition Therapy:
Nutrition History: N.P. was on bariatric diet protocol after partial gastrostomy surgery
(7/2014). In August 2014, N.P. met with an outpatient dietitian here and reported
eating 4-6 small meals per day, consisting of mostly soft foods such as oatmeal, eggs,
baby cereal, baby food, cottage cheese, and bananas. Prior to admission, patient was
consuming a soft diet with no supplements at the nursing home. Patient reports that
she did not like the pureed diet that she received at the nursing home.
Diet History: At re-admission on 3/25/15.
Typical Intake Recall:
Medications: Takes with applesauce, pudding, or yogurt
Breakfast: 6 oz. yogurt, oatmeal
Lunch: may have chicken, hamburger, or macaroni and cheese
Dinner: similar items as lunch, ~4 oz. chicken, fish, or steak, hamburger,
hotdog, or macaroni and cheese
Pt. states that she “eats what my husband gives me” and may take up to
1 hour to finish the meal.
Fluids: Pt. drinks PowerAde, Pedialyte, ginger ale
Current Diet Order:
Admission 1/8/15 - 1/16/15: TPN and NPO.
1/9/15 TPN order: Clinimix 5/15 with 250 ml 20% lipids. This provides 1920 kcal
(140% of kcal needs) and 100 gm pro (192-114% of protein needs). Multivitamin
added to the TPN.
The physician recommended a complete bowel shut down for bowel rest for a
minimum of two weeks related to the mesenteric edema. Total parental nutrition (TPN)
was started at this time.
1/12/15 TPN order changed to 1320 ml with 250 ml 20% lipids per RD
recommendations. This provides 1437 kcal/day (104% of kcal needs) and 66 g/d (75127% of protein needs) protein.
Re-admission 3/25/15: TPN and progression of Regular Diet, Pureed, Clear Liquids,
Full Liquids, and Regular Diet.
Patient continued to receive the same TPN amount that she was receiving at
home prior to this admission. The order was 1320 ml with 250 ml 20% lipids per RD
recommendations. This provides 1437 kcal/day (104% of kcal needs) and 66 g/d (75127% of protein needs) protein.
Oral Intake:
3/25: Breakfast 75% (Regular diet: oatmeal, scrambled eggs, banana, and
coffee)
Lunch 50% (Regular diet: meatloaf, potatoes, green beans, juice, coffee,
and gelatin),
Dinner 50% (Pureed diet: cream soup, fruit ice, gelatin, and coffee)
3/26: Breakfast unknown % consumption (Pureed diet: oatmeal, milk, coffee)
Lunch unknown % (Pureed diet: fruit ice, Ginger ale, gelatin, yogurt)
Dinner unknown % (Pureed diet: yogurt, banana, fruit ice, soda)
3/27: NPO, no meal orders.
3/28: Lunch (Clear liquids: 8 oz. chicken broth)
Dinner (Clear liquids: 8 oz. chicken broth, 4 oz. gelatin)
3/29: Breakfast unknown % (Clear liquids: juice, ginger ale, gelatin, fruit ice,
coffee)
Lunch unknown % (Clear liquids: chicken broth, ginger ale, fruit ice)
Dinner unknown % (Full liquids: gelatin, fruit ice, cream soup)
3/30: Breakfast 50% (Full liquids: oatmeal, milk, yogurt, soda)
Lunch 100% (Full liquids: cream soup, yogurt)
Dinner 25% (Full liquids: fruit ice, gelatin, yogurt)
3/31: Breakfast 50% (Full liquids: gelatin, soda, ginger ale)
Lunch unknown % (Full liquids: ginger ale, soda, cream soup, popsicle)
Dinner unknown % (Full liquids: ginger ale, soda, cream of wheat, milk,
pudding)
4/1: Breakfast 25% (Full liquids: oatmeal, ginger ale, soda, yogurt)
Lunch unknown % (Full liquids: soda, ginger ale, juice, pudding, gelatin,
popsicle)
Dinner 25% (Regular diet: macaroni and cheese, yogurt, banana, soda,
ginger ale)
4/2: Breakfast 25% (Regular diet: oatmeal, milk, banana, soda, coffee)
Lunch: unknown % (Regular diet: cream of wheat, milk, yogurt, ginger
ale, soda)
Physical and Physiological Response to the Diet:
Admission 1/8/15 - 1/16/15: Weight increased from 44 kg (1/8/15) to 56kg
(1/16/15). However, this is most likely due to intake greater than output, with
>11,000ml positive balance the first three days of admission. Patient was also receiving
IV fluids. Bedside blood glucose values increased due to direct infusion of dextrose from
TPN into the blood stream. Patient was started on Novolog (insulin) to regulate blood
glucose levels. Per progress notes, decreased drain and stoma output, and no nausea
reported. Per GI symptoms, pt. had abdominal pain. Patient had decreased ileostomy
output related to lack of food entering the GI tract.
