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Medical Nutritional Therapy - Case Study #33
Professor Matel
Marie Claire Donaghy
14th October 2013
I. Understanding the Disease and Pathophysiology
1. Mr. Seyer has been diagnosed with adenocarcinoma of the esophagus. What does the term
adenocarcinoma mean?
Adenocarcinoma is cancer of an epithelium that originates in glandular tissues. This is Cancer
that begins in glandular (secretory) cells. Glandular cells are found in tissue that lines certain
internal organs and makes and releases substances in the body, such as mucus, digestive juices,
or other fluids. Adenocarcinomas usually form in the lower part of esophagus, near the stomach.
(http://www.cancer.gov/dictionary?cdrid=46216).
4. Cancer is generally treated with a combination of therapies. These can include surgical
resection. The type of malignancy and stages of the disease will, in part, determine the types of
therapies that are prescribed. Define and describe each of these therapies. Briefly describe the
mechanism for each. In general how do they act to treat malignancy?
Surgical Resection - Involves using surgery to remove abnormal tissue. This is done because the
tissue already unhealthy and destroyed and would only continue to affect healthy tissue. Surgery
may be the only treatment or may be used with other therapies, such as hormone therapy,
radiation therapy, chemotherapy or others to continue treatment.
Radiation Therapy- Is a type of treatment that can be used on cancer patients to kill cancerous
cells. It destroys these calls by altering the cellular and nuclear material, especially DNA. Power
from X-rays, protons and other types of energy may contribute to intensifying beams of energy
that target and kill these cells. Often times, high-energy beams are sourced from an external
machine that aims the beam at a specific location on the body. This is often referred to as
external beam radiation therapy. This is done on a daily basis, in a five to six week period;
however, the frequency depends on the cancer being treated. During brachytherapy, another
form of radiation therapy, radiation is used inside the body rather than the outside. During
radiation therapy, the genetic material that is responsible for controlling the growth and rate of
division of cells is destroyed, damaging cells. Both cancerous and healthy cells are damaged
during this process, but the goal is to damage as few healthy cells as possible.
Chemotherapy - Chemotherapy is the treatment of cancer with one or more cytotoxic
antineoplastic drugs. Traditional chemotherapeutic agents act by killing cells that divide rapidly,
one of the main properties of most cancer cells. This means that chemotherapy also harms cells
that divide rapidly under normal circumstances: cells in the bone marrow, digestive tract, and
hair follicles. This results in the most common side-effects of chemotherapy: myelosuppression
(i.e. decreased production of blood cells, hence also immunosuppression), mucositis (i.e.
inflammation of the lining of the digestive tract), and alopecia (i.e. hair loss). Some newer
anticancer drugs (e.g. monoclonal antibodies) are not indiscriminately cytotoxic, but rather target
proteins that are abnormally expressed in cancer cells and that are essential for their growth.
Such treatments are often referred to as targeted therapy, distinct from classic chemotherapy, and
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are often used alongside traditional chemotherapeutic agents in antineoplastic treatment
regimens. Chemotherapy works on cells that are actively reproducing.
Immunotherapy – This is a treatment that uses an individual’s own immune system to fight
cancer. This can be done by either stimulating your immune system to work harder or smarter to
attack cancer cells, or by giving the immune system components, such as man-made immune
system proteins.
II. Understanding the Nutrition Therapy
6. Many cancer patients experience changes in nutritional status, briefly describe the potential
effect of cancer on nutritional status.
The primary symptom is unintentional and progressive weight loss due to Cancer Cachexia
The possible causes of weight loss is due to increased energy needs due to tumor growth
Metabolic changes (cytokines/tumor necrosis factor). These factors are what cause your body to
begin the “fight” These factors can start the fight and rev things up for higher calorie needs
Decreased intake associated with taste changes, fatigue, and anorexia (cytokines/tumor necrosis
factor)
7. Both surgery and radiation affect nutritional status. Describe potential and metabolic
effects of these treatments.
Both surgery and radiation affect nutritional status in a cancer patient. Post surgical barriers may
be presented, preventing the patient from receiving adequate nutrition. These barriers may be
physiological or mechanical, depending on the nature of the surgery. Surgery may be required
for a person with esophageal cancer, which may affect their ability to digest or even eat food.
Nutrition therapy such as enteral nutrition, parenteral nutrition, and nutritional supplement drinks
may help the patient meet their nutritional needs. A metabolic response is often initiated post
surgery where energy needs of the patient is increased and necessary for recovery and wound
healing.
