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Michelle HoffmanPUD Case StudyProfessor MatuszakJanuary 29, 2013List all the food items that may contribute to GG’s condition and explain why.Due to her stressful and fast-paced life, GG’s diet is high is fast food, frozen meals, black coffee, chocolate, and alcohol. There is a specific nutrition therapy for those with gastritis because the etiology for many patients may be the consumption of foods that decrease mucosal integrity, and GG’s diet is likely causing this to occur and thus her pain and discomfort after eating or drinking.The reason fast food may cause flair up of gastritis symptoms is because it is usually high in fat. In general, foods high in fat (especially saturated fat) tend to increase inflammation of the stomach lining. Alcohol is another major trigger of gastritis because it can irritate and erode the mucosal lining of the stomach, and with constant consumption without a real break for the stomach lining to heal, it will also cause inflammation and spur on the painful and uncomfortable symptoms of gastritis. In addition, coffee and chocolate contain caffeine, which irritates the stomach by stimulating the secretion of gastric acids. Finally, frozen meals are known to be generally high in sodium, and with long-term consumption, excessive sodium may also agitate the stomach lining.Nutrition Therapy & Pathophysiology, pg. 361 any additional oral intake that may have contributed to GG’s condition and explain why.GG’s decision to begin smoking as well as consuming aspirin and antacids on a daily basis most likely contribute to her gastritis. Occasional use of NSAIDs, such as aspirin, generally does not exert negative side effects, yet if taken several times a day, aspirin may weaken the stomach lining or even cause bleeding and contribute to gastritis. Antacids were once thought to be a good treatment for gastritis because they decrease the amount of acid in the stomach thus alleviating symptoms. However consumption of too many antacids can have negative effects because acid in the stomach forms a physical barrier between bacteria such as H. pylori, which may cause infections and damage gastric mucosal cells, leading to gastritis. Smoking is a well-known irritant of gastritis; it interferes with the protective lining of the stomach making it susceptible to gastritis and ulcers. As with caffeine, smoking also increases stomach acid making the stomach more irritated. the non-oral stimulants (physical or psychological stress) that could contribute to GG’s condition and what she could do to change them.GG’s psychological chronic stress comes from a sudden divorce, raising a child who has severe ADHD, returning to school as a part-time student while keeping up her grades to keep her student loan, and maintaining a mediocre job to financially support her child and herself. In addition, lack of sleep is another stress that seems to be a result of her daily stress. As is this wasn’t enough, GG is also experiencing physical stress in the form of painful headaches, stomach pains, and indigestion. Although divorce is hard and often is not reversible, the stress coming from a separation may be ameliorated through exercise and/or attending a local support group for those who have separated. Both of these outlets would help GG manage her frustration about her divorce in a healthy way. Having GG’s mother around to help watch her son is a step in the right direction. By meditating for 5-10 minutes per day may help GG to stay positive about her son’s condition, and in the process calm her stress as well. She might even be able to find a support group to talk with other parents dealing with overactive children. Besides taking care of her son, GG’s top priority should be her education. She should keep a planner to help stay organized with her home and school obligations, making sure never to fall behind on her work. While her mother is watching her son perhaps she should study at the library or a calming and non-stressful environment. In terms of the physical stress GG is feeling, the best way to deal with her headaches by taking a small dosage of advil before meals as well as cut out the foods that will exacerbate her gastritis. By eating healthy meals, incorporating fiber, cutting out alcohol, and smoking cessation, GG’s gastritis-related headaches as well as her stomach pains may resolve all together.List the symptoms of GG’s gastritis.Although it is possible to not experience any symptoms, it