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Erin Nyberg
Title: Case 8 Ulcer Disease: Medical and Surgical Treatment
Questions:
1.

Identify the patients risk factors for ulcer disease.

Ms. Rodriguez has a familial history of peptic ulcer disease. She is a smoker, drinks 8-10 cups of coffee per
day, and 12-24 ounces of soda.

2.

How is smoking related to ulcer disease?

Smoking decreases the elasticity of the pyloric sphincter, allowing excess HCl into the duodenum. Smoking
inhibits the pancreas release of bicarbonate, resulting in a consistently more acidic duodenal environment.
Gastrin and acetylcholine stimulate the production of HCl from the parietal cells of the stomach; cigarette
smoke causes increased HCl response to these hormones. Smoking can also inhibit the action of medications
that treat ulcers.

3.

What role does H. pylori play in ulcer disease?

H. pylori is a gram-negative bacterium that can survive in the acidic conditions of the stomach. It causes
sustained inflammation of the gastric mucosa. It does not spontaneously resolve itself and must be treated with
one or more medications including antibiotics and acid-suppressants.

4.

Four different medications were prescribed for treatment of this patients H. pylori infection. Identify the drug
functions/mechanisms. (Use table below.)
Drug
Metronidazole
Tetracycline
Bismuth subsalicylate
Omeprazole

5.

Action
Antibiotic, amebecide, antitrichomonal
Antibiotic
Antidiarrheal, antinauseant
Antiulcer, antigerd, antisecretory

What are the possible drugnutrient side effects from Mrs. Rodriguezs prescribed regimen? (See table above.)
Which drugnutrient side effects are most pertinent to her current nutritional status?
Metronidazole This drug can be taken with food if it causes GI discomfort but medication availability
decreases. This drug can increase sodium levels, which can be important for persons on a low sodium diet.
This drug can cause anorexia, dry mouth, candidiasis, stomatitis, diarrhea, constipation, and epigastric distress.
All alcohol should be avoided during and 3 days after the use of this medication. This drug can decrease LDH,
TG, and blood glucose levels.
Tetracycline Take this medication an hour before meals or 2 hours after. Supplements or fortified foods
containing divalent/trivalent minerals (Ca, Fe, Mg, Zn) must be taken separately, 3 hours before or 1 hour after
taking drug. Drug can cause anorexia. This medicine chelates with minerals which can decrease both food and
medication absorption. The drug can decrease Vitamin K by decreasing colonic bacteria. With long-term use,
Vitamin B deficiency can occur. Vitamin A supplements should be used with caution as they can cause benign
intracranial hypertension in combination with tetracycline. This drug can decrease skeletal growth in children
under 8 years of age.
Oral and GI side affects can include stomatitis oral candidiasis, esophagitis, dysphagia, nausea and vomiting,
cramps, diarrhea, and flatulence.
This medication can cause decreased serum levels of B12 and B5. It can also decrease the level of Vitamin C in
WBC.
Bismuth subsalicylate Chew tablets well. Diabetics must use caution with this medication as it can cause
hypoglycemia in combination with insulin and other oral medications. Serum potassium levels may decrease.
Serum uric acid levels may increase or decrease.

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Omeprazole Take 30-60 minutes before a meal, open caplet and sprinkle onto applesauce or into orange
juice. Follow by cool water. This drug may decrease the absorption of Iron and B12. Omeprazole and
decrease calcium absorption; supplementation is advised. Avoid SJW and gingko as they can decrease drug
level.
6.

Explain the surgical procedure the patient received.

Mrs. Rodriguezs gastrointestinal tract was rerouted to allow its contents to bypass the duodenal perforation.
Her specific surgery is called a gastrojejunostomy; the Billroth II. The greater curvature of the stomach was
attached to the proximal jejunum, which runs horizontally to the bottom of the stomach.

7.

How may the normal digestive process change with this procedure?
As the duodenum is being bypassed entirely, absorption of nutrients will likely decrease considerably.

8.