Radiation Therapy (RT) is often used in conjunction with surgery, and contributes to delay in
wound healing. RT may be given before, during or after surgery. Side effects such as fatigue,
mucositis, dysphagia, and odynophagia may be apparent during RT targeting the head and neck
region. The risk for dehydration increases, and may require the need of intravenous fluids. A
feeding tube may be required to provide nutrition support, but may not be used if there is an
obstruction of the esophagus, preventing the placement of the tube.
III. Nutrition Assessment
8. Calculate and Evaluate Mr. Seyer’s %UBW and BMI.
%UBW = 86.8% (198 lbs. vs. 228 lbs.) BMI = 24.74
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9. Summarize your findings regarding his weight status. Classify the severity of his weight
loss. What factors may have contributed to his weight loss? Explain.
The reports indicate that the patient has unintentionally lost over 30 lbs. to get to his current
weight of 198 lbs. This is over 13.2% of his usual body weight lost; his weight loss can be
classified as cachexia (weight loss of over 10% of body weight). This would be considered
Cancer Cachexia. Some factors that may have contributed to weight loss are:
1. Difficulty of swallowing (Dysphagia) and painful swelling in throat (Odynophagia) in-patient.
Patient indicated that this has caused him to not be able to eat.
2. Higher caloric needs due to cancer state. Cachexia to be at least partially attributable to
metabolic alterations that lead to increased energy expenditure.
3. Patient stated that heartburn has stopped him from eating.
11. Estimate Mr. Seyer’s energy and protein requirements based on his current weight.
Energy Requirements – Patient Weight = 198lbs/90kgs Height = 6ft 3inches/ 75inches/190.5cm
REE - 66.5+(13.8x90kgs)+(5.0x190.5cm)-(6.8x58) x (Stress Factor 1.2/1.3)= 2240kcal 2430kcals.
35kcal x 90kg = 3150kcals
Protein requirements needs are high – This need is due to unintentional weight loss and the
patient’s physical state, demonstrates that joint appears prominent and there is evidence of
muscle wasting.
Healthy person 0.8g protein /kg of body weight
Increased protein needs - 1.5-2.5g protein/kg of body weight
1.5g/protein x 90kg = 135g protein/ per day
12. Estimate Mr. Seyer’s fluid requirement based on his current weight.
Fluid Requirements - 30-35ml/kg -Increased needs for fluid as the patient has lost over 13.2% of
his usual body weight, and shows signs of dehydration including dry mucous membranes and dry
skin.
30-35ml x90kg = 2700-3150ml
13. What factors noted in Mr. Seyer’s history and physical may indicate problems with eating
prior to admissions.
The factors noted in Mr. Seyer’s history and physical indicate several issues with his food intake.
History: Over a period of 3-5 months, Mr. Seyer had dysphagia (i.e. difficulty swallowing) and
for 5-6 months he experienced odynophagia (i.e. painful swallowing). Over the previous year,
the patient experienced significant heartburn. The patient stated he was unable to consume food,
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because of esophageal pain and heartburn. When he did eat, he experienced difficulty with
swallowing foods, notably textured foods. In addition, he noted a decrease in appetite and a sense
of feeling full all the time.
Physical: It was observed that Mr. Seyer had dry mucous membranes in his throat, which likely
exacerbated his dysphagia and odynophagia. In addition, the dry mucous membranes in his
throat and nose and his dry skin suggest dehydration. Upon abdominal palpation, the patient
displayed signs of epigastric tenderness.
16. Are any clinical signs of malnutrition noted in the patient’s admission history and
physical?
Admission history – Patient has chief complaint of heartburn and also difficulty in swallowing in
the past 4-5 months. This will cause discomfort in-patient and may lead to inadequate food
intake
General appearance: Patient distressed, thin, pale white male
Eyes: Sunken, sclera clear without evidence of tears
Nose: Dry Mucus membranes
Throat: Dry Mucus membranes
Extremities: Joints appear prominent with evidence of some muscle wasting.
Skin: Warm, dry
Abdomen: Epigastric tenderness on palpation
17. Review the patient’s chemistries upon admission. Identify any that are abnormal and
describe their clinical significance for this patient, including the likely reason for each
abnormality and its nutritional implication.
Abnormal chemistry lab results for patient include: High direct bilirubin, low total protein, low
albumin, low prealbumin, low PT Coagulation, low red blood cell count, low hemoglobin, low
hematocrit, high mean cell hemoglobin and high mean cell hemoglobin content.
The abnormally low values of total protein, albumin, and prealbumin may stem from an
inadequate intake of protein and probably calories overall. The symptoms of the cancer being of
the esophagus would most likely be a major cause. The patient indicated having both painful
swelling of the esophagus and difficulty swallowing foods. In addition, the patient indicated that
heartburn has made it very difficult to eat. The patient has lost over 30 lbs. unintentionally,
indicating cancer cachexia. The patient probably has increased energy needs due to tumor
growth. The patient’s nutrition therapy should probably consist of high-calorie pureed foods with
high protein content.