is common to experience indigestion, heartburn, abdominal pain, hiccups/belching, loss of appetite, nausea/vomiting, and/or dark stools. Of these, GG is experiencing indigestion, abdominal pain/burning, and burning stomach 30 minutes after eating. a bland diet necessary? Explain and list the principles of the diet plan that you think GG should follow.Although GG is experiencing several symptoms of gastritis, a bland diet does not seem to be the course of action at the current time. If her symptoms become more severe and she begins to experience nausea and vomiting, a bland diet may be considered. If her gastritis becomes severe enough to need gastric surgery, a bland diet is definitely an appropriate course of action. A bland diet is used to treat ulcers, heartburn, nausea, vomiting, diarrhea, gas, or after surgery. As it sounds, it is a diet consisting of foods that are bland, i.e. soft, not spicy, and low in fiber. Spicy, fried, raw foods, alcohol, and caffeinated beverages are prohibited. If GG had gastritis caused by H. pylori, then she would need to take medication, such as antibiotics in a strict treatment regimen. This is not the case for GG, as her lifestyle choices and experiences have spurred on her gastritis. Thus I would recommend a combination of diet and lifestyle changes for GG. In order to cease the irritation and inflammation of GG’s gastric mucosa that are causing her symptoms, she needs to incorporate fiber, fruits, vegetables, lean meats, a multivitamin, as well as whole grains into her diet in replacement for fast food and frozen meals. This will create a balanced and healthy diet for GG. In addition, she needs to watch the types of fats she is consuming. She should avoid saturated and trans fats while focusing on increasing PUFA’s and MUFA’s. She also needs to quit smoking and drinking. Since the last two recommendations may be especially difficult to do, I would also have GG speak to her mother about giving her faith and encouragement with such a drastic lifestyle change. She needs to remember that her symptoms are reversible, but she is also on a dangerous track and should make these changes as soon as possible. is the mechanism of action of the following medications GG is receiving: Carafate, AlternaGel, and Pepcid?Carafate: A drug used to treat ulcers of the upper GI tract; it is a complex of sucrose, sulfate, and aluminum, and acts on the lining of the stomach and duodenum. It binds to the surface of ulcers and coats it to protect from injury by acid and pepsin. It is also thought to directly inhibit pepsin in the presence of stomach acid, bind to bile salts to further protect the stomach from injury, and increase prostaglandin production (protects the stomach lining).AlternaGel: Antacid that chemically react to neutralize/buffer existing quantities of stomach acid with no direct effect on its output. This increases the pH value of the stomach contents thereby providing relief of hyperacidity symptoms. It also decreases pepsin activity.Pepcid: This is an H2 blocker, or a histamine-receptor antagonist. This means it prevents histamine, a chemical in cells, to produce acid in the stomach, or reduce gastric secretion in the stomach. the nutrient-drug interactions that are associated with these medications.Carafate: when taken with other drugs, Carafate may bind to that drug and reduce absorption of the drugs. Take any other drugs two hours prior to taking Carafate. Overall it is a well-tolerated drug that doesn’t seem to have any nutrient interactions.AlternaGel: may interfere with calcium metabolism and may interfere with thiamine absorption as well; should be aware of osteoporosis in the future with the continuation of antacids throughout one’s life.Pepcid: may increase the risk of becoming iron and zinc deficient. May lower the absorption of vitamin B12 and folic acid as well—may need supplementation. It is recommended to avoid supplements with caffeine while taking Pepsid. are GG’s IBW and percent of IBW?Height: 5’2”Weight: 98 lbsRecent 12 lbs weight loss in 6 monthsHamwi method for IBW: 100 lbs + 5 lbs x (2 addition inches)= 110 lbs% IBW= 98/110= 89% Estimate her daily energy needs using the Harris-Benedict equation and appropriate stress factor.655.1 + 9.6 W (kg) + 1.9 H (cm) – 4.7 A (yrs.)Weight: 98/2.2= 44.5 kgHeight: 5’2”= 62 in. x 2.54= 157.48 cm655.1 + (9.6 x 44.5) + (1.9 x 157.48) – (4.7 x 27)~ 1,254.6 kcals/daySince GG has a moderately active life and at this point may have an ulcer, a stress factor of 1.6 should