Transcript Ulcer Disease

Christina Cheung
 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.
 Maria Rodriguez
 Female
 DOB: 12/19 (age 38)
 Smoker
 Works in computer programming
 Work schedule: M-F, 9am-5pm
 Hispanic
 Catholic
 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
 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
 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.
 BP: 78/60 mm Hg
 Pulse: 68
 Respiration: 32 bpm with rapid breath sounds
 Temp: 101.3F
 Abdomen: Tender with guarding, absent bowel sounds








Height: 5’2”
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
 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 @ 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.
 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 pyruvate:ferredosin
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.
 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
hydrogen–potassium 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.
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
 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.
 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, maldigestion, and mal-absorption.
 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.
 “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.
 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-causing 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.
 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
- High glucose
70-120
80
128 mg/dL
- High Bilirubin
<0.3
1.3
0.6 mg/dL
- Low HGB
12-15 (W)
11.2
10.2 g/dL
- Low HCT
37-47 (W)
33
- 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
15 mg/dL
24
12.5
31 %
 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.
 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
 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
 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.
• Evident protein-energy malnutrition related to
inadequate protein intake and GI dysfunction as
evidenced by low prealbumin of 14 mg/dL (normal 1635), 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.
Addressing Maria Rodriguez’s 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.
Addressing Maria Rodriguez’s 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.
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.
 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 <4 g of fat and 41.5g protein/L per 300-Cal
serving—beneficial 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 1020ml/hr until the goal rate of 71ml/hr is achieved.
 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.
 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.
 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.
 Patient’s 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.
 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.
 Vitamin B-12 and iron absorption depend on an acidic
environment. Mrs. Rodriguez’s 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.
 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.
 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 postgastrectomy diet.
 For quite awhile, she will need to stay away from tough
foods that are not easily broken down mechanically.
 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.
 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-bloodpressure/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.