Download Gastroesophageal reflux disease case study

Nikki Karetov
February 20, 2014
Case Study #7
1.
How is acid produced and controlled within the GI tract?
The parietal cells of the stomach start secreting hydrochloric acid (HCl) before food
enters the upper GI tract. Seeing, smelling and tasting food can stimulate this secretion to prepare
the stomach for digestion. There are three phases involved in the release of gastric secretions that
control how fast or how slow the secretions are released. The cephalic and gastric phases
stimulate gastric secretions to initiate the breakdown of food. The presence of protein, distention
of the stomach, alcohol and caffeine can also stimulate stomach secretions. In contrast, the
intestinal phase inhibits gastric secretions for when the chyme begins it's entry into the small
intestines.
2.
What role does LES pressure play in the etiology of GERD? What factors affect LES
pressure?
The lower esophageal sphincter (LES) is located in between the esophagus and the
stomach and serves as a barrier to protect the esophagus from gastric secretions and food from
the stomach. It remains closed except for when swallowing occurs. This is due to the difference
in atmospheric pressure in the esophagus (where it is greater) and the stomach, where
atmospheric pressure is lower. In GERD, the LES may open at times other than in swallowing, or
when atmospheric pressure in the stomach exceeds that of the esophagus, resulting in reflux of
gastric contents into the esophagus. Factors that can lower LES pressure include certain foods
(high-fat, chocolate, spearmint, peppermint, alcohol, caffeine, and pepper), increased secretion of
gastrin, estrogen and progesterone (hormones), presence of a hiatal hernia, scleroderma, or
obesity, cigarette smoking or use of certain medications.
3.
What are the complications of GERD?
Complications of GERD include Barrett's Esophagus, in which the epithelial cells of the
esophagus change. If a patient experiences this dysplastic cellular change, they may be at higher
risk for developing adenocarcinoma of the esophagus. Other complications of GERD include
impaired swallowing, aspiration of gastric contents into the lungs, ulceration, and
perforation/stricture of the esophagus.
4.
The physician biopsied for H. pylori. What is this?
Helicobacter pylori is a bacterium that lives under the mucous layer of the stomach. It
can survive the extreme conditions of the stomach by breaking down urea to form ammonia,
which helps neutralize the acid surrounding the bacteria. It can also produce proteins that can
damage mucosal cells. Persistent inflammation can then occur due to the constant attraction of
lymphocytes. H. pylori can cause peptic ulcer disease (PUD) and gastritis.
5.
Identify the patient's signs and symptoms that could suggest the diagnosis of GERD.
Patient Jack Nelson's signs and symptoms include complaints of increasing indigestion.
He answers that indigestion occurred only at night at first but is now occurring constantly.
7.
Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s
overall health? Explain.
Mr. Nelson's BMI is 32 (97.73 kg/(1.753m²)), which means he is considered obese.
Obesity is a risk factor for GERD. He also takes 325 mg of aspirin daily, along with an additional
500 mg of ibuprofen twice per day for the last month. Medications like aspirin and ibuprofen
may cause irritation and pain in the esophagus from reflux of the stomach. Taking such doses per
day is most likely contributing to Mr. Nelson's symptoms of GERD. In addition, he states that he
eats more food and drinks alcohol more frequently. Larger meals and alcohol may be possible
contributors to the recurring refluxes. His usual dietary intake reflects some undesirable food
choices as well. He states he eats ice cream and other processed foods after dinner and that his
family orders pizza for dinner a few times per week. According to his 24 hour recall, Mr. Nelson
consumed fried foods at lunch and dinner, as well as other high-fat foods throughout the day.
Excessive fat intake is a risk factor for GERD.
10.
Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s
overall health? Explain.
The current recommendations for nutrition therapy for GERD include the assessment of a
24-hour recall, diet history or food diary to identify which specific foods worsen their symptoms.
These consumption of these foods should then be decreased. However, avoidance of certain food
groups may result in unwanted weight loss or nutritional deficiency, so careful monitoring of
these nutritional problems must also occur. Cessation of smoking and increasing physical activity
may also benefit the patient's symptoms. Other general recommendations include:
 Avoid foods that relax LES or increase gastric acid secretion (peppermint, coffee,
alcohol, chocolate, pepper)
 Avoid fried, high fat foods
 Decrease acidic or spicy foods
 Decrease frequency/volume of reflux by elevating head 30 degrees with laying down, sit
upright for 3-4 hours after eating, eat small, frequent meals, lose weight if overweight
12.
Calculate the patient’s energy and protein requirements for Mr. Nelson. How would this
recommendation be modified to support a gradual weight loss?