The most common physical side effects from this surgery are development of early or late dumping syndrome.
Describe each of these syndromes, including symptoms the patient might experience, etiology of the symptoms,
and standard interventions for preventing/treating the symptoms.
Dumping syndrome is usually the result of the gastrointestinal tracts response to the presence of a hyperosmolar
food. Fluid is shunted to the bowel to dilute the solution and gastric transit speeds up. Early dumping
symptoms occur 10-30 minutes after eating and include a feeling of fullness and nausea.
Late dumping symptoms occur 1-3 hours after a meal is consumed. Symptoms of late dumping syndrome are
the result of reactive hypoglycemia. The rapid delivery of nutrients to the bloodstream results in a magnified
insulin response by the pancreas. Glucose is transported to target tissues leaving blood glucose levels low
enough to result in hypoglycemia.

9.

What other potential nutritional deficiencies may occur after this surgical procedure? Why might Mrs.
Rodriguez be at risk for iron-deficiency anemia, pernicious anemia, and/or megaloblastic anemia?
The gastrojejunostomy routes food from the stomach directly into the jejunum. Because the duodenum is
completely bypassed, B12 absorption will be affected. The carrier protein intrinsic factor is produced by the
parietal cells of the stomach and binds B12 in the small intestine, which then transports it to the ileum where it
binds another transporter at the brush border for absorption. A B12 deficiency can result in megaloblastic
anemia, a form of anemia characterized by large immature red blood cells.
Again, because the duodenum is bypassed in a gastrojejunostomy, iron absorption is compromised.
Approximately .6 - 1.5 mg of Fe2+ are absorbed daily in the duodenum (Krause 107). Hemoglobin is a protein
that carries oxygen through the blood. It contains 4 heme units, each of which have a atom of iron that binds
oxygen. Without adequate iron intake, heme cannot fully develop and less oxygen is carried to tissues resulting
in iron deficiency anemia.
Pernicious anemia is a type of megaloblastic anemia that is usually associated with an autoimmune disease that
causes the destruction of intrinsic factor and a subsequent B12 deficiency. Mrs. Rodriquez would be more
likely to suffer from one of the previously discussed forms of anemia (or both).

10. Should Mrs. Rodriguez be on any type of vitamin/mineral supplementation at home when she is discharged?
Would you make any recommendations for specific types? Explain.
Mrs. Rodriquez will be prescribed an enteral formula that will provide the DRI of vitamins and minerals.
Because her small intestine has been restructured, the absorption of key micronutrients such as iron and B12
will be compromised. An additional vitamin and mineral supplement would be appropriate based on her
inability to affectively absorb nutrients.
11. Prior to being diagnosed with GERD, Mrs. Rodriguez weighed 145 lbs. Calculate %UBW and BMI. Which of
these is the most pertinent in identifying the patients nutrition risk? Why?
BMI: 20.3 - normal
% UBW: 76% - moderate deficit