be added to her daily energy needs: 1,254.6 x 1.6 ~ 2,000 kcals/day.What may be the cause of the LUQ pain along with her usual pain (consider the enzymes that are elevated)?The cause of GG’s Left Upper Quadrant pain in addition to her usual pain may be due to elevated alkaline phosphatase and amylase levels, as revealed in her lab results. Both are part of liver function tests, and because they are much higher than normal, it may reveal some complications. Elevated amylase levels may be due to acute pancreatitis, which is commonly associated with alcoholism. Since GG is a heavy drinker, her LUQ pain could be a sign of an inflamed pancreas. Since GG had very high alkaline phosphatase levels, it may be indicative of a liver problem. It is likely brought on by her high alcohol intake, and may be experiencing abdominal pain as a sign. 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:c. Dehydrated when the first labs were drawnIn the second set of lab values, serum amylase, AST, and ALT all dropped. This probably means that:Enzymes were elevated due to alcoholRefer to the two lab values again, and not that two days after admission, GG’s Alk Phos and CPK remained essentially unchanged. Why?These enzymes are not affected by alcohol or hydrationWhat diagnostic tests (not lab values) indicate(s) that GG has an ulcer?Common tests that are used to help diagnose an ulcer are an endoscopy of the stomach, a stool test for the presence of blood, or a biopsy of tissue from the esophagus or stomach. A breath test may be taken to test for the presence of H. pylori as well. GG underwent a stool test to see if there was any presence of blood as well as an esophagogastroduodenoscopy before she was diagnosed with gastrisis. sketch the anatomical position where GG’s ulcer can be foundDefine:H2 antagonist: a class of drugs that help decrease stomach acid by blocking the action of histamine on parietal cells in the stomach.Proton pump inhibitor: drugs that reduce acid secretions in the stomach; these may affect the treatment effectiveness for H. pylori infections Therapy & Pathophysiology, pg. 209, 214What is the mechanism of action of the following medications GG is receiving: Nexium, amoxicillin, and clarithromycin?Nexium: a proton pump inhibitor that works in conjunction with amoxicillin and clarithromycin to eradicate H. pylori for patients with duodenal ulcer disease. It’s also known to relieve GERD symptoms. Since it is a proton pump inhibitor, it works by suppressing gastric acid secretion by blocking the final step in gastric acid production.Amoxicillin: binds to penicillin-binding protein 1A in located inside the bacterial cell wall where it inactivates transpeptidase ultimately inhibiting the last stage in bacterial cell wall synthesisClarithromycin: similar to erythromycin; binds to the bacteria’s ribosome’s inhibiting the translation of peptides thereby blocking protein synthesis in bacterial cells. 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 in and 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 would feel comfortable and competent to counsel GG with her diet. She is having a difficult time with cutting alcohol and fast food from her diet, which is where several of her symptoms have originated. I would sit down with her and first perform a 24-hr recall to see approximately how much alcohol and fast food she is currently consuming. I would then create a diet plan for her to follow, keeping in mind that she is on a strict budget and constant time crunch. My goal would be to teach her that she doesn’t need to sacrifice her health in order to fit in all her other daily activities and worries. In fact, she may see that home cooked meals could de-stress her day, allow her to be with her son and teach him proper nutrition/behavior, as well as improve GG’s nutritional status. Meal times would become a social and happy time, not a rushed time and a time to de-stress with alcohol and smoking. However, she is severely stressed from all that she must do and worry about, and I don’t feel that I, alone, could help solve her problems. I would therefore refer her to a professional therapist in order to get the proper mental health care that she needs.In Oxford, OH there are some agencies/organizations that could provide assistance to GG. First of all, there is the Oxford Community Choice Pantry, and seeing as her financial status is poor, she would most likely be eligible to shop at the pantry for groceries every other week. In addition, there is the