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Case Study: Peptic Ulcer Disease Resulting in Gastrectomy
1. List all of the food items that may contribute to GG’s condition and explain why.
Rum and Coke- Gastritis may be caused by irritation due to excessive alcohol use.
GG started drinking rum and coke at night to help her sleep. One night she had a few to
many and woke up with severe stomach pain. (http://www.webmd.com/digestivedisorders/digestive-diseases-gastritis).
Fast food- Fast food is often high in fat and cholesterol, which can be hard on the
digestive system and can intensify gastritis. Fat and cholesterol may also increase
stomach acids, which can irritate the stomach lining further. Also GG probably was
consuming less fruits and vegetables to help get proper nutrients and fiber to aid in
digestion. (http://www.healthassist.net/food/side-effects/side-effects.shtml).
Coffee and chocolate bars- Both coffee and chocolate bars contain caffeine. Foods
with caffeine can increase the amount of stomach acid produced in the stomach. The
increase in stomach acid can slowly destroy the lining of the stomach over time,
increasing her symptoms of gastritis. (stomach pain particularly)
(http://www.drugs.com/cg/diet- for-ulcers-and-gastritis.html).
Frozen dinners- Frozen dinners are high in sodium. High amounts of sodium
consumed over long periods of time can damage the stomach lining and further increase
the symptoms of gastritis. (http://www.healthassist.net/food/side-effects/sideeffects.shtml).
Fried foods for dinner- Fatty foods can increase the inflammation of the stomach
lining. Fried foods, such as onion rings and fried chicken, should be avoided because they
are high in fat, sodium, and cholesterol. All three of these (fat, sodium, and cholesterol)
can harm the stomach lining over time increasing the symptoms of gastritis.
(http://www.livestrong.com/article/84965-foods-avoid-gastritis/).
2. List any additional oral intake that may have contributed to GG’s condition and
explain why.
Antacids- Most of the time antacids, including TUMS, help decrease or neutralize
acid in the stomach, which can relieve the burning stomach symptoms often felt in
gastritis (http://www.crohns-disease-probiotics.com/gastritis.html). Antacids can reduce
stomach acidity, which reduces the physical barrier to infections. One infection that can
lead to gastritis is the Helicobacter pylori infection.
(http://drweyrich.weyrich.com/disorders/hypochlorhydria.html).
ASA (Aspirin)-Regularly taking aspirin or other pain relievers can irritate the lining
of the stomach. GG has been regularly taking aspirin for her stress headaches. By doing
this though she is further irritating her stomach lining, causing her gastritis to worsen.
She needs to find another way to relieve her headaches.
Cigarettes/Smoking- Chemical irritants, such as those found in cigarettes, can
damage the stomach lining and increase the risk of peptic ulcers.
(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.
While GG cannot really give up going to school, because she needs to earn a degree
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to support her son, she could manage her school life a little better. One way to do this, as
long as she won’t lose her loan, would be to decrease the number of classes she is taking.
By decreasing the number of classes, GG will have less work to do allowing her to better
manage her class work, homework, on-campus job, and being a single mom. Being a
single mom is hard enough but having a child with of a ADHD adds even more stress.
She cannot change this, but she can try to manage this as much as possible. GG could
create a schedule to balance her job, coursework, and home life. By creating a schedule
she can determine a timeline and schedule for when she needs her mother to baby sit and
for when she can spend time with her child. GG’s divorce is another stresser in her life.
She has been dependant on her husband for support for eight years. GG could manage the
stress of divorce by doing different stress relieving exercises. This could be working out,
doing yoga, reading, or taking her child to a park. A physical stress on her body would be
her severe stomach pains. This pain is a symptom of gastritis. She can reduce her
stomach pain by eating healthier and reducing her alcohol, cigarette, antacid, and aspirin
consumption. Hopefully with a combination of all of these, she can be less physically and
psychological stressed and can get back on her feet.
