Ulcer Disease Christina Cheung Ulcer Disease What is

Ulcer Disease Christina Cheung

Ulcer Disease: What is it? 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.

Meet the Patient Maria Rodriguez Female DOB: 12/19 (age 38) Smoker Works in computer programming Work schedule: M-F, 9 am-5 pm 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

Patient History 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 525 mg, 4 X/day Metronidazole 250 mg, 4 X/day Tetracycline 500 mg, 4 X/day Omeprazole 20 mg, 2 X/day

Risk Factors 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.

Physical Exam BP: 78/60 mm Hg Pulse: 68 Respiration: 32 bpm with rapid breath sounds Temp: 101. 3 F Abdomen: Tender with guarding, absent bowel sounds

Physical Exam 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

Tx Plan 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.

About the Current Treatment 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.

About the Current Treatment Tetracycline: Also used to treat infections by bacteria. Work by binding the 30 S ribosomal subunit and through an interaction with 16 S r. RNA. They prevent the docking of amino-acylated t. RNA. 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-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 Ca 2+ 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

Tx Plan: Surgery 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.

Surgery: Summary of the Nutritional Risks 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.

Tx Plan: Surgery How does this procedure affect normal digestion? Normal digestion process may change due to decreased acid production. This leads to malabsorption of calcium, vitamin B 12, 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.

Surgery: Post-Op Complications “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.

Surgery: Post-Op Complications Three phases of Dumping Syndrome: Early dumping syndrome-which occurs 10 -20 mins 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 -3 hrs 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.

Nutritional Assessment: Biochemical Lab Values Abnormal Biochemical Measures: Normal Admit Post Op Day 3 - High transferrin 250 -380 425 419 mg/d. L - Low total protein 6 -8 5. 5 6. 0 g/d. L - Low Albumin 3. 5 -5 3. 0 3. 3 g/d. L - Low Prealbumin 16 -35 15 14 mg/d. L - High WBC 4. 8 -11. 8 16. 3 - High glucose 70 -120 80 128 mg/d. L - High Bilirubin <0. 3 1. 3 0. 6 mg/d. L - Low HGB 12 -15 (W) 11. 2 10. 2 g/d. L - Low HCT 37 -47 (W) 33 - Low MCHC 31. 5 -36 31 28. 5 g/d. L - 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/m. L - High BUN 8 -18 15 mg/d. L 24 12. 5 31 %

Nutritional Assessment: Biochemical Lab Values 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 B 12 deficiency which is common in duodenal ulcers.

Nutritional Assessment: Usual Dietary Intake 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

Nutritional Assessment 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) = 1360 kcal/day 1360 x injury factor of 1. 1 -1. 3 = 1496 -1768 kcal/day content if patient received 1632 kcal/day Normal Protein Needs = 0. 8 -1. 0 g protein X kg body weight 0. 8 -1. 0 g X 50 kg = 40 -50 kg protein Postoperatively Protein Needs = 1. 0 -1. 5 X 50 kg = 50 -75 kg protein/day

Nutritional Assessment 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.

Nutritional Diagnosis: PES Statements • Evident protein-energy malnutrition related to inadequate protein intake and GI dysfunction as evidenced by low prealbumin of 14 mg/d. L (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.

Nutritional Intervention Addressing Maria Rodriguez’s protein malnutrition: Goal: to increase her energy and protein intake, to increase her prealbumin from 14 to 16 -35 mg/d. L and to maintain her weight in the healthy BMI range of 18. 5 -24. 9 kg/m 2. Intervention: to adjust her enteral feeding of Vital HN from 25 m. L/hr to 50 m. L/hr and then to 68 m. L/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 prealbumin and energy intake.

Nutritional Intervention 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.

Nutritional Intervention 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.

Nutritional Intervention: Formula 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. 5 g 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 25 ml/hr is the standard starting rate to monitor tolerance prior to increasing the formula- will increase the rate every 8 -12 h by 1020 ml/hr until the goal rate of 71 ml/hr is achieved.

Nutritional Intervention: Are we meeting the patient’s needs? 1632 kcal/ 1 kcal/ml = 1632 ml x 1 L / 1000 ml = 1. 632 L Meet protein Requirement? 1. 632 L X 41. 6 g protein/ L = 67. 9 g protein (yes meets requirement) Goal Rate? 1632 ml/ 24 hr = 68 ml/hr Both needs are being met.

Nutritional Intervention: Are we meeting the patient’s needs? 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.

Nutritional Intervention 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.

Nutritional Intervention 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.

Nutritional Intervention 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.

Nutritional Intervention 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.

Monitoring and Evaluation 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 post-gastrectomy diet. For quite awhile, she will need to stay away from tough foods that are not easily broken down mechanically.

Monitoring and Evaluation 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.

Questions?

Reference 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/DS 00590 http: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 11910 41/ Nelms M, Sucher K, Lacey, K. , Habash, D. , Roth S. Nutrition Therapy and Pathophysiology. 2 nd ed.