family resource center, whose mission is to “Promote self-sufficiency for individuals and families in the Tallawanda School District.” For example, there are cooking seminars as well as nutrition education lessons. There support groups offered all over Southwest Ohio for divorced/separated individuals (kids as well) in order to help cope. There are also women’s issues support groups for GG to talk in general about her life and all the stresses while she’s surrounded around people who want to listen and help. is the significance of the dark stools?Dark stools are often an indication of blood in the stool. It may come form any part of the digestive tract, and sometimes bloody stool is only detected using a fecal occult blood test. When it’s dark enough to see with the naked eye, one’s doctor may perform an endoscopy or x-ray to see any abnormalities. If it is really dark stool, the bleeding often comes from the upper GU tract, such as the esophagus or stomach; this is often a sign of a peptic ulcer. the pathophysiology for the cause of the following abnormal values: BUN, NH3, and WBC.BUN: Elevated blood urea nitrogen levels indicate impaired kidney function due to an excessive protein breakdown. In GG’s case, this elevation is most likely due to the GI bleeding she is experiencing from the blood found in her stool. It may also be due to her probable dehydration from the alcohol consumption.NH3: This is mostly ordered on children, however ammonia levels are tests in adults when there are changes in mental status, disorientation, sleepiness, or coma. This test is ordered along with a liver function test when one becomes acutely more ill. Elevated amounts in the blood may indicate liver or kidney damage because the body is not effectively metabolizing and eliminating ammonia. Increased levels may also be seen with GI bleeding, as would be the likely case with GG.WBC: Higher than normal amounts of white blood cells indicate inflammation and/or infection because with either the body will produce more wbc’s to fight, which is why GG has a high amount. This measurement is also part of a routine complete blood count. was probably dehydrated on admission since she had been drinking. This means that some of her lab values were probably higher / lower (circle one) than indicated.After admission GG received packed cells and IV fluids. How would that affect the next set of lab values.GG’s hematocrit and hemoglobin levels would most likely increase in the next set of lab values, placing the values in a more normal range. Since she is dehydrated, her BUN levels are higher than the normal, and receiving fluids will cause a decrease.Define the following terms:Packed cells: a preparation of blood cells separated by liquid plasma; often seen in patients with severe anemia to help restore adequate levels of red blood cells and hemoglobin without an overload of excessive fluids.Abdominal tap: procedure used to remove fluid from the abdominal cavityPerforated ulcer: serious condition where an ulcer extends through the wall of an organ (mostly GI tract).Fistula: a permanent abnormal opening between two internal organs or between an organ and the exterior of the body.Exploratory Laparotomy: laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods and is often done in patients with acute abdominal painBillroth I: surgical removal of the pylorus in the treatment of gastric cancer of PUD; the proximal end of the duodenum is anatomized to the stomachVagotomy: surgical cutting of the vagus nerve to reduce acid secretion in the stomach; often a component of gastric surgery's+operation+I a Billroth pare a Billroth I to a Billroth II as to anatomical changes as well as to dietary changes, if any.Billroth I is a gastroduodenostomy, meaning the top half of the stomach is reconnected to the proximal end of the duodenum. Billroth II is a gastrojejunostomy, or partial gastrectomy, meaning the top half of the stomach is reconnected to the proximal end of the jejunum.As with any gastric surgery, there is nutrition risk with reduced capacity of the stomach and changes in stomach emptying. Since various portions are resected in each procedure, digestion of various nutrients may be altered, leading to vitamin and mineral deficiencies. B12 deficiency, specifically, is a concern with Billroth I because it is digested in the duodenum. In addition, calcium, magnesium, and iron are absorbed here as well, and deficiencies should be monitored. In the jejunum, there may be a concern with