4. List the symptoms of GG’s gastritis.
GG awoke in the middle of the night with severe stomach pain on the right side and
in the chest. When she woke up in the morning she had severe gastric pain. In the last
month she was experiencing burning and pain in her right lower quadrant that would
occur 30 minutes after she ate. She also had burning pains after drinking coffee and
would get stress headaches.
5. Was a bland diet necessary? Explain and list the principles of the diet plan that you
think GG should follow.
GG does not need to follow a bland diet, she just has to watch which foods she is
eating. There are certain foods that can worsen the side effects and the physical qualities
of the ulcer. Since foods can affect ulcers, it is important that she gets nutrition therapy
and talks to a dietitian/nutritionist about what she can and cannot eat. Some foods she can
eat include low-fat dairy, non-carbonated beverages, tea, scrambled or hard-cooked eggs,
ready to eat cereals, low-fat non-fried meats, any fruit or vegetable, and spices that do not
have pepper (363).
6. What is the mechanism of action of the following medications GG is receiving:
Carafate, AlternaGel, and Pepcid?
Carafate: The exact mechanism of action is unknown. Carafate sticks to the
damaged tissue helping proect against acid and enzymes to help healing.
(http://www.drugs.com/mmx/carafate.html). AlternaGel: Bind the phosphate ions in the
intestine to form insoluble aluminum phosphate to prevent calcium stones. It helps to
relieve the heartburn, sour stomach, and pepetic ulcer pain. It promotes the healing of
peptic ulcers. (http://www.drugs.com/mmx/alternagel.html). Pepcid: is used to treat
ulcers as well as GERD. There is over the counter pepcid, which helps prevent heartburn
from acid indigestion from eating and drinking certain foods. It also helps decrease the
amount of acid made in the stomach.
(http://www.medicinenet.com/famotidine/article.htm).
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7. List the nutrient-drug interactions that are associated with these medications. Nutrientdrug interactions:
Carafate: Other drugs should not be taken within one half hour before of after. Take
1 hour before a meal or 2 hours after a meal, it should not be taken on an empty stomach.
Try to avoid taking with magnesium and or calcium supplements. It is important to avoid
alcohol, cocoa, and cola because it can increase stomach acid production.
(http://www.rxlist.com/carafate-drug/patient-avoid-while-taking.htm)
AlternaGel: Can deplete or interfere with the absorption of nutrients so taking in
more calcium, folic acid, and phosphorus. It is important to avoid citrate because it can
produce dangerous results.
(http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf)
Pepcid: Can reduce the absorption of vitamin B12, iron or zinc. May need to
supplement Vitamin C and E to help protect the lining of the
Stomach. (http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf)
8. What are GG’s IBW and percent of IBW (Appendix A, Tables 7 and 8)?
IBW: 5’2 = 100 + 2(5) = 110 pounds
%IBW: ABW/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).
Harris-Benedict equation 655+(9.56x44.5kg)+(1.85x157.48cm)–(4.68x27) =
655 + 425.42 + 291.338 – 126.36 x 1.6 = 1245 kcals
Stress Factor: 1.5 since she is active and has an ulcer
10. What might be the cause of the LUQ pain along with her usual pain? (Hint: Consider
the enzymes that are elevated.).
Left upper quadrant pain can come from epigastric pain in the stomach that leads to
a gastric ulcer. A perforated peptic ulcer can also be a cause. Elevated liver enzymes can
be from her consumption of alcohol, causing some pain (Knott, & Gronow, 2011).
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:
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
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
14. What diagnostic test(s) (not lab values) indicates(s) that GG has an ulcer?
She had an esophagogastroduodenoscopy that revealed blood in the stool and gastritis
with the pyloric sphincter and an ulcer on the dorsal wall of the duodenum. An
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endoscopy showed a section of HCl and that she was positive for H. pylori.
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
16. Define:
H2 antagonist: Agent that blocks the action of histamine by competitive binding
to the H2 receptor, inihits acid secretion of the peptic ulcer
Proton pump inhibitor : Class of medications that block the H, K, ATPase
enzyme, a component in HCl production, and reduce acid secretion in the stomach (G-21)
17. What is the mechanism of action of the following medications GG is receiving:
Nexium, amoxicillin, and clarithromycin?
