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Christina%20Cheung

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She was admitted through the ER for a surgical consult for possible perforated duodenal ulcer. Therefore, a gastrojejunostomy was completed. – PowerPoint PPT presentation

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Title: Christina%20Cheung


1
Ulcer Disease
  • Christina Cheung

2
Ulcer Disease What is it?
  • Role of H. pylori 
  • Disrupts mucosal mucus produced by gastric and
    duodenal mucosa.
  • Causes inflammation and cell damage secretes
    phospholipids and proteases
  • Produces cytotoxins
  • Stimulates gastric secretion
  • Invokes self-destructive immune response H.
    pylori produces enzymes that degrade oxygen
    radicals produced by phagocytes phagocytes lyse
    in high acid environment and release oxygen
    radicals that cause cell damage. Over many years,
    this can lead to ulceration.

3
Meet the Patient
  • Maria Rodriguez
  • Female
  • DOB 12/19 (age 38)
  • Smoker
  • Works in computer programming
  • Work schedule M-F, 9am-5pm
  • Hispanic
  • Catholic

4
  • Chief complaint
  • I found out I had an ulcer 2 weeks ago. Last
    night I seemed to have gotten worse. I have been
    vomiting, and I have diarrhea. My pain is
    terrible. I think I have blood in my vomit and
    diarrhea.
  • Patient says that she has eaten very little since
    her ulcer was diagnosed and wonders how long it
    will be until she can eat again

5
Patient History
  • Gastric/abdominal pain/heartburn
  • Diagnosed with GERD 11 months ago
  • Diagnosed with duodenal ulcer 2 wks ago
  • Treatment 14-day course of four medicines
  • Bismuth subsalicylate 525mg, 4X/day
  • Metronidazole 250mg, 4X/day
  • Tetracycline 500mg, 4X/day
  • Omeprazole 20mg, 2X/day

6
Risk Factors
  • Family history
  • Father and Grandfather both had Ulcer Disease
  • Large amounts of caffeine
  • 8-10 coffees daily
  • 1-2 sodas daily
  • Tobacco use
  • First and second-hand smoke
  •  
  • High caffeine intake increase gastric secretion.
  • Tobacco use impairs bicarbonate secretion and
    mucosal blood flow, increases acid secretion and
    may aggravate H. pylori infection.

7
Physical Exam
  • BP 78/60 mm Hg
  • Pulse 68
  • Respiration 32 bpm with rapid breath sounds
  • Temp 101.3F
  • Abdomen Tender with guarding, absent bowel
    sounds

8
Physical Exam
  • Height 52
  • Weight 110 lb
  • UBW 145 lb
  • UBW (current weight/ usual weight) x 100
  • (110/145) x 100 75.86
  • 75-84 indicates moderate malnutrition
  • BMI weight (lbs)/ height (in) 2 x 705
  • (110/ (62) 2 ) x 705 20.174
  • IBW actual body weight/IBW /-10
  • 110/110 10 .9
  • recent weight change usual weight actual
    weight x 100
  • usual weight
  •  
  • 145-110 x 100 24.1
  • 145
  • Skin-fold thickness or Tricep Skin-Fold (TSF)
    Could also measure skin-folds to look at body fat
    and lean tissue in comparison to standards

9
Tx Plan
  • Two weeks ago as an outpatient, she is s/p
    endoscopy that revealed the 2-cm duodenal ulcer
    with generalized gastritis with a positive biopsy
    for Helicobacter pylori. She has completed 10
    days of her 14 day treatment. She was admitted
    through the ER for a surgical consult for
    possible perforated duodenal ulcer. Therefore, a
    gastrojejunostomy was completed. Patient is now
    s/p gastrojejunostomy secondary to perforated
    duodenal ulcer. Feeding jejunostomy was placed
    during surgery, and she is receiving Vital HN _at_
    25 cc/hr by continuous drip. NTR consult orders
    have been left to advance the enteral feeding to
    50 cc/hr. She is receiving only ice chips by
    mouth.

