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Annelise ChmelikKNH 413February 11, 2014Case Study #14: Peptic Ulcer Disease Resulting in GastrectomyList all the food items that may contribute to GG’s condition and explain why.Foods that are spicy, fried, acidic, high in fat, or contain dairy may contribute to GG’s condition. These foods can irritate and increase inflammation in the stomach lining. In particular, GG consumes a high amount of fast food, frozen dinners, coffee, chocolate, and alcohol (rum and coke). List any additional oral intake that may have contributed to GG’s condition and explain why.Antacids: can reduce stomach acidity, which reduces the physical barrier to infectionsAspirin: certain pain medications can irritate or inflame the lining of the stomach and small intestineAlcohol: alcohol abuse can irritate and erode the mucous lining within the stomach, and it increases the amount of stomach acid that is producedCoffee: can inflame the lining of the esophagus, stomach, and the whole intestinal trackChocolate: can irritate the stomachTobacco: smoking can inflame the lining of the esophagus the non-oral stimulants (physical or psychological stress) that could contribute to GG’s condition and what she could do to change them.Stress: GG’s life is filled with several stress inducing factors. She is a single mother to a child suffering from ADHD and is currently undergoing a divorce. Also, she is returning to school and is feeling the overwhelming pressure to keep her grades high so she can earn a degree and provide for her and her son. To combat the daily stress, I would recommend engaging in physical activity. Moreover, I would suggest that individual or family therapy would be beneficial in dealing with the hardships of being a single parent. Lastly, I would recommend looking into some type of relaxation technique, such as yoga or meditation.List the symptoms of GG’s gastritisGG’s symptoms include severe abdominal pain, indigestion, burning pain in the stomach 30 minutes after a meal, loss of appetite, and recurrent stomach pain on her right side and up to her chest.Was a bland diet necessary? Explain and list the principles of the diet plan that you think GG should follow.In order to properly treat the symptoms of gastritis, it is crucial to determine the primary cause of the inflammation. In GG’s case, her gastritis is most likely caused by stress, smoking, alcohol abuse, frequent use of aspirin, and high consumption of coffee and fatty foods. Due to the many risk factors GG has, a bland diet could lessen her symptoms somewhat by eliminating certain foods, but not entirely.The principles of a bland diet include avoiding foods that spicy, fried, or raw, and eliminating alcoholic or caffeinated beverages. While on a bland diet it is also recommended that individuals refrain from smoking, avoid aspirin, eat smaller more frequent meals, eat and chew slowly, and stop eating two hours before bedtime. Therefore, it is crucial that GG eliminates coffee, chocolate, alcohol, and fried foods from her diet. is the mechanism of action of the following medications GG is receiving: Carafate, AlternaGel, and Pepcid?Carafate: sucralfate’s antiulcer activity is the result of formation of an ulcer-adherent complex that covers the ulcer site and protects it against further attack by acid, pepsin, and bile saltsAlternaGel: aluminum hydroxide is an antacid that works quickly to lower the acid in the stomach. This medication works only on existing acid in the stomach; it does not prevent acid productionPepcid: suppresses acid concentration and volume of gastric secretion the nutrient-drug interactions that are associated with these medications.Carafate: when administered with other drugs sucralfate may bind to the drugs in the stomach and reduce absorption of the drugs; thus, those medications should be taken two hours prior to sucralfate.AlternaGel: can interfere with calcium metabolism and thiamin absorption. AlternaGel should not be taken at a meal time.Pepcid: decreases the absorption of iron salts, Sporanox, ketoconazole, and drugs that require acid for adequate absorption. May increase the risk for deficiencies in iron and zinc. May also affect the levels of folic acid and vitamin B12 are GG’s IBW and percent of IBW?IBW: 100 pounds for the first 5 feet of height, plus 5 pounds for every inch over 5 pounds100 lbs. + (5 × 2) = 110 lbs.