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Caitlin MazurekKNH 411Case Study 2Gastroesophageal Reflux DiseaseHow is acid produced and controlled within the gastrointestinal tract?Acid is produced in the stomach where the gastric glands are located. The hydrochloric acid is secreted from the parietal cells within the gastric gland. The hydrochloric acid activates the pepsinogen, kills microorganisms, and denaturizes proteins. It is produced and secreted during the first phase, called cephalic phase where the HCL and pepsinogen are released when stimulated by tasting, smelling, or even seeing food. What role does lower esophageal sphincter (LES) pressure play in the etiology of the gastroesophageal reflux disease? What factors affect LES pressure?Normally, the atmospheric pressure is greater in the esophagus than in the stomach, and this prevents reflux of gastric contents. The LES stops serves as a barrier between the esophagus and the stomach. The etiology of reflux is affected by many factors including physical and lifestyle factors. Things that lower LES pressure include increased hormones, other bodily conditions like a hernia, cigarette smoking, medications, and foods high in fat among others. What are the complications of gastroesophageal reflux disease?Complications of untreated or unresponsive GERD may include impaired swallowing, aspiration of gastric contents into the lungs, ulceration, and perforation or stricture of the esophagus. Barrett’s Esophagus or Barrett’s metaplasia, has the cells change in the esophagus going from normal squamous cell epithelium to metaplastic columnar cell epithelium. What is H. pylori and why did the physician want to biopsy the patient for H. pylori?H. pylori or heliocobacter pylori is the bacteria responsible for most ulcers and stomach inflammation. It can weaken the protective coating of the stomach. Many of the symptoms of carrying H. pylori are similar to GERD. The physician wanted to biopsy the patient just to cover all of the areas and make sure what he was working with. Identify the patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal reflux disease.The patient has severe indigestion, and was afraid he was having a heart attack or having some heartburn. Describe the diagnostic tests performed for this patient.Jack Nelson was admitted to the hospital and an intraesophageal pH monitoring and barium esophagram support a diagnosis of gastroesophageal reflux disease. pH monitoring is placing a capsule that has an acid sensing probe, battery and a transmitter inside. The probe monitors the acid in the esophagus and transmits the information to a recorder that is worn by the patient on a belt. The capsule transmits for two days and then the battery dies. Within a week, the capsule is passed in the stool. Information is taken and put into the computer to figure out the pH. A barium esophagram is a procedure where Mr. Nelson drinks a mixture of barium sulfate, that is chalky and white like a milk shake. The barium can be seen by fluoroscopy or b x-ray. It allows swallowing to be seen and movement through the stomach into the duodenum. What risk factors does the patient present with that might contribute to his diagnosis? (Be sure to consider lifestyle, medical, and nutritional factors.)Mr. Nelson is considered obese due to his high BMI. He has a very low activity rate due to his past knee surgery and now his shoulder injury. He does not smoke but does take many different pills each day such as atenolol, aspirin, and ibuprofen. His 24-hour dietary recall contains many foods that are very high in fat such as fried chicken, potato salad, French fries, and ice cream. He also has alcohol 3-4 times a week, which can decrease LES pressure as well leading to GERD. The MD has decreased this patient’s dose of daily aspirin and recommended discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect gastroesophageal disease?Certain medications can control the gastric secretions certain ways, while others can interfere with control of gastric secretions by blocking several of those control pathways. Ibuprofen and aspirin can block these pathways. These drugs can provide short-term relief, but over-the-counter drugs should not be used more than a few weeks at a time, not every day. Aspirin and ibuprofen can weaken the LES causing GERD to become more prevalent. The MD has prescribed lansoprazole. What class of medication is this? What is the basic mechanism of the drug? What other drugs are available in this class? What other groups of medications are used to treat GERD?Lansoprazole is a proton pump inhibitor that works by suppressing the molecules that release the stomach acid. They block the H+, K+-ATPase ezyme, a component in HCL production. Other proton pump inhibitors include omeprazole, pantoprazole, rabeprazole, and esomeprazole which are all only available by prescription only. Over-the-counter strength Prilosec is also available. Other groups of medications that are used to treat GERD include antacids, foaming agents, H2 antagonists, and prokinetics. Are there specific foods that may contribute to GERD? Why or why not?Specific foods that may contribute to GERD include foods high in fat, and also include chocolate, spearmint, peppermint, alcohol, and caffeine. These all contribute to GERD because they lower the LES pressre and thus contribute to LES incompetence. Summarize the current recommendations for nutrition therapy in GERD.The current recommendations for nutrition therapy include avoiding black and red pepper, coffee, and alcohol as well as reducing the amount of food eaten at each meal. Avoiding foods such as chocolate, mint, and high fat foods is also recommended. Increasing calcium and iron may help as well. Reducing the amount of carbonated beverages may also help. Calculate this patient’s percent UBW and BMI. What does this assessment of weight tell you? In what ways