The hematology chemistries show a low amount of red blood and low percentage of hematocrit,
which indicates anemia. The red blood cells are shown to be hyperchromic yet normocytic. The
anemia may be resulting from lack of Vitamin B12 and Folate. The Vitamin B12 or Folate
deficiency would probably be a result of inadequate protein or caloric intake.
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IV. Nutrition Diagnosis
20. Select two high priority nutrition problems after Mr. Seyer’s surgery and complete the PES
statement for each.
1. Inadequate oral intake of foods and beverages related to dysphagia, odynophagia, and
heartburn evidenced by unintentional weight loss.
2. Inadequate intake of nutrients related to loss of appetite evidenced by unintentional
weight loss, muscle wasting and malabsorption.
V. Nutrition Intervention
21. For each of the PES statements you have written, establish an ideal goal (based on the
signs and symptoms) and appropriate intervention (based on the etiology).
Goal: Provide adequate food intake to meet needs – (modifications)
Intervention: Individuals with dysphagia may require more specific modifications of texture and
consistency. Individual is at high risk of dehydration due to inadequate fluid intake, and may
need intravenous fluids for hydration and electrolyte correction. Esophageal tissue may become
extremely irritated and friable to the extent that oral intake is impossible. A surgically placed
feeding tube may be indicated to provide nutritional support for these patients.
Goal: Provide adequate nutrients intake for needs
Intervention: Provide structure for elimination of the malabsorption nutrients from the diet. May
include enteral feeding /Parenteral Feeding. Also provide appropriate substitutions in order to
ensure maintenance of nutritional status. (possible supplements B12, Iron & folate).
VI. Nutritional Monitoring and Evaluation
25. Mr. Seyer will receive radiation therapy as an outpatient. In question #7, you identified
potential nutritional complications with the radiation therapy. Choose one of these nutritional
complications and describe the nutrition intervention that would be appropriate.
One of the nutritional complications of radiation therapy is inadequate oral/ nutrients intake due
to odynophagia and dysphagia. This affects the patient’s ability to eat food. Nutrition therapy
maybe modifications in texture and consistency of foods. In certain cases enteral nutrition,
parenteral nutrition, and nutritional supplement drinks may be implemented to help facilitate
oral/nutrient intake.
26. Identify major assessment indices you would use to monitor his nutritional status once he
begins therapy.
One of the most significant nutritional issues that can arise during cancer treatment is
malnutrition, which is why monitoring nutritional status is an imperative part of treatment.
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The effect of radiation therapy on healthy tissue in the treatment field can produce changes in
normal physiologic function that may ultimately diminish a patient’s nutritional status by
interfering with ingestion, digestion, or absorption of nutrients. Once the patient begins therapy,
the following major indices will be monitored: visceral protein status including serum albumin,
transferring, and prealbumin and hematologic measures monitoring RBC, Hgb, Hct, MCV,
MCH, MCHC, RDW. In addition to these biochemical indices, the patient’s weight will continue
to be monitored (adjusting for edema), including his hydration status and kcal and protein intake
to ensure these values sufficiently meet the patient’s nutritional needs.
The assessment indices were chosen for the following reasons:
Serum hepatic protein (e.g. albumin, transferrin, and prealbumin) levels have historically been
linked to nutritional status. Nutritional status and protein intake are the significant correlates with
serum hepatic protein levels. Evidence has consistently suggested that serum hepatic protein
levels correlate with morbidity and mortality and thus are useful indicators of severity of illness.
Although serum hepatic proteins do not measure nutritional repletion (with the exception of
prealbumin), it has been shown to be useful in identifying those who are the most likely to
develop malnutrition. Secondly, radiation therapy, among other factors (e.g. hypermetabolic
state, angiogenesis) increase the patient’s micronutrient needs and is the reason why the
hematologic indices are measured to prevent and monitor anemia. Thirdly, another important
assessment is checking the patient’s hydration status (e.g. examining urine color, urine flow rate,
dry mouth, acute weight loss) because patients undergoing radiation therapy can become
dehydrated easily. Lastly, the patient’s weight should be monitored to ensure a minimal amount
of weight is lost, because weight loss is associated with increased mortality.
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References
National Cancer Institute. (2013). Dictionary of Cancer Terms – adenocarcinoma. Retrieved on
From: http://www.cancer.gov/cancertopics/pdq/treatment/esophageal/Patient/page1
Nelms, Marica. Sucher, Kathryn P. Lacey Karen. Roth, Long. (2011). Nutrition Therapy &
Pathophysiology. (2nd Ed). Brooks/Cole: Cengage Learning. p702- 734.
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