Nicole Karetov



Nikki Karetov

February 20, 2014

Case Study #7

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.

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.

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.

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.

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.

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 |Add more fiber, increase satiety and decrease |

| | |LDL levels |

|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 |Fried foods can relax the LES |

|French fries |Avoid or choose different vegetable option |Fried foods can relax LES |

|Iced tea |Decrease consumption or avoid. Choose beverages that |Caffeine may cause reflux |

| |do not contain caffeine | |

|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 |High-fat foods like condensed cream soup can |

| |instead |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 spice and that do |Spicy foods can irritate the esophagus and bacon|

| |not contain bacon. |is high in fat, which can relax LES. |

|Milkshake |Avoid and choose a low-fat, non-acidic dessert if |High-fat foods can relax LES |

| |dessert is desired | |

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