Re-admission 3/25/15: Patient was tolerating TPN and diet was advanced to
regular. Patient’s nurse reported that the Ensure supplement was passing very quickly
through the stomach and the small intestine and going straight into the ileostomy bag.
This may be due to the high osmolality and high sugar content of the supplement. The
supplement order was changed to PRN. The patient’s weight increased to 62.2 at
discharge. Total input and output during this admission was recorded as +7300 ml,
which contributed to the weight gain.
Nutrition-Related Problems with Supporting Evidence:
PES Statement:
Admission 1/8/15 - 1/16/15:
Malnutrition related to chronic illness of sepsis as evidenced by 19% weight loss
past 6 months, poor grip strength, subcutaneous fat loss, muscle atrophy and poor oral
intake for 3 days which meets the parameters for severe protein-calorie malnutrition
(PCM)15,16
Re-admission 3/25/15:
Inadequate oral intake r/t poor appetite and fatigue as evidenced by reported
poor po intake >5 days.16
Weight History:
Date
Weight
3/24/15
49.0kg
1/8/15
44.0kg
12/28/15
45.18kg
12/2/14
45.6kg
10/23/14
56.5kg
8/2/14
59.8kg
7/22/14
54.3kg
3/18/14
61.3kg
% change
11% wt.
gain in 2 ½
months.
22% wt.
loss in <3
months.
(severe)
28% wt.
loss in past
10 months.
(severe)
5.5% wt.
loss in 2 ½
months
10% wt.
gain in past
1 month
11.4% wt.
loss in 4
months
Nutrition-Focused Physical Assessment:
Orbital: loss of bulge under eye, somewhat hollow (indicates mildmoderate)
Triceps: upper-arm muscle area below average
Temporal: slight depression of the temporalis muscles (mild-moderate)
Clavicle: somewhat protrusion of clavicle
Shoulders: some squaring of shoulders/loss of roundness, some protrusion
of the acromion process
Interosseous: slightly depressed
Hand-grip strength: poor
Nutritional Needs: (based on IU Health Goshen Hospital standards of practice)
Calories: BMR = 917 kcal (based on Mifflin-St. Jeor)
Activity Factor: 1.0
Stress Factor: 1.4 for sepsis = 1375 kcal
Protein: 52-88 g/d; based on 1.2-2.0 g/kg for sepsis/catabolic
Fluid: 1200 ml/d; based on 30 ml/kg
Nutritional Complications and Recommendations for GI Illness and Surgeries
The standard progression of oral intake following most types of gastric surgery
begins with small, frequent feedings of ice or water. Next, liquids and easily digested
solid food, and lastly a regular diet. If an extended period of healing is anticipated, the
patient may receive enteral nutrition. There are nutritional complications after this
surgery, including obstruction, dumping, abdominal discomfort, diarrhea, and weight
loss. The roux-en-Y procedure causes impaired digestion and absorption, due to the
chyme not passing through the duodenum.6 This malabsorption may lead to anemia,
osteoporosis, and certain vitamin and mineral deficiencies long-term. There is a loss of
gastric acid secretion which normally facilitates the iron absorption. In addition, intrinsic
factor production may be inadequate causing incomplete Vitamin B12 absorption.6 As a
result, patients should take Vitamin B12, either as an injection or oral supplement. Diet
recommendations post-RNY are to avoid concentrated sweets and emphasize protein,
fat, and fiber to slow digestion. Small, frequent meals are typically tolerated better.
Following an ileostomy, nutritional complications may occur due to
malabsorption. There is a decrease in fat, bile acid, and vitamin B12 absorption.8 Since
bile is not adequately reabsorbed, malabsorption of fat and fat-soluble vitamins may
occur.11 In addition, there is a greater loss of sodium, potassium, as well as fluid due to
diarrhea.8 In addition, vitamin B12 will not be absorbed because its site of absorption is
in the distal small intestine which is removed in the ileostomy.11 The patient will need
adequate intake of protein, vitamin B12, folic acid, calcium, magnesium, iron, sodium,
vitamin C, potassium, and fluids.8
Gas and order may also be a problem with an ileostomy. Avoiding cruciferous
vegetables, legumes, and other potential gas-forming fruits and vegetables may help to
reduce gas.11 Foods that may cause odors are similar to those that cause gas, but may
also include corn, fish, highly spiced foods, and medications such as antibiotics and
vitamin-mineral supplements.11 To reduce incidence of dumping, take fluids between
meals instead of with meals. A reduction in simply carbohydrates and an increase in
complex carbohydrates may help to lessen osmotic diarrhea.