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Her BMI is within a normal range, it does not provide any information about recent weight changes. The %
UBW highlights that she has lost 24% of her normal weight. This information is more significant as it shows
that her intake has been suboptimal for some time and her risk for nutrient deficiency is high.
12. What other anthropometric measures could be used to further confirm her nutritional status?
% Weight Change: 24%
A greater than 10% loss of body weigh over 6 months is considered severe. Because her weight loss has
occurred over the last 11 months, the value cannot be categorized according to the Assessment of Weight
Change. Despite this, the value shows that she has lost almost of her body weight, which is not
inconsequential.
13. Calculate energy and protein requirements for Mrs. Rodriguez.
Empirical: 25-30 kcal/kg = 1250 1500 kcal/day
Mifflin St. Jeor: 10(50kg) + 6.25(175cm) 4.92(age)-161 = 1246 kcal/day x I.F. (1.3) = 1620 kcal/day
Protein: 1.0-1.5 g/kg = 50-75 g/day
14. This patient was started on an enteral feeding postoperatively. What type of enteral formula is Peptamen AF?
Using the current guidelines for initiation of nutrition support, state whether you agree with this choice and
provide a rationale for your response.
Peptamen AF is a high-calorie elemental formula intended for critically ill patients suffering from sepsis, burns,
or other metabolically demanding illness or injury.
The patient is not able to meet her caloric needs orally. She has sustained weight loss of 24% of UBW in the
past 3 months. She will not be able to eat normally for approximately another 6 weeks, therefore placement of a
PEG tube is warranted.
Peptamen AF provides a hydrolyzed protein source, which is preferable for a patient that may suffer from malabsorption. It supplies lipids in the form of medium chain triglycerides also for easier absorption.
Peptamen AF contains fiber. As she is recently postoperative from a GI surgery, this may be a contraindication
for using this formula. It would be best to try another elemental formula that will be as easy to digest but wont
pose risk for irritation. If she tolerates the first formula it would then be appropriate to try Peptamen AF.
15. Why was the enteral formula started at 25 mL/hr?
The enteral formula was started at 25 mL/hr to slowly introduce the nutrition formula and assess for tolerance.
The rate can be increased as Mrs. Rodrigues tolerates the formula.
16. Is the current enteral prescription meeting this patients nutritional needs? Compare her energy and protein
requirements to what is provided by the formula. If her needs are not being met, what should be the goal for her
enteral support?
Peptamen AF: 1.2 kcal/ml; 76g PRO, 81% Free Water
50 cc/hr x 24 hours = 1200 ml = 1.2 L
1.2kcal/ml: 1.2 kcal x 1200 ml/day = 1440 kcal/day
Pro: 76g/L = 1.2 L x 76g = 91.2 g/day
Free H2O: 811 ml/L = 1.2 L x 811 ml/L = 973 ml/day
Nutrition facts from http://www.nestle-nutrition.com/Products/Nutrition_Panel.aspx?ProductId=649c190dbe60-42ca-bf10-676f9236e4c9
Her protein needs would be easily met by the nutrition prescription of 50cc/hr. Her caloric needs with an injury
factor of 1.3 are 1620 kcals/day. Her nutrition prescription is for 1440 kcal per day. If she tolerates a feeding
rate of 50 cc/hr, she could be increased to 55cc/hr and her intake would increase to 1584 kcal/day.

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17. What would the RD assess to monitor tolerance to the enteral feeding?
The RD would assess for intolerance that would present as abdominal discomfort, distention, or high gastric
residuals. Also important to monitor is actual intake versus prescribed intake. In the hospital setting, enteral
nutrition can be interrupted for a variety of reasons including tests and therapy. To make up for the feeding time
lost during these procedures, the rate can be increased for several hours if the patient can tolerate it.
18. Using the intake/output record for postoperative day 3, how much enteral nutrition did the patient receive? How
does this compare to what was prescribed?
During the 24 hour period from 7am 9/3 to 7am on 9/4 the patient received 450 ml of enteral nutrition. By day 3
the feeding rate should have been advanced to 50 ml/hr for a total of 1200 ml in a 24-hour period. Mrs.
Rodriguez received about 1/3rd of the nutrition prescription.
19. As the patient is advanced to solid food, what modifications in diet would the RD address? Why? What would
be a typical first meal for this patient?
A first meal for this patient would be clear liquids. She will be limited to clear liquids for the first 3 days and
then advanced to pureed foods. The RD would advise Mrs. Rodriguez on which foods must be avoided with a
diagnosis of GERD. Complicating her situation is the recent gastric resectioning that she underwent. Mrs.
Rodriguez will have to be on a pureed diet for 3 weeks, then a soft diet before progressing to small regular
meals. The RD should address the potential side effect of dumping syndrome and advise Mrs. Rodriguez on
how she can prevent it from occurring.
20. What other advice would you give to Mrs. Rodriguez to maximize her tolerance of solid food?
It would be important for Mrs. Rodriguez to eat small, frequent meals; 5-6 times per day. To help avoid gastric
discomfort she should eat slowly and stop eating at the first signs of satiety.
21. Mrs. Rodriguez asks to speak with you because she is concerned about having to follow a special diet forever.
What might you tell her?
22. Using her admission chemistry and hematology values, which biochemical measures are abnormal? Explain.
BUN:

High: Can be elevated due to gastrointestinal hemorrhage.

BUN/Crea Ratio:

High: Can be elevated due to gastrointestinal hemorrhage.

Glucose:

High: Value was high on 9/3; normal for a post-surgical patient.