10
About the Current Treatment
  • Bismuth subsalicylate Pepto-Bismol is an oral
    medication that exhibits both anti-secretory and
    anti-microbial action. May provide some
    anti-inflammatory action as well.
  • Salicylate moiety anti-secretory effect
  • Bismuth exhibits anti-microbial effects directly
    against bacterial and viral gastrointestinal
    pathogens.
  • Used to treat ulcers and inflammation caused by
    H. Pylori.
  • Metronidazole Taken up/reduced by anaerobic
    bacteria by reacting with reduced ferredoxin,
    which is generated by pyruvateferredosin
    oxido-reductase.
  • Reduction produces toxic products and allows for
    selective accumulation in anaerobes.
  • Metronidazole metabolites taken up into bacterial
    DNA, and form unstable molecules.
  • This only occurs when metronidazole is partially
    reduced, which only happens in in anaerobic
    cells. Therefore, it has little effect on human
    cells or aerobic bacteria.

11
About the Current Treatment
  • Tetracycline Also used to treat infections by
    bacteria.
  • Work by binding the 30S ribosomal subunit and
    through an interaction with 16S rRNA.
  • They prevent the docking of amino-acylated tRNA.
  • Omeprazole A selective and irreversible proton
    pump inhibitor that suppresses gastric acid
    secretion by specific inhibition of the
    hydrogenpotassium adenosinetriphosphatase (H ,
    K -ATPase) enzyme system found at the secretory
    surface of parietal cells.
  • Inhibits the final transport of hydrogen ions
    (via exchange with potassium ions) into the
    gastric lumen. 
  • The inhibitory effect is dose-related.
  • Omeprazole inhibits both basal and stimulated
    acid secretion irrespective of the stimulus.

12
Drug Drug-Nutrient Interactions
Metronidazole FOOD May take with food to decrease GI distress, but food decreases bioavailability.ALCOHOL Avoid drinking alcohol and taking medications that contain alcohol while taking metronidazole and for at least three days after you finish the medication. Alcohol may cause nausea, abdominal cramps, vomiting, headaches, and flushing
Tetracycline FOOD Take on an empty stomach with 8 ounces of water. Avoid taking tetracycline with dairy products, antacids, or vitamin/mineral supplements containing iron as they will all inactivate the medication. Inactivated by Ca2 ion, not to be taken with milk or yogurt Inactivated by aluminum, iron and zinc, not to be taken at the same time as indigestion remedies such as bismuth subsalicylate.
Bismuth subsalicylate Avoid ethanol and dairy
Omeprazole Acid suppresant can lead to malabsorption of Ca, Fe, Vit B-12
13
Tx Plan Surgery
  • Gastrojejunostomy Surgical removal of the
    pylorus and the first part of the duodenum.
  • Cut end of the stomach joined to the jejunum,
    which is pulled through the transverse mesocolon
    from the lower abdomen.
  • Remaining duodenum carrying biliary and
    pancreatic secretions drains into the ileum
    through a new anastamosis in the lower abdomen.

14
Surgery Summary of the Nutritional Risks
  • Reduced capacity of the stomach
  • Potential change in gastric emptying and transit
    time
  • Additionally, when portions of the stomach are
    restricted or altered-valuable components of
    digestion are lost.
  • These issues place the patient at significant
    nutritional risk due to decreased oral intake,
    mal-digestion, and mal-absorption.

15
Tx Plan Surgery
  • How does this procedure affect normal digestion?
  • Normal digestion process may change due to
    decreased acid production. This leads to
    malabsorption of calcium, vitamin B12, and iron.
  • Digestive tract is shortened as the stomach
    contents empty into the jejunum instead of the
    duodenum.
  • Potential for Dumping Syndrome Food bypasses
    digestion it would normally undergo in the
    duodenum by pancreatic juices. Instead, the
    jejunum experiences a load of partially digested
    food, resulting in sudden loading of the upper
    small intestine and increased intestine
    contractility, which is responsible for nausea,
    bloating, abdominal cramps and explosive
    diarrhea.
  • In addition, because of the osmotic load in the
    small intestine, fluid shifts from the
    intravascular compartment resulting in
    hypovolaemia (less blood), which decreases BP and
    leads to more intense symptoms flushing,
    dizziness, palpitations, faintness and rapid
    heartbeat.