IBW = 106 + (6 in x 9) = 160 lbs
160 lbs/2.2 = 72.73 kg
REE = 66.5 + 13.8 (72.73 kg) + 5.0 (175.3 cm) – 6.8 (48 years) = 1620 kcal
TEE = 1620 kcal x 1.2-1.3 = 1944 – 2106 kcal/day
PRO requirements = 0.8 x 72.73 kg = 58 grams PRO/day
A healthy, gradual weight loss is a loss of 1-2 pounds per week. In order for Mr. Nelson
to do so, he would have to consume 1444 – 1606 kcal per day, or 500 kcal less per day. This
decrease of 500 kcal per day would result in a decrease of 3,500 kcal per week. Since 1 pound =
3,500 kcal, Mr. Nelson would be able to lose 1 pound per week.
14.
Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s
overall health? Explain.
Mr. Nelson's lab values for cholesterol, LDL, LDL/HDL ratio and triglycerides all read
high and his HDL reads lower than normal. These should be addressed to improve his overall
health, and may improve with avoidance of high-fat or fried foods, previously mentioned to
alleviate his symptoms of GERD, and with additional nutrition education.
15.
What other components of lifestyle modification would you address in order to help in
treating his disorder?
If he desires to lose weight, I would recommend regular exercise with a goal of 30
minutes per day/5 days per week. A good starting point would be 1-2 days per week, and then
build from that as time goes on. Since he has a decreased ability to run, he could accomplish this
by walking. He may find that exercise could be a way for him to alleviate stress instead of
turning to food or alcohol. I would advise him to decrease his alcohol and diet soda consumption
to help with his symptoms. If he does not desire to give up snacking before bedtime, I would
advise him to choose a low-fat or low-acid option to see if that helps.
16.
Identify pertinent nutrition problems and corresponding nutrition diagnoses and write at
least 2 PES statements for them.
 Recurring symptoms of GERD
◦ Excessive fat intake related to frequent consumption of high-fat or fried foods as
evidenced by increased occurrence of indigestion and worsening of indigestion.
◦ Food and nutrition related knowledge deficit related to intake of diet soda, alcohol,
calorie dense and oversized meals as evidenced by elevated BMI and abnormal
cholesterol, triglycerides, LDL and HDL lab values.
 Obesity/overweight
◦ Physical inactivity related to lack of exercise as evidenced by weight gain and an
elevated BMI.
◦ Excessive energy intake related to frequent intake of processed and fast foods as
evidenced by an elevated BMI.
17. Determine the appropriate intervention for each nutritional diagnosis.
Recurring symptoms of GERD-- interventions
 Reduce gastric acidity by limiting consumption of orange juice, diet soda and beer
 Reduce high-fat foods by avoiding anything fried or battered. Choose low-fat options
instead and opt for baked or grilled items
 Choose low-fat dairy options
 Reduce meal size. Eat smaller, more frequent meals
 Weight reduction
Obesity/overweight
 Increase physical activity by starting where Mr. Nelson feels is comfortable to him
with the goal of 30 min/5 days per week
 Reduce caloric intake
18.
Using Mr. Nelson’s 24-hour recall, outline necessary modifications you could use as a
teaching tool.
Food Item
Modification
Rationale
Crispix
Choose whole grain cereals
Skim Milk
OK, may also choose low-fat or
reduced-fat milk
Orange juice
Reduce consumption to 1 cup per
day or less
Citrus may cause irritation of the
esophagus
Diet Pepsi
Decrease consumption. Better to
avoid completely
Carbonated beverages may
increase pressure in the stomach,
causing reflux
Fried chicken sandwich Choose a grilled or baked version
Add more fiber, increase satiety
and decrease LDL levels
Fried foods can relax the LES
French fries
Avoid or choose different vegetable Fried foods can relax LES
option
Iced tea
Decrease consumption or avoid.
Choose beverages that do not
contain caffeine
Caffeine may cause reflux
Chips
Avoid and choose a healthier snack
Fried foods can relax LES
Beer
Avoid or limit consumption
Alcohol may relax LES, and
carbonation may increase
pressure in the stomach. Alcohol
may also increase stomach acid
secretions.
Fried Chicken
Choose grilled, broiled, or baked
versions
Fried foods can relax LES
Potato salad
Choose a healthier vegetable side
dish
High-fat foods like mayonnaise
can relax LES
Green bean casserole
Choose sautéed, boiled, or steamed
green beans instead
High-fat foods like condensed
cream soup can relax LES
Fruit salad
Choose non-acidic fruits
Acidic foods can cause irritation
of the esophagus
Baked beans
Choose baked beans that are low in Spicy foods can irritate the
spice and that do not contain bacon. esophagus and bacon is high in
fat, which can relax LES.
Milkshake
Avoid and choose a low-fat, nonacidic dessert if dessert is desired
High-fat foods can relax LES