% of IBW = (actual body weight ÷ UBW) × 100% of IBW = (98 lbs. ÷ 110 lbs.) × 100 = 89%Estimate her daily energy needs using the Harris-Benedict equation and appropriate stress factor.Harris-Benedict equation: 655 + (9.56 × wt) + (1.85 × ht) – (4.68 × A)REE = 655 + (9.56 × 44.5 kg) + (1.85 × 157.48 cm) – (4.68 × 27)REE =1,245 kcalStress factor = 1.2Total Energy Needs = 1,245 × 1.2 = 1,494 1,500 kcalWhat might be the cause of the LUQ pain along with her usual pain?Pain in the left upper quadrant (LUQ) can be caused by stomach ulcers. Based on GG’s other symptoms, this would be the most primary cause of her pain. However, there are several other factors that may be contributing to GG’s pain. Angina is closely linked with pain in the LUQ, which is much greater in those that are stressed and use tobacco. Additionally, pain in the LUQ is commonly associated with a ruptured spleen.In particular, GG’s blood work shows that her Alkaline Phosphatase (ALP) and Amylase levels are elevated. Elevated ALP levels can indicate that there has been damage to the liver. In GG’s case, she may be experiencing abdominal pain due to frequent and excessive alcohol consumption, which is damaging her liver. GG’s lab values also indicated elevated Amylase levels. Amylase tests are usually ordered as part of a liver panel and when a patient is experiencing abdominal pain. Elevated amylase levels are associated with pancreatitis, which is also associated with alcoholism. Therefore, GG’s high consumption of alcohol may have led to her severe abdominal pain. 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:BleedingEating poorly in the hospitalDehydrated when the first labs were drawnOver hydrated when the second set of 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 alcoholHer medications caused them to dropGG was dehydrated when the first labs were drawnGG was overhydrated when the second set of labs were drawnRefer to the two lab tables again, and note that two days after admission, GG’s Alk Phos, and CPK remained essentially unchanged. Why?These enzymes are not affected by alcohol or hydrationHer medications caused them to dropDehydrated when the first labs were drawnOverhydrated when the second set of labs were drawnWhat diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?GG’s stool tests, her blood test that indicated H.pylori, and an esophagastroduodenostomy are the diagnostic tests that indicate that she has an ulcer.Briefly sketch the anatomical position where GG’s ulcer can be found.See attachment in AppendixDefine:H2 antagonist: A class of drugs used to block the action of histamine on parietal cells in the stomach, decreasing the production of acidProton pump inhibitor (PPI): a drug that limits acid secretion in the stomach is the mechanism of action of the following medications GG is receiving: Nexium, amoxicillin, and clarithromycin?Nexium: a proton pump inhibitor that suppresses gastric acid secretion by specific inhibition of H+/K+-ATPase in gastric parietal cell. This reduces gastric acidity by blocking the final step in acid productionAmoxicillin: a type of penicillin that inhibits the third stage of bacterial cell wall synthesis by binding to penicillin-binding proteins located in the bacterial cell wallClarithromycin: a drug that interferes with protein synthesis of bacteria. It specifically binds to bacterial ribosomes inhibiting the translation of peptides 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 would feel competent to counsel GG on a diet that would decrease all of her symptoms. I would write up a simple yet detailed diet plan that will give her enough direction that she would be able to adhere to the diet. I would want to educate her on easy ways to incorporate healthy foods into her daily diet; specifically, on the foods that she should be including within her diet. Lastly, I would want to educate and show her how to grocery shop in a short yet efficient amount of time. I believe that it is crucial that GG receives counseling for her alcohol abuse, tobacco abuse, and how to manage stress. I would recommend a therapist that is specialized in counseling individuals with these specific and unique needs. I would also recommend a smoking cessation class and encourage GG to attend an alcoholic’s anonymous meeting. What is the significance of the dark stools?Dark stools are indicative of the presence of blood in the stools. This indicates that the blood is coming from the upper part of the gastrointestinal tract, usually due to a bleeding duodenal or stomach ulcer. Dark stools can also represent inflammation of the stomach lining or gastritis. HYPERLINK "" the pathophysiology for the cause of the following abnormal values: BUN, NH3, WBC.BUN: increased BUN levels suggest impaired kidney function, which can be due to acute or chronic kidney disease, damage, or failure. Elevated levels can also be due to dehydration, which can be a result from GG’s excessive alcohol consumption. BUN concentrations may also be elevated when there is gastrointestinal bleeding. NH3: elevated ammonia levels indicate liver or kidney damage. GG’s NH3 levels were not included in the lab results, but one can assume that GG’s ammonia levels will be elevated due to her excessive alcohol consumptionWBC: elevated white blood cell count is indicative of infection, inflammatory disease, and a period of severe emotional stress. In GG’s case, the WBC count may be elevated due to the presence of H.pylori bacteria 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 next set of lab values will be different because the packed cells and IV fluids rehydrated and nourished her. This will most likely impact/stabilize the hemoglobin, HCT, BUN, and glucose levels in the patient.Define the following terms:Packed cells: a preparation of blood cells separated from liquid plasma, often administered in severe anemia