In the post-operation period following small bowel surgery, a high-energy, highprotein diet is important for would healing. Following surgery, a clear liquid diet is
ordered, which typically progress to full liquids and then soft foods. As the diet
advances, it is important to chew foods well, especially fibrous items to avoid
obstruction and small, frequent meals are recommended.11 As the ileum heals and
adapts, a near regular diet can often be tolerated and the patient can learn to alter
their diet based on foods that cause gas or other complications.
Nutrition therapy following a small bowel resection is critical to a patient’s
prognosis. In cases where less than 100 centimeters of the small intestine remains, only
about 50-60% of oral intake is absorbed and therefore oral intake needs to be
doubled.11 Following a surgery that removes over half of the small intestine, TPN is the
firth method of nutrition, followed by enteral feedings as soon as possible to stimulate
adaptation. Enteral feedings should be an elemental formula to lessen the work load of
the intestine and should be begin with a small volume. Medium-chain triglycerides
require minimal enzyme activity for digestion and can provide necessary calories.
Ideally, the TPN rate can be reduced as the enteral nutrition increases. As the oral
intake progresses, eating 6-10 small meals a day is recommended and a low-fat diet
can help to control steatorrhea. Foods that may cause a problem are concentrated
sweets, caffeine, sugar alcohols, and lactose. It is important to monitor fluid needs and
intake because patients with SBS are at high risk for dehydration, particularly those
without a colon.10 Oral rehydration supplements taken throughout the day can help to
maintain hydration.10
Supplements and medications can help to meet nutritional needs and manage
complications. A chewable or liquid vitamin and mineral supplement that includes
calcium, magnesium, zinc, iron, manganese, vitamin C, selenium, potassium, folic acid,
B-complex vitamin, and water-miscible forms of vitamins A, D, E, and K is
recommended.11
Long-term TPN
Parental nutrition has been able to be managed at home on a long-term basis
since the 1970’s. PN is commonly used in managing patients with intestinal failure.
There are three subclasses of intestinal failure and N.P.’s condition would fall under
type 2, which occurs in severely ill patients who develop septic, metabolic, and nutrition
complication following gastrointestinal surgery.17 About half of patients with type 2
intestinal failure will go on to develop type 3, a chronic condition requiring long-term
nutritional support.17
PN formulas are often compounded in a single bag that typically includes
macronutrients and trace elements. The addition of vitamins to PN mixtures may
accelerate chemical degradations and therefore some patients chose to add vitamins to
their PN bags just prior to delivery. Trace elements, including zinc, selenium, copper,
manganese, and chromium, are essential components of PN and should be monitored
regularly. A fixed dose of these trace elements may contribute to excessive copper,
manganese, and chromium and may provide less than optimal zinc and selenium.18
Complications with home PN may occur, however delivery by skilled nutrition teams has
a low incidence of catheter-related complications and fatality incidences are primarily
related to the underlying condition.17
Nutrition Monitoring & Evaluation
Energy intake: Meeting 80-100% of her nutrition needs via TPN.
Fluid intake: Monitor for meeting fluid needs through TPN and orally. A patient with a
small bowel stoma, such as N.P., will have greater fluid loss compared to a patient who
still has her colon in continuity with the small bowel.
Anthropometrics: Monitor for weight changes. Goal is to not have any further wt. loss
while here.
Parental Nutrition: Monitor TPN for changes.
Biochemical: Monitor anemia, renal, glucose control, and other nutrition and hydration
markers.
Prognosis:
Prognosis remains fair for long-term morbidity and mortality. N.P. will need to remain
on home parenteral nutrition long-term due to short bowel syndrome. Long-term PN
has increased risks complications such as recurrent infections, thrombosis, and hepatic
malfunction.
Summary & Conclusion:
This patient presented a complicated case due to multiple abdominal surgeries
with complications that resulted in poor oral intake and the need for nutrition support.
While researching the relevant conditions, I expanded my knowledge about the
physiology of the gastrointestinal system. I gained a better understanding of the
causes, treatments, and symptoms of various conditions, including peptic ulcers, sepsis,
and short bowel syndrome. Although one may have a good understanding of a patient’s
medical conditions, each patient may respond differently to medical or nutritional
management. For this reason, it is vital to speak with the patient (or caregiver/family
member) to gather subjective information on how they are feeling. Overall, the best
patient care is typically given through a multi-disciplinary team who is each able to
approach the case with their own perspective.
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