Mg:

Low: Related to surgery

Ca:

Low: Related to surgery

Bilirubin total:

High: Related to duodenal perforation

Bilirubin direct:

High: Related to duodenal perforation

Protein, total:

Low: Can be due to protein malnutrition.

Albumin:

Low: Can be low due to peptic ulcer disease.

Prealbumin:

Low: Can be low due to malnutrition.

WBC:

High: Can be high due to tissue necrosis or hemorrhage.

Hemoglobin:

Low: Hb can be low due to protein malnutrition and low albumin.

Hematocrit:

Low: Can be low due to anemias, iron intake deficiency, or folate deficiency.

Mean cell Hgb:

Low: Can be low due to microcytic anemia, hypochromic anemia and sideroblastric anemia.

Mean cell Hgb content:

Low: Can be low due to hypochromic anemia, iron deficiency, or sideroblastric anemia.

Lymphocyte:

Low: Can be low due to malnutrition.

Segs:

High: Related to duodenal perforation.

a.

Which values can be used to further assess her nutritional status? Explain.

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Prealbumin is an indicator of overall protein status. A low level can be indicative of inadequate caloric
intake. The severity of malnutrition can be assessed by how low the value is.
b.

Which laboratory measures (see lab results, pages 8485) are related to her diagnosis of a duodenal ulcer?
Why would they be abnormal?
BUN can be elevated due to gastrointestinal hemorrhage.
Albumin can be low due to peptic ulcer disease.

23. Do you think this patient is malnourished? If so, what criteria can be used to support a diagnosis of
malnutrition? Using the guidelines proposed by ASPEN and AND, what type of malnutrition can be suggested
as the diagnosis for this patient?
The patient has nonsevere (moderate) malnutrition in the context of chronic illness. She has been consuming
75% of her energy requirements for greater than 1 month.
24. Select two nutrition problems and complete the PES statement for each.
1. Inadequate oral intake related to pain associated with eating as evidenced by 35 pound weight loss since
diagnosis with GERD 11 months ago.
2. Undesirable food choices related to nutrition related knowledge deficit as evidence by consumption of 8-10
cups of coffee per day and 1-2 caffeinated soft drinks.
25. 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).
1.

Goal: Prevent further weight loss.

Intervention: Nutrition Education Content: Nutrition relationship to health/disease - Provide education
to patient on appropriate food choices for her disease that will allow her to tolerate oral intake.

2.

Goal: Eliminate consumption of beverages that will aggravate her disease.

Intervention: Nutrition Education Content: Nutrition relationship to health/disease Provide education
about how her food choices affect the functioning of her LES and how her beverage choices increase the
production of HCl, exacerbating her condition.

26. What nutrition education should this patient receive prior to discharge?
Mrs. Rodriguez needs information about which foods exacerbate her disease. This would include caffeine,
alcohol, carbonated be beverages, high fat foods (fried foods, whole fat dairy, fatty meats), pepper, peppermint
and spearmint. Certain fruits and vegetables may cause aggravation also; types will vary for individuals.
Depending on the length of her hospitalization, Mrs. Rodriguez will need information on how to progress her
intake of solid foods when she returns home. The guidelines for consumption will resemble those for patients
who undergo other bariatric surgeries. She will remain on a pureed diet for 3 weeks, then move to soft foods
until she is 6 weeks post surgery. At that point she can resume eating normal foods while making sure to avoid
potential irritants such as nuts and seeds, gristle, and woody vegetables. To avoid dumping syndrome she
should eat frequent, small meals that include complex carbohydrates, good sources of fat, while avoiding sugary
foods.
27. Do any lifestyle issues need to be addressed with this patient? Explain.
The patient must discontinue smoking. Because the chemicals in cigarette smoke increase HCl production she
could potentially further exacerbate her existing ulcer or cause a new one to form. She will still suffer from
symptoms of GERD if she continues to smoke, which will compromise her ability to eat and cause continued
weight loss. Her caffeine intake must be addressed. She is consuming 10-12 caffeinated beverages per day.
Caffeine contributes both to gastric acid production and the loss of elasticity in the lower esophageal sphincter.

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Should she not make serious lifestyle modifications she will continue to suffer from symptoms and
complications of GERD and PUD.

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license distributed with a certain product or service or otherwise on a password-protected website for classroom use.