16
Surgery Post-Op Complications
  • Dumping Syndrome-when an increased osmolar
    load enters the small intestine too quickly from
    the stomach. Can vary based on the type of
    gastric surgery.
  • Normal Function of Stomach
  • In a normal stomach food may remain in the
    stomach anywhere from 1-3 hrs as it becomes
    liquefied and partially digested. Slowly the
    pyloric sphincter releases the food into the
    duodenum, giving time for the acidic chime to
    become neutralized by the pancreatic bicarbonate.
  • However, when the pyloric portion of the stomach
    is removed, bypassed, or destroyed, the rate of
    gastric emptying is increased.
  • Because the chyme is hyperosmolar (missed the
    neutralizing step), fluid is quickly drawn into
    the small intestine from the intravascular space
    in an attempt to dilute intestinal contents. This
    process results in cramping, abdominal pain,
    hypermotility (over activity of the intestinal
    tract), and diarrhea.

17
Surgery Post-Op Complications
  • Three phases of Dumping Syndrome
  • Early dumping syndrome-which occurs 10-20mins
    after eating.
  • Symptoms Gas, abdominal pain, cramping, and
    diarrhea.
  • Intermediate dumping syndrome occurs 20-30 min
    after eating.
  • Symptoms Gas, abdominal pain, cramping, and
    diarrhea.
  • Late dumping syndrome occurs from 1-3hrs after
    eating-is especially after consuming simple
    carbohydrates.
  • Symptom Hypoglycemia
  • Due to rapid absorption in the small intestine
    that stimulates the release of insulin and rapid
    absorption of glucose. This results in high
    insulin level and subsequently hypoglycemia-causin
    g symptoms of shakiness, sweating, confusion, and
    weakness.
  • The post-gastrectomy or anti-dumping diet
    encourages a well balanced diet, slightly higher
    in protein and fat than what is recommended by
    the US Dietary Guidelines.

18
Nutritional Assessment Biochemical Lab Values
  • Abnormal Biochemical Measures Normal Admit
    Post Op Day 3
  • - High transferrin 250-380 425 419
    mg/dL
  • - Low total protein 6-8 5.5
    6.0 g/dL
  • - Low Albumin 3.5-5 3.0 3.3 g/dL
  • - Low Prealbumin 16-35 15 14 mg/dL
  • - High WBC 4.8-11.8 16.3
    12.5
  • - High glucose 70-120 80
    128 mg/dL
  • - High Bilirubin lt0.3 1.3
    0.6 mg/dL
  • - Low HGB 12-15 (W) 11.2 10.2 g/dL
  • - Low HCT 37-47 (W) 33 31
  • - Low MCHC 31.5-36 31 28.5
    g/dL
  • - High RDW 11.6-16.5 19.5
    22
  • - High SEGS 50-62 87
    78
  • - Low LYMPHS 24-44 12 22
  • - High Ferritin 20-120 (W) 241 232
    mg/mL
  • - High BUN 8-18 24 15
    mg/dL

19
Nutritional Assessment Biochemical Lab Values
  • Lab values related to duodenal ulcer
  • A high WBC is an indication of infection, most
    likely from H. Pylori.
  • The low HGB and HCT can be an indication of
    anemia caused by vitamin deficiencies and chronic
    bleeding. There is a loss of blood which is
    appearing in her stools due to the ulcer
    bleeding.
  • She has low MCHC (mean corpuscular hemoglobin
    concentration) which can be an indication of
    iron-deficiency anemia because there is abnormal
    dilution of HGB inside the RBC.
  • She also has a high RDW (red blood cell
    distribution width) (19.5, 22) which can indicate
    iron-deficiency anemia and B12 deficiency which
    is common in duodenal ulcers.

