Patrick Burrows

KNH 413
Prof. Matuszak
2/11/16
Case Study #14 Peptic Ulcer Disease Resulting in Gastrectomy
1. List all of the food items that may contribute to GGs
condition and explain why.

Food that may attribute to increase of symptoms of peptic ulcer

disease (PUD) are: cola, coffee, tea, cocoa, alcohol, 2% milk,
whole milk, cream, high-fat yogurt, chocolate milk, eggs fried or
scrambled using high fat methods, fried meats, high fat meats,
pepper, and high-fat or fried desserts (367). Based on the history
that GG provided she commonly consumed strong black coffee,
chocolate, fast foods, fried foods, and alcohol.

2. List any additional oral intake that may have contributed

to GGs condition and explain why.

GG stated that she typically consumes strong black coffee as

well as alcohol. Current nutrition therapy recommends the
restriction of food that increase acid secretion or causes direct
irritation to gastric mucosa such as caffeine, coffee, and alcohol.

GG admits to consuming all of these for a prolonged amount of

time in her history (366).

3. List the non-oral stimulants (physical or psychological

stress) that could contribute to GGs condition and what
she could do to change them.

GG has several non-oral stimulants that could be contributing to

her overall condition. GGs husband left her 6 months ago and
now she is faced with supporting not only herself but her son as
well. GG is also trying to pursue a degree in accounting so she is
trying to acclimate to student and work life. She is also having
problems with her son acting out. GG began drinking after the
divorce to help her sleep since she was having difficulty.

4. List the symptoms of GGs gastritis.

Typically a person experiencing gastritis may be subjected to the

following symptoms: belching, anorexia, abdominal pain,
vomiting, bleeding, and hematemesis. Out of these symptoms
GG is experiencing severe abdominal pain.

5. Was a bland diet necessary? Explain and list the

principals of the diet plan that you think GG should
follow.

I believe that the bland diet was necessary due to the vast
amount of possible things in GGs life that could be contributing
to her issue. The principals of the bland diet plan are to avoid
certain foods such as vegetables that may cause gas, dried
fruits, berries and figs, whole grain and course cereals, fried
chips, highly seasoned meats and salad dressings, fried pastries,
alcohol, coffee, aspirin, and any strong flavored seasonings
(Bland Diet). GG should try and follow the guidelines of not
eating fried foods and not consuming alcohol or coffee. It seems
that she consumes a large amount of these items and cutting
them out would potentially help her condition.

6. What is the mechanism of action of the following

medications GG is receiving: Carafate, AlternaGel, and
Pepcid?

Carafate works by binding to duodenal and gastric ulcers and

draws in defective mucosa to protect the site. Carafate also
buffers acid, absorbs bile salts, and inhibits the action

mechanism of pepsin. Essentially Carafate builds a protective

layer over the ulcer to allow it to heal (Nagashima). AlternaGel
works by converting HCl in the stomach to form soluble
aluminum chloride (Aluminum hydroxide). Pepcid is an H2antagonist, which means that it blocks the release of histamine
that causes excess acid to be produced in the stomach (Pepcid
Complete).

7. List the nutrient-drug interactions that are associated

with these medications.

There are no nutrient-drug interactions associated with these

medications.

8. What are GGs IBW and percent of IBW?

GG is 52
Using the Hamwi Method it can be determined that her IBW is
100lb+(2x5)= 110lb.
GG %IBW=(98/110)x100= 89%

9. Estimate her daily energy needs using the HarrisBenedict equation and appropriate stress factor.

655+(9.56x45.45)+(1.85x157.48)(4.68x27)=1254.48(1.5)=1881
Using the Harris-Benedict equation and a stress factor of 1.5 her
daily energy needs are 1800-2000 calories/day.

10.

What might the cause of the LUQ pain along with

her usual pain?

Based on GGs signs/symptoms and her diet history it is possible

that she has a hiatal hernia. A hiatal hernia can allow for food
and acid to push up into the esophagus giving the individual
heartburn. It is possible to manage these signs and symptoms
with home remedies like GG has with Tums tablets and milk
(Abdominal pain).

11.

In 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:

This probably means that GG was bleeding internally and over

hydrated. A decreased HGB value is indicative of internal
bleeding (60). When someone is overhydrated their BUN, Cr, Ser

Alb, Na, K, and CL values will be lowered because their

concentration in the blood will also be lower.

12.

In the second set of lab values, serum amylase, AST,

and ALT all dropped. This probably means that:

When GG was admitted she had said that she had consumed
alcohol within the past 24 hours. Alcohol consumption will
increase these lab values because they are all liver enzymes.
This means that when the second set of lab values were drawn
these enzymes should show lower levels because it has been
some time since she has consumed alcohol.

13.

Refer to the two lab tables again, and note that two

days after admission, GGs Alk Phos and CPK remained

essentially unchanged. Why?

When GG was admitted she was dehydrated and admitted to

consuming alcohol. They are unchanged because they all
correlate to alcohol consumption and hydration status.