to restore adequate levels of hemoglobin and red blood cells without overloading the vascular system with excess fluidsAbdominal tap: a procedure used to remove fluid from the abdominal cavityPerforated ulcer: a condition where an untreated ulcer burns through the wall of the stomachFistula: an abnormal connection between an organ, vessel, or intestine and another structure. It usually results from injury, surgery, or inflammationExploratory Laparotomy: a diagnostic tool that allows physicians to visualize and examine the structures inside the abdominal cavityBillroth I: a partial gastrectomy is performed with a reconstruction that consists of an anastomosis of the proximal end of the duodenum to the distal end of the stomachVagotomy: severing of the vagus nerve; often a component of gastric surgery Therapy and Pathophysiology. 2nd edSketch a Billroth I.See attachment in AppendixCompare a Billroth I to a Billroth II as to anatomical changes as well as to dietary changes, if any.Billroth I: a partial gastrectomy or pyloroplasty is performed with a reconstruction that consists of an anastomosis of the proximal end of the duodenum to the distal end of the stomach.Billroth II: a partial gastrectomy with a reconstruction that consists of an anastomosis of the proximal end of the jejunum to the distal end of the stomach. In this surgical procedure, a blind loop of the duodenum is created.Billroth I (gastroduodenostomy) and Billroth II (gastrojejunostomy) are fairly similar procedures. Both surgical procedures involve a partial gastrectomy with a reconstruction. Therefore, dietary changes and nutritional risks are also similar for both procedures. These changes and risks involve reduced capacity of the stomach, potential changes in gastric emptying, and maldigestion and/or malabsorption.Nutrition Therapy and Pathophysiology, 2nd ed.Calculate GG’s energy and protein needs. Energy needs:655 + (9.56 × 44.5 kg) + (1.85 × 157.48 cm) – (4.68 × 27) = 1,245Stress Factor = 1.5Total Energy Needs: 1,867 1,800 – 1,900 kcal/dayProtein needs:1,800 × 0.25 = 450 kcal 112 g1,900 × 0.25 = 475 kcal 119 g112 – 119 g protein/dayList the principles of a postgastrectomy diet and briefly describe the scientific basis for each principle.Adequate protein and energy: ensures appropriate healing and recovery postoperativelySlow progression of solid food: to prevent the onset of early and late dumping syndromesInitially avoid all simple sugars: prevent hyperosmolarity and hypoglycemiaAvoid dairy and lactose-containing products: lactose products are difficult to digest and are typically not tolerated post-gastrectomyEat 5-6 small meals a day: smaller meals are easier for the stomach to digestConsume liquids 30 minutes to 1 hour after solid food: liquids will help facilitate quick movement through the small intestine. Therefore, consuming liquids will assist in preventing dumping syndromeIncorporate functional fibers: functional fibers will delay gastric emptying by bulking up stoolIncorporate supplements to prevent nutrient deficiencies: it will be much more difficult for the body to absorb nutrients so vitamin B12 injections and liquid vitamins can be considered to improve the chance of absorptionIncrease calorie needs: this will help in maintaining weight that can be affected post-gastrectomyNutrition Therapy and Pathophysiology. 2nd ed. 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.As time progresses, GG should be able to incorporate more foods into her daily diet and will not be as limited as she is currently. However, it is crucial that GG adheres to this diet to the best of her ability as often as possible. Moreover, she must make sure she eliminates all diet and risk factors that can worsen her state. 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?If GG were to undergo hospitalization for an extended period of time and required a tube feeding, I would recommend and advise the medical team to administer small, frequent feeds with a high protein formula. Also, since there is an increased risk for vitamin and mineral deficiencies, I would recommend that vitamins and minerals be administered through the tube feed as well. GG should consume calorically dense foods orally, but it is crucial that these foods will not worsen her peptic ulcer disease state. Moreover, GG should be aware of how much added sugar she is consuming and try to minimize the amount in her regular diet. Nutrition Therarpy and Pathophysiology. 2nd ed. Pg 364-366.Using the table below, compare several of the enteral nutritional supplements that would be appropriate for GG.ProductProducerFormCal/mLNon- pro cal/g NProg/LCHOg/LFatg/LNa mgK mgmOsm/kg waterVol to meet RDA in mLg of fiber/ LFree H2O/L in mLPerativeAbbottFormula1.397:166.7180.337.31,0401,7354601,1551.6790Osmolite 1.5 CalAbbottFormula1.5125:162.7203.649.11,4001,8005251,0000762PromoteAbbottFormula1.075:162.5130.026.01,0001,9803401,0000839Vital 1.5 CalAbbottFormula1.5114.1101.328085.72,2503,0006101,0009.01,150OxepaAbbottFormula1.5125:162.7105.393.81,3101,9605359460785Abbott Nutrition ................
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