Download Peptic Ulcer Disease

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Case Study #1: PUD
Lynne Roller
Miami University
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1. List all the food items that may contribute to GG’s condition and explain why.
GG’s consumption of on the go fast food items are filled with grease and high fat
contents. Eating frozen meals and fried food dinners also contains high fat. She also
consumes excessive amounts of coffee and coke daily. These foods increase the acid
secretions, which contribute to the development of PUD. Her high alcohol consumption is
also not helping, since alcohol decreases mucosal integrity (Nelms 361).
2. List any additional oral intake that may have contributed to GG’s condition
and explain why.
GG consumed Aspirin daily to combat the sever pain she was experiencing. NSAIDs
can increase gastric irritation and are not recommended for patients with PUD (Nelms
362).
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.
Lying down or sleeping shortly after poor food choices may increase symptoms. GG
should leave gaps of time in between large meals and sleeping. Smoking is also a major
influence on the development and worsening of PUD because it reduces the blood supply
(Nelms 363). The psychological stress that stems from her son’s condition, school, and her
divorce may be increasing GG’s symptoms. Stress can impact the gastric blood flow,
decreasing the ability of the gastric mucosal barrier to function properly (Levenstein,
Ackerman, Kiecolt-Glaser, Dubois 10).
4. List the symptoms of GG’s gastritis
GG is experiencing abdominal pain, indigestion, and burning pain after her meals.
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5. Was a bland diet necessary? Explain and list the principles of the diet plan that
you think GG should follow.
Since the doctor was unclear whether or not her diet is the sole problem of GG’s
ulcer, a bland diet was not necessary. After discovering that H. pylori was present, the best
way to heal would be from antibiotics. However, changes in her diet are necessary in order
to remove symptoms and decrease inflammation. Removing foods such as peppers, coffee,
fried foods, high fat foods, and alcohol will help decrease acid secretion. Since GG did not
tolerate the milk very well, I would recommend her to refrain from too many dairy
products in her diet. Her new diet could include: herbal teas instead of coffee, cooked
cereals, baked, roasted, broiled, or grilled low-fat meats, peanut butter, non-fried potatoes
and rice, high amounts of fruits and vegetables, and low fat desserts (Nelms 363).
6. What is the mechanism of action of the following medication GG is receiving;
Carafate, AlternaGel, and Pepcid?
Carafate (Specifically Sucralfate), binds to gastric ulcers specifically produced by
anti-inflammatory drugs. The drug forms a bridge between the negatively charged
Sucralfate and positive proteins of the mucous. This drug also buffers acid and helps inhibit
pepsin (Nagashima 117). AlternaGel (Aluminum Hydroxide gel), is used as a gastric
antacid by increasing immune responsiveness (Alhydrogel). Pepcid blocks histamine’s
action to the cells, reducing acid production.
7. List the nutrient-drug interactions that are associated with these medications.
Sucralfate- it is important to not combine other drugs with this medicine during the
same 30-minute time frame. It is also important to drink a glass of water with this medicine
and to space an hour before and after each meal. AlternaGel could potentially inactivate
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thiamin and calcium metabolism. To decrease this possibility, do not take AlternaGel
medications at mealtime. Pepcid can have an effect of the absorption of vitamin B12.
8. What are GG’s IBW and percent of IBW? (appendix A, tables 7 and 8)
IBW= 100lb +10lb = 110lbs or 50kg
% IBW= 98/110 = 89%
9. Estimate her daily energy needs using the Harris-Benedict equation and
appropriate stress factor (Appendix A, Table 17).
EER= 655.1 + (9.563 x 50) + (1.850 x 157cm) – (4.676 x 27)
= 655.1 + 478.15 +290.5 -126.3
=1297kcal  1300kcal
Stress factor (1.5) x 1300kcal = 1950kcal
10. What might be the cause of the LUQ pain along with her usual pain? (consider
the enzymes that are elevated).
GG’s lab results showed very high levels of amylase and alkaline phosphatase due to
a diseased on inflamed pancreas. These high levels can lead to the development of peptic
ulcers. Her increased amylase levels were probably caused by her habitual dose of Apirin.
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:
Dehydrated when the first labs were drawn
12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This
probably means that:
Her enzymes were elevated due to alcohol.
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13. Refer to the two lab tables again, and note that two days after admission, GG’s
Alk Phos and CPK remained essentially uncharged.
These enzymes are not affected by alcohol or hydration
14. What diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?
An esophagogastroduodenoscopy showed an ulcer on the dorsal wall of the
duodenum. A BUT (Urea Blood Test) test was then performed to confirm a positive
occurrence of H. pylori. This is a more reliable and accurate test than a tissue biopsy
(Nelms 362).
15. Briefly sketch the anatomical position where GG’s ulcer can be found.
16. Define:
H2 antagonist: Blockers used to treat duodenal ulcers. They can help relieve
or prevent heartburn and acid indigestion.
Proton pump inhibitor: Drugs used to relieve acid reflux symptoms and to
treat peptic or stomach ulcers (Proton).
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17. What is the mechanism of action of the following medications GG is receiving:
Nexium, amoxicillin, and clarithromycin.
Nexium (Esomeprazole) acts as a proton pump inhibitor and decreases peptic acid
secretion. Amoxicillin binds to penicillin binding proteins in the bacterial cell walls and
inhibits synthesis. Clarithromycin stops the protein synthesis.
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 feel as if I could guide GG in the correct direction by helping her create a diet that
would decrease her symptoms. However, I do not feel as equipped to provide guidance in
the stressful areas of her life. I would refer GG to a therapist who could provide better help.