20
Nutritional Assessment Usual Dietary Intake
  • AM
  • Coffee, 1 slice dry toast on weekends, cooks
    large breakfast for family which includes
    omelets, rice/grits, or pancakes, waffles, fruit
  • Lunch
  • Sandwich from home (2 oz turkey on whole wheat
    bread w/ mustard), 1 pc raw fruit, cookies (2-3
    chips ahoy)
  • Dinner
  • 2 c rice, 2-3 oz chicken, 1 c steamed fresh
    vegetables, coffee

21
Nutritional Assessment
  • Nutrient Requirements
  • REE (10 x weight) (6.25 x height) (5 x age)
    - 161
  • (10 x 50 kg) (6.25 x 157.48 cm) ( 5 x 38)
    161 1133.25
  • TEE REE x activity factor
  • 1133.25 x 1.2 (for hospital patients)
    1360kcal/day
  • 1360 x injury factor of 1.1-1.3
    1496-1768kcal/day
  • content if patient received 1632kcal/day
  • Normal Protein Needs 0.8-1.0g protein X kg
    body weight
  • 0.8-1.0g X 50 kg 40-50 kg protein 
  • Postoperatively Protein Needs 1.0-1.5
  • 1.0-1.5 X 50 kg 50-75 kg protein/day

22
Nutritional Assessment
  • Possible malnutrition
  • She is 35 lbs less then her normal weight and she
    has been vomiting and had diarrhea.
  • We can use her UBW of 145 compared to her current
    weight of 110 to assess malnutrition and also
    consider vomiting and diarrhea as indicators.
  • She falls in the moderate malnutrition category
    which is 75-80 UBW and she is 76 UBW.

23
Nutritional Diagnosis PES Statements
  • Evident protein-energy malnutrition related to
    inadequate protein intake and GI dysfunction as
    evidenced by low prealbumin of 14 mg/dL (normal
    16-35), 76 of UBW (moderate malnutrition), and a
    BMI of 20.
  • Food and nutrition knowledge deficit related to
    gastrojejunostomy as evidenced by the patients
    question on how long it will be until she can eat
    again and her previous diet high in caffeine and
    simple sugars for breakfast.

24
Nutritional Intervention
  • Addressing Maria Rodriguezs protein
    malnutrition
  • Goal to increase her energy and protein intake,
    to increase her prealbumin from 14 to 16-35 mg/dL
    and to maintain her weight in the healthy BMI
    range of 18.5-24.9 kg/m2.
  • Intervention to adjust her enteral feeding of
    Vital HN from 25 mL/hr to 50 mL/hr and then to 68
    mL/hr as suggested. Doing so will increase her
    protein and calorie consumption to meet her needs
    adequately. To educate her on nutrient dense
    foods and possible supplemental foods that will
    increase her pre-albumin and energy intake.

25
Nutritional Intervention
  • Addressing Maria Rodriguezs food/nutrition
    knowledge deficit due to gastrojejunostomy
  • Goal For Maria Rodriguez to be able to describe
  • and understand the strategies to reduce and
  • prevent dumping syndrome.
  • Intervention Nutrition education to manage
  • and avoid dumping syndrome.

26
Nutritional Intervention
  • This patient was started on an enteral feeding
    postoperatively.
  • Maximize nutritional absorption leading to a
    faster recovery
  • Prevent malabsorption/malnutrition.
  • Plus, our patient was already malnourished when
    she came in which could impair wound healing and
    recovery time.
  • The patient will be placed on enteral feeding
    until she is released from her NPO diet.

27
Nutritional Intervention Formula
  • Vital HN is a peptide-based, elemental,
    low-residue feeding intended as a source of
    complete and balanced nutrition for patients with
    chronically impaired gastrointestinal function
    (maldigestion, malabsorption).It is administered
    via tube or NOT for parenteral use. Most
    importantly, it contains peptides and free amino
    acids to use the dual protein absorption systems
    of the gut. Vital HN contains lt4 g of fat and
    41.5g protein/L per 300-Cal servingbeneficial
    for patients who need a low-fat diet.
  • To aid in caloric consumption, MCT is already
    included in the formula
  • 25ml/hr is the standard starting rate to monitor
    tolerance prior to increasing the formula- will
    increase the rate every 8-12 h by 10-20ml/hr
    until the goal rate of 71ml/hr is achieved.

