Case study Peptic Ulcer Disease

Brooke Bryant
02/02/2016
Gretchen Matuszak
KNH 413

1. List all the food items that may contribute to GGs condition and explain why.
Some foods that may have contributed to GGs condition are her fast food/ high fat diet and
chocolate intake. These foods cause irritation to the stomach lining. When infection or trauma
interrupts the protective mechanisms, an acute inflammatory condition initiates. Thus acute
gastritis is due to the localized inflammatory state of the gastric mucosa. By blocking
prostaglandin release, NSAIDS assist in control of inflammation but may also inhibit their
protective function for the gastric mucosa, leading to gastritis (Nelms,365). It is also
recommended that when patients are diagnosed with gastritis/ peptic ulcer disease that they avoid
fried foods, high fat cooking methods until the ulcers have healed and the inflammation has gone
down (Nelms,367).
2. List any additional oral intakes that may have contributed to GGs condition and explain
why.
Some of the additional oral intake that may have contributed to GGs condition are her alcohol
use, smoking, carbonated beverages, coffee, if the milk she consumed was 2% or whole milk,
and the amount of NSAIDS. The caffeine in the coffee that GG consumes increases acid
secretion in the stomach causes pain and inflammation of the ulcer. Alcohol is not directly linked
to peptic ulcer disease but most cases of peptic ulcer disease the patient does or did use to
consume large quantities of alcohol. The NSAIDS that GG was consuming per day was making
her stomach more vulnerable to pepsin and acid (Hopkins Medicine,2015).According to Nelms
the 2% milk/ whole milk and carbonated beverages are two foods not recommended when
having problems with gastritis or peptic ulcer disease (Nelms,367). All of these oral intakes
cause inflammation in GGs stomach which affected the healing process of the stomach lining
and ulcers.

3. List the non-oral stimulates (physical or psychological stress) that could contribute to
GGs condition and what she could do to change them.
GG over the past six months have been put under a lot of physical and psychological stress. Her
husband of eight years left her and her four year old son. She was left to support herself and her
son whom she had never done before. She had always been dependent on her husband to be the
provider and now she is left with the stress to figure out how to support herself and her son. Her
family has not been financially supportive of her and she is faced with expenses of a divorce
settlement so she can receive child support for her son. GG has been encouraged to go back to
school by her parents to pursue a degree but she also has to work a part-time job. GGs son has
also recently been diagnosed with ADHD. This is a new stress for GG since she did not have to
work or go to school and was a stay at home mom when she was with her husband. In order for
GG to keep her student loan she has to keep an acceptable GPA and with working and raising a
child she is trying to balance her time but is not getting adequate nutrition or sleep. GG has also
started to manage stress with cigarettes and alcohol (Hopkins Medicine, 2015).
The way GG can better manage her stress is by cutting back on her classes and managing
her hours at work so it is more balanced. This will give her time to spend time with her son and
to be able to study for her classes. Also the extra time would give GG the ability to prepare
healthy meals and work out 30 minutes to help manage her stress she is going through instead of
using cigarettes and alcohol to manage it. The working out for 30 minutes daily would also give
GG more energy throughout the day. GG could also use the extra time to get the proper amount
of sleep that will help her to not have to consume as much caffeine and sugar to keep her awake
throughout the day to study, and spend more time focusing on her son .
4. List the symptoms of GGs gastritis.

Severe pain in the RLQ that occurred 30 minutes after eating

Severe pain that occurred after consuming alcohol and caffeinated beverages
Pain in the gastric system that would subside after taking antacid that would return

shortly after.
Fatigue
And not always having an appetite

5. Was a bland diet necessary? Explain and list the principles of the diet plan that you think
GG should follow.
A bland diet is not necessary. Foods high in flavonoids will help reduce the growth of the H.
pylori. These foods that GG can consume are apples, cranberries, onions, celery, garlic, and
decaffeinated tea. GG can drink flavored beverages as long as they are not carbonated and are
decaffeinated. GG should consume enough water throughout the day to help hydrate her and
cleanse her body. Foods high in antioxidants like cherries, berries, tomatoes, squash and bell
peppers. Foods high in B vitamin and calcium such as roasted nuts, beans, green leafy vegetables
and whole grains, refined grains should be avoided. Lean meats such as chicken and fish, both
of these should be baked and not battered. Foods can be flavored with mild spices, none of which
are spicy because this could irritate her gastritis. Foods should not be fried and a low fat high
fiber diet should be followed (Gastritis, 2014).
6. What is the mechanism of action of the following medications GG is receiving: Carafate,
AlternaGel, and Pepcid?