14.

What diagnostic test(s) (not lab values) indicate(s)

that GG has an ulcer?

A stool sample was obtained that was positive for the presence
of blood and a esophagogastroduodenoscopy revealed the
presence of helicobacter pylori.

15.

Briefly sketch the anatomical position where GGs

ulcer can be found.

GGs ulcer is located on the dorsal wall of her duodenum

Stomac
h

16.

Define:
a. H2 antagonist: are H2-receptor antagonists and are used
to treat duodenal ulcers and prevent their return. When
given in over the counter strengths they are used to
prevent heartburn and indigestion. They are also used to
treat gastric ulcers. H2 antagonists work by decreasing acid
production in the stomach (Histamine H2 Antagonist).

b. Proton pump inhibitor: are a medication that works to

reduce the amount of acid in a persons stomach that is
made by the glands in the lining of the stomach. Proton
pump inhibitors are used to treat symptoms related to
GERD, treat peptic ulcers, and damage to the lower
esophagus caused by acid reflux (Proton pump inhibitors).

17.

What is the mechanism of action of the following

medications GG is receiving: Nexium, amoxicillin, and

clarithromycin?

Nexium is a proton pump inhibitor. It works by blocking the final

step in acid production (Nexium (Esomeprazole Magnesium)
Drug Information: Clinical Pharmacology). Amoxicillin is an
antibiotic that kills bacteria during the stage of active
multiplication(Amoxil (Amoxicillin) Drug Information).
Clarithromycin works by interfering with amino acid translocation
during the protein assembly process of bacteria
(Clarithromycin).

18.

GG 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 able to provide assistance to someone
like GG.

I would feel competent in providing GG with nutritional

intervention therapy. I would help her assess her current diet,
help her find foods that will not agitate her condition, educate
her on her condition, monitor and evaluate weight status over
time, and educate her on drug/nutrient interactions. I would refer
her to someone else to help her with cessation in drinking and
smoking. Additionally I would refer her to someone else to help
her with her financial issues, relationship issues, and the
problems with her son. In the Oxford area I would refer her to the
Community Counseling and Crisis Center as well as Student
Counseling Services if she was a student at the Univeristy.

19.

What is the significance of dark stools?

Dark stools are typically an indication of some type of internal

bleeding of the lower gastrointestinal tract.

20.

Give the pathophysiology for the cause of the

following abnormal values: BUN, NH3, and WBC.

An abnormal BUN value is indicative of intestinal bleeding

because it measures the amount of urea nitrogen in the blood.
An abnormal WBC value is indicative that the body is currently
trying to fight off some type of infection by increasing the
number of white blood cells.

21.

GG was probably dehydrated on admission since she

has been drinking. This means that some of her lab

values were probably higher/lower(circle one) than
indicated.

When someone is dehydrated their body is trying to pull fluid into

the bloodstream. When the body is trying to pull fluid into the
bloodstream the blood will be more concentrated.

22.

After admission GG received packed cells and IV

fluids. How would that affect the next set of lab values?

After she received the packed cells and IV fluids some of her lab
values should return to normal. This is because due to her

bleeding she needed the packed cells to fix her HGB values and
the IV fluids will help bring her to a normal hydration status.

23.

Define the following terms:

a. Packed cells- are made up from a unit of whole blood after
the removal of plasma by centrifugation (Blood Products)
b. Abdominal tap- a procedure used to relieve fluid from in
between the abdominal wall and the spine (Abdominal
tap)
c. Perforated ulcer- an ulcer that bursts through the stomach
wall and leaks food and gastric juices into the abdominal
cavity (Perforated ulcer)
d. Fistula- a permanent abnormal passageway between two
organs or between an organ or the outside of the body
(Fistula)
e. Exploratory Laparotomy- a procedure where a large
incision is made into the abdomen and used as a
diagnostic tool (Laparotomy, exploratory)
f. Billroth I- a partial gastrectomy that is performed that
connects the distal end of the stomach to the proximal end
of the duodenum (368)
g. Vagotomy- a procedure that eliminates that cholinergic

24.

stimulation of the stomach (367)

Sketch a Billroth I.

25.

Compare a Billroth I to a Billroth II as to anatomical

changes as well as to dietary changes, if any.

In a Billroth I the top half of the stomach is reconnected to the

duodenum but in a Billroth II the top half of the stomach is
connected to the small bowel. There are no dietary restrictions
for either operation however one must keep in mind that the
stomach is now smaller and that they may have some problems
with vitamin deficiency (368).

26.

Calculate GGs energy and protein needs.

655+(9.56x45.45)+(1.85x157.48)(4.68x27)=1254.48(1.5)=1881
Using the Harris-Benedict equation and a stress factor of 1.5 her
daily energy needs are 1800-2000 calories/day.

0.8(45.45)=36.36
1.5(45.45)= 68.18
GG needs 0.8g-1.5g/kg of protein daily due to the stress that her
body is under. She would need approximately 36-68g of protein
per day.

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