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.