Carafate is an antiulcer medication; it is not directly absorbed into the body. It works in
the stomach lining by adhering to ulcer sites and protects from acids, enzymes, and bile
salts. It is used to heal an active duodenal ulcer (Drugs, 2016).

AlternaGel is also known as aluminum hydroxide and it is used to treat increased

stomach acid, upset stomach, heartburn, sour stomach, and acid indigestion (Drugs,2016).
Pepcid is used to prevent ulcers in the stomach and intestines. And it also treats when
there is too much acid in the stomach, heart burn, and GERD (Drug, 2016).

7. List the nutrient-drug interactions that are associated with these medications.

Carafate nutrient and drug interactions include the medications abacavir / dolutegravir /
lamivudine, dolutegravir, and paricalcitol. The nutrient interactions is it cannot be taken with
alcohol (Drugs, 2016).

AlternaGels nutrient and drug interactions include abacavir, dolutegravir, lamivudine

aspirin, citric acid, sodium bicarbonate, caffeine pheniramine, phenylephrine, sodium citrate,
sodium salicylate, calcium citrate, citric acid, glucono-delta-lactone, magnesium carbonate, topical
magnesium oxide, sodium picosulfate, potassium bicarbonate, potassium citrate, sodium citrate
simethicone, sodium bicarbonate codeine, pheniramine, phenylephrine and to not consume alcohol
while taking this medication (Drugs, 2016).

Pepcid nutrient and drug interactions include atazanavir, cobicistat, Evotaz, Reyataz, tizanidine,
zanaflex and famotidine (Drugs,2016).
Question Continued:
8. What are GGs IBW and percent of IBW (Appendix A, Tables 7 and 8)?
IBW: 110
Calculated by the Hamwi Method for women- 100 lbs. for the first 5 feet of ht. ; add 5lbs for
every inch over 5ft. or subtract 5lbs for every inch under 5ft.
IBW%: 89%

Calculated by taking actual weight over the ideal body weight times 100 to get percentage.
9. Estimate her daily energy needs using the Harris- Benedict equation and appropriate
stress factor (Appendix A, Table 17)
655+(9.56x44.5(kg))+(1.85x157.48(cm))-(4.68x27)= 655+425.42+291.34-126.36x1.5= 1,182
Stress factor is 1.5 because she is active and has an ulcer that is in the process of healing. So her
estimated daily energy needs should be between 1,182-1,200kcal
10. What might be the cause of the LUQ pain along with her usual pain? (Hint considers
the enzymes that are elevated).
The LUQ pain along with the usual pain that she is experiencing is caused by epigastric pain that
is in her stomach that is most likely leading to an ulcer forming or that is already developed. The
pain is usual caused by the ulcer being irritated by different foods that she is consuming that are
high in acidity. The other pain that she is experiencing could be from the alcohol that she has
been consuming. This could be why her liver enzymes are high from having to process the large
amount of alcohol that she has been consuming (MayoClinc,2011).
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:
She was over hydrated when the second set of labs were done because there was no indication in
the first lab report of dehydration. There is also no indication that she was bleeding and there is
no 24 hour recall to show that she was eating poorly in the hospital.
12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This
probably means that:
GGs lab values in the second set dropped and it is probably because the enzymes were elevated
due to her alcohol consumption.

13. Refer to the two lab tables again, and note that two days after admission, GGs Alk
Phos and CPK remained essentially unchanged. Why?
These enzymes were not affected by alcohol or hydration because CPK is an enzyme found in
the brain and heart. CPK levels only change if there has been trauma to the brain or heart. GGs
Alk and Phos are related to her abdominal bloat and pain she has been experiencing due to the
disease state she is in (CPK, 2009).
14. What diagnostic tests(s) (not lab values) indicate(s) that GG has an ulcer?
Endoscopy is a nonsurgical procedure used to examine a persons GI tract. It is a flexible tube
that has a light and a camera that goes down the esophagus and can take pictures of the GI tract
inside (Medline, 2016). The doctors conducted this on GG and found the ulcer within her GI
tract at the anatomical position.

15. Briefly sketch the anatomical position where GGs ulcer can be found.

16. Define H2 antagonist, and Proton Pump inhibitor.

H2 antagonist is a drug (as cimetidine, famotidine, nizatidine, or ranitidine) that reduces

or inhibits the secretion of gastric acid by binding competitively with histamine to

H2 receptors on cell membranescalled also H2 receptor antagonist (Merriam,2014).