19. What is the significance of the dark stools?
Dark stools indicates the presence of blood. This blood could be anywhere from
along the digestive tract from the mouth to the anus (bloody).
20. Give the Pathophysiology for the cause of the following abnormal values: BUN,
NH3, and WBC.
GG’s BUN elevated levels suggest dysfunctional kidneys as well as dehydration
(BUN). Her NH3 levels were not given the blood work. However, high NH3 levels could
indicate liver or kidney damage. GG’s NH3 levels could be high due to her excessive
drinking. GG’s WBC count was high most likely due to her body fighting an infection. Since
H.pylori is present in her body, elevated WBC levels are expected (High).
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21. GG was probably dehydrated on admission since she had been drinking. This
means that some of her lab values were probably higher/lower than indicated.
22. After admission GG received packed cells and IV fluids. How would that affect
the next set of lab values?
These packs will lower her lab values for the next round of tests.
23. Define the following items:
Packed cells: RBC that separate from the liquid plasma.
Abdominal tap: The removal of fluid from the abdominal cavity
Perforated ulcer: An ulcer that involves the entire thickness of a cell wall
Fistula: Opening between two organs from the inside organ to the surface of the
body.
Exploratory Laparoscopy: Incision through the abdominal wall in order to
examine peritoneal cavity.
Billroth I: (Gastroduodenostomy) Formation of stomach and the duodenum
surgically.
Vagotomy: Cutting the vagus nerve in gastric surgery.
24. Sketch a Bilroth I
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25. Compare a Bilroth I to a Billroth II as to anatomical changes as well as to
dietary changes if any.
The Billroth I connects the proximal end of the duodenum to the distal end of the
stomach (Nelms 364). Dietary changes may include difficulty to absorb nutrients such as
folate, calcium, magnesium, and iron. Billroth II connects the proximal end of the jejunum
to the distal end of the stomach. Dietary changes may include trouble absorbing nutrients
such as iron, magnesium, calcium, and folate) (Nelms 364).
26. Calculate GG’s energy and protein needs
Resting Energy
10 x wt(kg) +6.25 x ht(cm)-5 x age-161
10 x 44.5kg +6.25 x 157.48 cm -5 x 27 -161
445 +984.25- 135 -161 = 1133.25kcal 1100 kcal
EER
EER= 655.1 + (9.563 x 50) + (1.850 x 157cm) – (4.676 x 27)
= 655.1 + 478.15 +290.5 -126.3
=1297kcal  1300kcal
Stress factor (1.5) x 1300kcal = 1950kcal
Protein
1950 x .15 = 292.5g  290g
27. List the principles of a postgastrectomy diet and briefly describe the scientific
basis for each principle.
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Prescribe adequate energy and protein intake to ensure appropriate healing and
recover postoperatively.
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Initiate slow progression of solid food to prevent the onset of early and late
dumping syndromes
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Patient may be initially lactose intolerant and dairy products should be avoided
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Slowly progress to five to six small meals each day
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Consume liquids 30 minutes to 1 hour after solid food
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Lie down after eating
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Consider addition of functional fibers to delay gastric emptying and assist with
treatment of diarrhea.
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Prevent development of nutrient deficiencies
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Provide nutrition education that will promote optimal nutritional intake and
minimize symptoms of Malabsorption and maldigestion (Nelms 366).
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.
GG tried including her old-habit foods into her diet after symptoms decreased and
her disease worsened. Therefore, it might not be realistic to say GG will be able to go back
to that way of eating. Instead, it would be wise to remain on the postgastrectomy diet.
29. If GG were to be hospitalized for an extended period of time and required a
tube feeding via duodenum or jejunum, what characteristics would be
appropriate for the tube feeding you would use?
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Light meals given frequently would be appropriate. It would also be appropriate to
eat calorically dense foods and lots of liquid in between meals. It would be very important
to still consume adequate amounts of protein and fat in her diet.
30. Using the table below, compare several of the enteral nutritional supplements
that would be appropriate for GG
Product
F
O
R
m
Cal/ml
Pro
CHO
Fat
mOsm
/kg
water
Vol to meet
RDA in ml
Nutren 1.5
Lactose-free
high kcal
1.5
60
169
68
430
1,000
Protain XL
Wound
healing
Lactose-free,
high protein
HIV/AIDS
Malabsorption
1.00
57
145
30
340
1.250
1.2
54
156
40
400
1,000
1.28
1.00
60
51
216
139
23
28
680
540
1,184
1,422
Isocal HN
Advera
Optimental
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Resources
Alhydrogel. PubChem Substance. (2013).
Bloody or tarry stools. (2009). National Institutes of Health. 361. 1179-1187.
BUN-blood test. (2011). National Institutes of Health. 116.
http://www.nlm.nih.gov/medlineplus/ency/article/003474.htm.
High white blood cell count. (2012). MayoClinic.
http://www.mayoclinic.org/symptoms/high-white-blood-cell-count/
basics/definition/sym-20050611.
Levenstein, S., Ackerman, S., Kiecolt-Glaser, J., Dubois., Andre. (1999). Stress and peptic
ulcer disease. American Medical Association. 281. (1). 10-11.
Nagashima, R. (1981). Mechanisms of action of Sucralfate. US National Library of Medicine
National Institutes of Health. 3. (2). 117-127.
Nelms, M., Sucher, K., Lacey, K., Roth, S. Nutrition Therapy and Pathophysiology. 2/e.
Proton pump inhibitors. (2014). U.S. National Library of Medicine.
http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000381.htm.