does this contribute to his diagnosis?This patient’s percent UBW is 148% and his BMI is 31.7. He is considered obese due to his high BMI. His percent UBW is 148% meaning, is usual body weight should be around 145 pounds or a little more. Being obese does contribute to an increase chance of getting GERD and since he is obese, this lowers the LES pressure. Calculate energy and protein requirements for Mr. Nelson. Identify the formula/calculation method you used, and explain the rationale for using it.The calculated energy requirements for Mr. Nelson is 2970. His protein requirement is 111 g/day. The formula I used to calculate this out is as follows:662 – 9.53 x age + physical activity x (15.91 x weight + 539.6 x height)662 - 9.53 x 48 + 1.11 x (15.91 x 97.7 + 539.6 x 1.75) This formula was used because it can be controlled using the amount of physical activity which was only a 1.11. Complete a computerized nutrient analysis for this patient’s usual intake and 24-hour recall. How does his caloric intake compare to your calculated requirements?After calculating out his nutrient analysis, it is evident that the patient eats around 4,500 calories each day, or at least in the past 24-hours. His caloric intake is far higher than what he should be eating daily. Since he should be eating around 2970 calories a day, he is eating close to 1,530 more than he should. From the information gathered within the intake domain, list possible nutrition problems using the diagnostic term.Mr. Nelson’s diet includes a lot of carbonated beverages as well as plenty of high fat foods due to his dining out at fast food places. Although his diet is only about 30% of his nutrient intake, he should be eating less due to his obesity. Since he is less capable of getting exercise because of his knee and now shoulder injuries, he needs to be eating healthier to minimize his chances of GERD. Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s overall cardiac health? Explain. Mr. Nelsons’s cholesterol is very off. His LDH is very high and his HDL is very low. This is throwing off his overall cholesterol as extremely high at 220 when normal is between 120-199. Improving his cholesterol by lowering his weight can improve his overall health including his cardiovascular health. From the information gathered within the clinical domain, list possible nutrition problems using the diagnostic term.HTN, or hypertension can be a problem from high blood pressure. He also has high cholesterol, which can lead to many more problems in the future. His triglycerides are also above normal. What other components of lifestyle modification would you address in order to help in treating his disorder?I would try to break down his meals into smaller snacks almost. He should be eating five smaller meals instead of three large meals and two snacks. I would also try to lessen the amount of soda that he drinks. Drinking 5-6 cans of diet soda will increase sodium intake and decrease the water intake. Water is important to drink, because it normalizes most of the things in the body. From the information gathered within the behavior-environmental domain, list possible nutrition problems using the diagnostic term. Possible nutrition problems include a high-fat diet, as well as excess sodium intake. There is very little, if any water intake. Select two high-priority nutrition problems and complete the PES statement for each.Inadequate food intake related to excessive fat intake as evidenced by 24 hour dietary recall. Inadequate beverage intake related to excessive carbonated beverage intake, decreased water intake, as evidenced by 24 hour dietary recall and difficulty swallowing. For each of the PES statements that you have written, establish an ideal goal (based on the signs and symptoms) and an appropriate intervention (based on the etiology). An ideal goal to lessen the amount of fat eaten would be to switch to a grilled chicken sandwich instead of a fried chicken sandwich and to try to pack a lunch instead of eating out for both lunch and dinner.An ideal goal would be to try to cut out one soda a day and replace it with water and try to gradually decrease the amount of soda drank. These are both realistic goals that can eventually lessen Mr. Nelson’s weight as well as help with his GERD. Outline necessary modifications for him within his 24-hour recall that you could use as a teaching tool.Food itemModificationRationaleCrispixnonen/aSkim milknonen/aOrange juiceSwitch to a water based juice that is flavored with orangeThis will lessen the acidity in the juice and will help with the LES and GERD/acidity in the stomachDiet PepsiLessen the amount that is drank daily as much as possibleCarbonated beverages can increase gastric acid secretionFried chicken sandwichSwitch to a grilled chicken sandwichAid in the lessening of fat in the diet aspectFrench friesSwitch to apples or yogurt parfait at McDonaldsFries are fat loaded, and a fruit side would have less calories and more nutrientsIced TeaAvoid tea to see if it is symptomatic and causes irritationIf the tea causes irritation, then he should try to avoid itChipsSwitch to apple chipsHe would get the chip feel of the apple chips, but it would be less fatBeerAvoid for a whileIf the alcohol causes irritation, then it should be avoided, it may increase the gastric acid secretionFried chickenSwitch to grilled chicken Lessen the amount of fat eatenPotato SaladSwitch to a baked potatoLessen the amount of fat eaten and possibly increase vegetables and nutrients eatenGreen Bean CasseroleSwitch to just green beansLessen the amount of fat within the casserole and increase the nutrient value Fruit saladNonen/aBaked beansAvoid if it causes irritationIf it causes irritation, then try different foods. Milkshake Switch to a smoothieIncrease the amount of fruits eaten and lessens the amount of fat ................
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