Proton Pump inhibitor are medicines that work by reducing the amount of stomach acid
made by glands in the lining of your stomach (Medline, 2016)

17. What is the mechanism of action of the following medications GG is receiving :Nexium,
amoxicillin, and clarithromycin?

Nexium is a proton pump inhibitor that suppresses gastric acid secretion by specific
inhibition of the H+/K+-ATPase in the gastric parietal cell. The S- and R-isomers of
omeprazole are protonated and converted in the acidic compartment of the parietal cell
forming the active inhibitor, the achiral sulphenamide. By acting specifically on the

proton pump, esomeprazole blocks the final step in acid production, thus reducing gastric

acidity (Nexium, 2016).

Amoxicillin helps keep bacteria from multiplying and keeps it from spreading. It does
this by attaching to the cell wall which leads to the death of the bacteria (Amoxicillin,

2004).
Clarithromycin is a bacteriostatic drug acts by inhibiting protein synthesis. It binds
reversibly to 50S ribosomal subunits of sensitive microorganism. Clarythromycin
interferes with transpeptidation and translocation thus there is inhibition of protein
synthesis and hence inhibition of cell growth (Clarithromycin, 2003).
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 available to provide assistance to
someone like GG.
I would refer GG to the Hamilton Community Behavioral health clinic to help GG
manage her stress, smoking, and her financial problems she is having. I then would refer
her to a counselor for her alcohol use and a counselor on how to understand and work
with her sons recently diagnosed disability. As for GGs nutritional support as a RD I
would recommend to GG that she stop consuming alcohol for her stress relief and replace
it with working out to help her get exercise and use this as a coping mechanism instead. I
then would recommend to GG about going to the store once a week and buying food that
she can prep for her breakfast, lunch, and dinner to help cut down on her high fat, high oil
and greasy diet that she is currently on. This will also cut down on stress on wondering
what she is going to feed her son every day and will give her extra time to spend with
him and to do other things around the house like relax. I would recommend to GG that

she lower her caffeine use because this is one of the reasons she is unable to sleep at night
and it will help with her GI pain that she is experiencing. I would also encourage GG to
eat several small meals a day instead of not eating or eating large meals once or twice a
day.
19. What is the significance of the dark stool?
Dark stool can be caused from ingesting a lot of iron for example an iron supplement or
ingesting a lot of high protein foods that are dark in color for example steak. In GGs case
the dark stool is an indication of bleeding within the GI tract caused from the gastritis
being untreated and the formation of the ulcer (Mayo, 2012).
20. Give the pathophysiology for the cause of the following abnormal values: BUN,
NH3 and WBC.
BUN stands for Blood urea nitrogen and can be high because of gastrointestinal bleeding,
dehydration caused from not drinking enough fluids or alcohol use, a high protein diet,
shock and ect. GGs abnormal BUN levels are most likely due to gastrointestinal
bleeding, and dehydration form alcohol use (Mayo, 2013). NH3 stands for Ammonia and
high levels indicate liver or kidney damage. It also means that the body is not effectively
metabolizing and eliminating ammonia out of the blood (Ammonia, 2011). WBC stands
for white blood cells and when levels are abnormally high it indicates that it is fighting
infection within in the body. High WBC can also be caused from smoking and severe
mental stress (Medline, 2016).
21. GG 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?
Higher
22. After admission GG received packed cells and IV fluids. How would that affect
the next set of lab values?