fat-soluble vitamin malabsorsption/deficiencies. If any deficiencies do occur, the patient should consult their doctor immediately.Nutrition Therapy & Pathophysiology, pg. 364-365Previous knowledgeCalculate GG’s energy and protein needs.Energy:EER= 354- 6.91 x age + PA x (9.36 x wt. + 726 x ht.)EER=354-6.91 x 27 + 1.12 x (9.36 x 44.5kg + 726 x 1.57m)EER~ 1,900-2,000 caloriesA reasonable PA to fit GG’s current life style with PUD is 1.12 for low activeProtein:Since GG now has PUD, her injury level is going to slightly increase her protein needs, thus she should consume ~15% of her daily calorie needs from protein: 1,900 calories x .15= 475/4g ~118 g proList the principles of a postgastrectomy diet and briefly describe the scientific basis for each principle.A postgastrectomy diet, or “anti-dumping” diet encourages a well-balanced diet slightly higher in protein and fat than what is recommended. Simple sugars should be avoided to prevent hyperosmolality and hypoglycemia associated with dumping syndrome. The patient oftentimes becomes lactose-intolerant because they lack the enzyme needed to break down lactose, and a lactose-free alternative is needed. Since dairy milk is fortified with vitamin D and calcium, supplementation is usually required for these minerals as well. Other ways to help prevent nutrient deficiencies is to take a multivitamin, while vitamin B12 injections may be warranted if the gastric surgery is more extreme. In addition, liquids should be consumed 30 minutes to 1 hour after meals to help prevent dumping syndrome, since they help move food along the digestive tract. Rather than 3 large meals per day, patients who have undergone a gastric surgery should consume 5-6 small meals throughout the day and lie down after every feeding. Finally, due to the strict nature of this diet, nutrition education is recommended to optimize the patient’s nutrition status while minimizing adverse symptoms, such as nutrient malabsorption or dumping syndrome.Nutrition Therapy & Pathophysiology, pg. 366Is 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.Since gastric surgery is permanent, I believe that GG will be on a postgastrectomy diet for the rest of her life because the parts of her GI tract that were resected will always have complications with nutrient absorption. However, if GG remains compliant with her diet while maintaining a good mental health status, her postgastrectomy diet may not be as strict and severe in the future. Overall, her prognosis is very positive and if she stays on a healthy tract for the rest of her life she should encounter minor complications. 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?In the case gastric surgery patients who are placed on a tube-feeding regimen, characteristics should include small frequent feedings and should use a calorically dense formula in order to provide more calories at a lower flow rate. Most patients are able to tolerate the standard, polymeric formulas. In general, doctors will use the least expensive formula that meets the patients’ individual needs. In addition the formula should be high in protein. In patients with pancreatic exocrine insufficiency, powdered pancreatic enzymes can be added to enteral feedings or dosed periodically during infusion, yet I wouldn’t currently recommend this for GG. Receiving liquids between meals is also recommended to decrease the risks of dumping syndrome. Vagotomy’s reduce acid production, which is necessary for efficient iron absorption. Therefore chewable or liquid iron is the preferred iron replacement in patients like GG as solubilization of iron tablets may not be complete, resulting in poor absorption of the supplement. Finally, glucose control should be maximized in GG’s formula and should not exceed 200 mg.Nutrition Therapy & Pathophysiology, pg. 386 the table below, compare several of the enteral nutritional supplements that would be appropriate for GG.ProductProducerFormCal/mlNon pro cal/g NProCHOFatNa mgK mgmOsm/kg waterVol to meet RDA in mlG of fiber/LIsosourceNestleLiquid4.2 cal/ml77:116.9 g42 g16.2 g325 ml435 ml650 mOsm/kg1250 ml2 gSustacalMead-JohnsonLiquid4.2 cal/ml78:115 g33 g6 g220 mg490 mg650 mOsm/kg1060 ml0 gResource PlusNestleLiquid1.5 cal/ml146:113 g52 g11 g310 mg460 mg600 mOsm/kg1890 ml0 gIntroliteRossLiquid2.2 cal/ml125:122.2 g70.5 g18.4 g930 mg1570 mg220 mOsm/kg1321 ml0 gNuBasicsNestleLiquid4.2 cal/ml153:120 g49 g26.5 g325 mg480 mg500 mOsm/kg2000 ml0 g ................
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