Nexium is used to treat GERD, allows the esophagus to heal and prevents further
damage to the esophagus and the return of stomach ulcers (PubMed Health, 2011).
Amoxicillin is used to treat infections from bacteria and infections of through, urinary
tract, and the skin. It helps eliminate H. plyori, which causes ulcers. Clarithromycin has
the same mechanism of action as Amoxicillin (PubMed Health, 2010).
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 confident counseling her on a diet that would minimize all of her
symptoms. I would suggest she stop consuming alcohol and caffeine completely, since
both of those foods seem to aid her symptoms. I would refer GG to a
therapist/psychologist for the stress factors in her life, such as balancing school, work,
and being a mom.
19. What is the significance of the dark stools?
The dark stools are significant because that means there is blood present in them.
The blood is black because it comes from the upper part of the gastrointestinal tract
(http://www.livestrong.com/article/211969-what-are-the-causes-of-black-stool/).
20. Give the pathophysiology for the cause of the following abnormal values: BUN,
NH3, and WBS.
High BUN: increase with high amounts of protein in the diet and when kidneys
are damaged because they cannot clear the urea from the blood stream as well (WebMD,
2010). High WBC is often from an increased production of them to fight an infection or a
reaction to a drug. It can also increase from smoking, stress, and bacterial infections
(MayoClinic, 2010). Abnormal levels of NH3 can be caused from GI bleeding, liver
failure and other problems (Dugdale, & Zieve, 2011).
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.
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22. After admission GG received packed cells and IV fluids. How would that affect the
next set of lab values?
This can affect the next lab values by creating them to be in the more normal
range or in a lower level range. If she is over hydrated from them, her levels will be low.
If she was dehydrated and the packed cells and IV fluid helped her balance, the levels
would be more normal.
23. Define the following terms:
Packed cells: A preparation of blood cells separated from plasma to restore
adequate levels of hemoglobin and RBCs without overloading the vascular system
with excess fluid
Abdominal tap: Belly tap, helps differentiate a surgical abdomen
Perforated ulcer: An ulcer extending through the wall of an organ
Fistula: An abnormal opening or passage between two internal organs or from an
internal organ to the surface of the body (G-9)
Exploratory Laparotomy: A “look-see” operations into the peritoneal cavity
where the surgeon examines all surfaces for lesions
Billroth I: Excision of the pylorus with an end-to-end of the s and the duodenum,
helps manage peptic ulcer disease
Vagotomy: Severing of the vagus nerve from gastric surgery (G-26)
24. Sketch a Billroth I.
25. Compare a Billroth I to a Billroth II as to anatomical changes as well as to dietary
changes, if any.
Billroth I: Anatomical changes: Surgical procedure that connects the proximal end
of the duodenum to the distal end of the stomach (Nutrition Therapy &
Pathophysiology, 2nd edition, pg 364). Dietary changes: Patients who have under gone
this surgery might have difficulty absorbing certain nutrients, due to the removal of part
of the duodenum. Folate, calcium, magnesium, iron are all absorbed in the duodenum
(http://www.surgeryencyclopedia.com/Fi-La/Gastroduodenostomy.html#b).
BillrothII: Anatomical changes: Surgical procedure that connects the proximal end
of the jejunum to the distal end of the stomach (Nutrition Therapy & Pathophysiology,
2nd edition, pg 364-365). Dietary changes: Patients who have under gone this surgery
might have difficulty absorbing most nutrients, due to bypassing the duodenum and using
only part of the jejunum (sometimes). Patients who have undergone this surgery will
likely experience the malabsorption of all the duodenum nutrients (including: iron,
magnesium, calcium, and folate) and some of the jejunum nutrients (including: starches
in the form of glucose, proteins, vitamin C, A, D, E, K, the B vitamins, cholesterol, and
fat.) (http://www.livestrong.com/article/436603-in-which- digestive-organ-are-nutrientsabsorbed/).