GGs dehydration status would return to a hydrated status from the fluids received via IV.
The packed cells she received would help stabilize GGs Hgb,Hct,MCV,WBC,%lymph,
and MCH levels (Pathology,2007).
Questions Continued
23. Define the following terms:
Packed cells: A concentrated preparation of red blood cells that is obtained from whole
blood by removing plasma and is used in transfusion (Merriam/packed cells, 2016).
Abdominal tap: a minimal procedure using a needle to remove fluid from the abdomen
(Medline, 2011).
Perforated ulcer: is a condition where an untreated ulcer can burn through the wall of
the stomach allowing acid and other GI juices and food to leach into the abdominal cavity
(Medline, 2011).
Fistula: An abnormal or a surgically made passage way between a hollow or tubular
organ and the bodies surface or between two hollow tubular organs (Mayo, 2015).
Exploratory Laparotomy: A surgery where the abdomen is opened up and the organs
within the abdomen are examined and checked for disease or injury (Colorectal, 2016).
Billroth I: Excision of the pylorus and antrum and partial closure of the gastric end with
end-to-end anastomosis of stomach and duodenum (Medilexicon, 2005).
Vagotomy: A surgical procedure of cutting of the vagus to reduce acid secretion into the
stomach (Medilexicon, 2005).
24. 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 stomach is resection to the gastroduodenal anastomosis and for a Billroth II
procedure the stomach is resection to the gastrojejunal anastomosis. Both of these procedures
will cause for the patient to follow a post gastrectomy diet (National library of medicine, 2011).
26. Calculate GGs energy and protein needs.
Harris Benedict formula used
GG had a weight loss of 12 pounds in the last six months her original body weight was 110 and
now she is 98. I will put her on the higher caloric need and these calculations will be based off of
GG being 110 pounds. I used a 1.2 stress factor since she is within a disease state and is not able
to be up moving around much but enough to help with the healing process.

665+(9.56x (kg))+(1.85x(cm))-4.68x27(yr))x1.2
110/2.2= 50kg
62inchesx 2.54cm=157.5cm
665+(9.56x50(kg))+(1.85x(157.5(cm))-4.68x27(yr))x1.2
665+478+291.4-126.36x1.2=1,568.64
REE=1,500-1,600kcal
Protein needs=60g-75g
50kgx1.2=60g and 50kgx1.5=75g
27. List the principles of a post gastrectomy diet and briefly describe the scientific basis for
each principle.
The post gastrectomy diet also known as antidumping is a well-balanced diet that has a slightly
higher protein intake and fat. Simple sugars and clear liquids are avoided to prevent hyper
osmolality and hypoglycemia associated with dumping syndrome. Lactose is not recommended
in the beginning due to the intolerance of the stomach after surgery. Calcium and vitamin D
supplements are recommended during this time. Liquids should be consumed between meals to
prevent dumping syndrome because they facilitate quick movement through the small intestine.
Five to six small meals throughout the day are recommended. Nutrition support is recommended
if solid food does not progress and malnutrition is noticed. First meals of the day should consist
of protein and fat and complex carbohydrate but only one to two food items. Foods that contain
caffeine, or are fired, raw vegetables, and raw fruits should be avoided to intolerance and risk of

causing dumping syndrome. No alcoholic beverages should be consumed and cigarette smoking
is recommended to quit (Nelms, 369).
28. Is it possible that GGs diet will ever change or do you believe she will be on a post
gastrectomy diet for the rest of her life? Explain your answer.
If GG follows her nutrition therapy of working back up to eating regular foods she will be able to
get back to a normal diet. If GG avoids intolerant food such as caffeine, alcohol and fried foods
she will be able to heal and sufficiently go back to a normal all food diet. GG will need to be
careful of returning to the diet she original had that caused the GI problems because this will
cause complications and may possible result in another surgery.

29. 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?
As a registered dietician I would recommend 3 to 4 small snacks a day to keep her GI tract
working so she does not loose function with the tube feeding. I would also recommend high
protein to help with her healing process within her GI tract. I would choose proteins that are
short in their triglyceride chain due to digestive problems and with the damage she has done to
her liver with her aspirin use and alcohol use even though it is not severe damage. I would
recommend low carb because of the fiber intake I would not want her to excrete the nutrients she
is taking in right away. I would choose a tube feeding that is high in caloric intake since GG does
need to gain weight and has to have enough energy for her body to heal from surgery (Nelms,
364-370).

30. Using the table below, compare several of the enteral nutritional supplements that
would be appropriate for GG.

Product

Producer

F
O
R
M

Cal/
ml

Nonpro
cal/g N

g/L

Nutren 1.5

Nestle

375k/
cal
1,500
ml

N/a

Pro
17g
68ml

CHO
169g

Fat
15g
60ml

Optimental

Abbott

Low
Tolar/
High
Kcal/
Lactos
free
Mal
absor
ption

1.00

97:1

51g

139g

28g

Na
mg

K
mg

Vol to
meet
RDA
in ml

g of
fiber
/L

Free
H2O /
L in
ml

325m
g
1,300
ml

600m
g
2,400
ml

1,000
ml

N/a

191ml
764ml

46mg

45mg

1,000
ml

N/a

198ml
835L

(Nutren,2015) and (Optimental, 2006)

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