28
Nutritional Intervention Are we meeting the
patients needs?
  • 1632kcal/ 1 kcal/ml 1632ml x 1L / 1000ml
    1.632L
  • Meet protein Requirement?
  • 1.632L X 41.6 g protein/ L 67.9g protein (yes
    meets requirement)
  • Goal Rate?
  • 1632ml/ 24 hr 68ml/hr
  • Both needs are being met.

29
Nutritional Intervention Are we meeting the
patients needs?
  • To monitor tolerance of the feeding, the RD must
    monitor intake and output, take daily weights,
    monitor fluid balance and ask patient if feel any
    discomfort or bloating.

30
Nutritional Intervention
  • To manage/prevent dumping syndrome
  • Initially avoid all simple sugars to prevent
    hyper-osmolaltiy and hypoglycemia. Do not start
    clear liquids as first oral feeding.
  • The first should be protein, fat, complex
    carbohydrates. Be careful of lactose
    intolerance.
  • Slowly progress to 5 or 6 small meals each day
    with each containing a protein source
  • Lie down after eating to slow gastric emptying.
  • Add soluble fiber to delay gastric emptying and
    assist with treatment of diarrhea.
  • Patients can have lactose, if tolerated. If
    patients are lactose intolerant, commercial
    products that provide lactase can be
    recommended-also recommend calcium and vitamin D
    supplements.
  • Liquids should be frequently consumed between
    meals to prevent their contribution to dumping
    syndrome-liquids facilitate quick movement.

31
Nutritional Intervention
  • Maria Rodriguez should take vitamin B-12,
    calcium, and iron supplements. She may also
    consider taking a glutamine supplement which can
    help heal the damage caused by H. pylori. She
    should begin by taking the B-12, calcium, and
    Iron supplements orally. If this is not
    sufficient to avoid deficiency, other routes such
    as intravenous may be considered.

32
Nutritional Intervention
  • Vitamin B-12 and iron absorption depend on an
    acidic environment. Mrs. Rodriguezs stomach
    acidity has been altered because of the acid
    suppressor drugs that she is taking. If the
    absorption is interfered with too much,
    deficiency can occur causing iron-deficient
    anemia, pernicious anemia, and/or megaloblastic
    anemia.

33
Nutritional Intervention
  • During intervention, the patient gained 1 pound
    in 24 hours. Although we are concerned about the
    patients low body weight, we do not consider this
    a sign of improvement because it is most likely
    related to fluid shifts.

34
Monitoring and Evaluation
  • As the patient is slowly re-introduced to solid
    foods, RDs will need to advise her to begin by
    eating ice chips and small sips of water. She
    will need to follow a post-gastrectomy diet.
  • For quite awhile, she will need to stay away from
    tough foods that are not easily broken down
    mechanically.

35
Monitoring and Evaluation
  • Acidic foods may cause discomfort along with
    spicy foods, caffeine, chocolate, milk products,
    alcohol, and pepper.
  • The patient should not worry that she will have
    to stay on a strict, special diet forever.
    Simple carbs, lactose, and fresh fruits and
    vegetables can be added gradually as she is able
    to tolerate them.

36
Questions?
37
Reference
  • http//www.ncbi.nlm.nih.gov/pubmed/3053883
  • http//www.livestrong.com/article/545768-billroth-
    ii-post-procedure-diet
  • http//www.mayoclinic.com/health/low-blood-pressur
    e/DS00590
  • http//www.ncbi.nlm.nih.gov/pmc/articles/PMC119104
    1/
  • Nelms M, Sucher K, Lacey, K., Habash, D., Roth S.
    Nutrition Therapy and Pathophysiology. 2nd ed.
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