26. Calculate GG’s energy and protein needs.
EER = 354 – 6.91(27) + (1.45)[(9.36(44.55) + 726(1.57)]
354 – 186.57 +
1.45 (416.99 +
1139.82)
1.45(1556.81) = 2257.37
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2257.37 + 186.57 = 2443.94 – 354 = 2089.9
= about 2100 kcal/day
Protein = approximately 15%
2100 x .15 = 315 kcal/day
27. List the principles of a postgastrectomy diet and briefly describe the scientific basis
for each principle. Principles of a postgastrectomy (Nutrition Therapy &
Pathophysiology, 2nd edition, pg. 366):
Prescribe adequate energy and protein intake to ensure appropriate healing and
recovery postoperatively. Initiate slow progression of solid food to prevent the onset of
early and late dumping syndromes. Patients may be initially lactose intolerant and dairy
products should be avoided. Slowly progress to five to six small meals each day.
Consume liquids 30 minutes to 1 hour after solid food. Lie down after eating. Consider
addition of functional fibers to delay gastric emptying and assist with treatment of
diarrhea. Prevent development of nutrient deficiencies. Provide nutrition education that
will promote optimal nutritional intake and minimize symptoms of malabsorption and/or
maldigestion.
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 believe that GG’s diet will be on the postgastrectomy diet the rest of her life
because gastrectomy’s are permanent, however I also believe that while she may have to
be on this diet in the distant future she maybe able to go on a less strict postgastrectomy
diet.She should test it out and find what she can tolerate and not, that way she can find
out if her condition is getting better. Also, slowly introducing other foods could be a good
start to normalcy. By adding slowly, she will be allowing her GI tract to get used to foods
and potentially she will be able to eat more than what was assigned.
Optional:
29. If GG were to be hospitalized for an extended period of time and a required tube
feeding via duodenum or jejunum, what characteristics would be appropriate for
the tube feeding you would use?
Small, frequent feedings
Eat calorie dense foods
Eat a variety of foods
High protein and fat
Low CHO and concentrated sugars
Liquid between meals
References
Aluminum Hydroxide. (2010). Retrieved from PubMed Health website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001056/
Amoxicillin. (2010). Retrieved from PubMed Health website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000837/
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Blood Urea Nitrogen. (2010). Retrieved from WebMD website:
http://www.webmd.com/a-to-zguides/blood-urea-nitrogen
Dugdale, & Zieve. (2011). Ammonium Ion. Retrieved from Medline Plus website:
http://www.nlm.nih.gov/medlineplus/ency/article/003506.htm
Famotidine. (2010). Retrieved from PubMed Health website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000872/
High white blood cell count. (2010). Retrieved from MayoClinic website:
http://www.mayoclinic.com/health/high-white-blood-cellcount/MY00161/DSECTION=causes
Knott, & Gronow. (2011). Left upper quadrant pain. Retrieved from EMIS website:
http://www.patient.co.uk/doctor/Left-Upper-Quadrant-Pain.htm
Nelms, Sucher, Lacey, & Roth. (2011). Diseases of the upper gastrointestinal tract. In
Nutrition
therapy and pathophysiology (2nd ed., pp. 361-364). Wadsworth, Cengage Learning.
Pepcid. (2007). Retrieved from Applied Health website: http://www.naturalnews.com/
DrugWatch_Pepcid.htm
Peptic Ulcer. (2011). Retrieved from MayoClinic website:
http://www.mayoclinic.com/health/
peptic-ulcer/DS00242
Post gastrectomy diet. (n.d.). Retrieved from Aspen website:
http://www.nutritioncare.org/
uploadedFiles/Professional_Resources/ASPEN_Patient_Education_Manual_
Sample/III_B3b1_Post_Gast.pdf
Sucralfate. (2010). Retrieved from PubMed Health website:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000536/
Terms. (2012). Retrieved from Medical Dictionary website:
http://medical-dictionary.thefreedictionary.com/
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