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Disease Discription
Peptic Ulcers Stomach Duodenal Causes: H. pylori, NSAIDs, Aspirin, Corticosteroids, Lifestyle choices Symptoms: Pain, belching, nausea, decreased appetite, weight loss fatigue Treatment:
Antibiotics
Lifestyle changes Other medications
Complications
Ulcer Perforation
What is it?
Mostly caused by H. pylori Bacteria Infections from leakage out of GI tract
recommendations support to the start of enteral nutrition within 24-48 hours of admit if not contraindicated
Contradictions: hemodynamic instability, bowel obstruction,
Nutrition Support Therapy in the Adult Critically Ill Patient also support starting enteral nutrition within 24-48.
Reach caloric and protein needs within 48-72 hours
Benefits
Reduce infectious morbidity Shorter LOS
Cost Effective
Gut motility and build immune system
No differences in:
Vomiting
Positive blood cultures
Limitations
Gastric Residuals
Montejo et all; open, perspective, radomized study;
Gastric Residuals-cont.
Gastrointestinal complications higher in control group 63.6%
vs 47.8%
No difference in ICU acquired pneumonia
45 (27.3%) in the control group and 44 (28.0) in study
ICU mortality and hospital mortality results were all very similar
Importance?
Raising gastric residual limit to 500 ml has no difference in
complications
Case Presentation
80 year old Caucasian female
Chief complaint: abdominal pain, N/V Trip to Las Vegas
Poor appetite
CT scan results: Large amount of free intraperitoneal air with moderate abdominal ascites Suspected perforated ulcer Admitted to ER
Edema
Pressure Ulcer NPO >4 Days
Weights
Biochemical Data
Recommendations
Protein needs should be
appetite) 4 points for NPO for >4 days 4 points for serum albumin <2.4 4 points for AKI, vent dependency, sepsis Total of 14-15 points Severely Compromise
Assess every 4 days
Unable to assess weight history Without accurate information, the patient can not identified
as malnourished.
and poor swallowing functions as evidenced by start of TPN/possible start of enteral nutrition.
Dialysis
ml at 20% biweekly First @ 70 ml/hr, decreased to 45 ml/hr RD Recommendation: Taper down TPN, start EN
Enteral Nutrition Stopped for high residuals Running at 25 ml/hr of Nepro RD Recommendation: Increase to 35 ml/hr to meet needs Complications with feedings Defer fluid needs to physician
Conclusion
Peptic ulcers can cause serious problems
Enteral nutrition should be started 24-48 hours
Without contradictions
Mahan LK, Escott-Stumo S, Raymond JL. Krauses Food & the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012 Stomach and Duodenal Ulcers (Peptic Ulcers). John Hopkinds Medicine. http://www.hopkinsmedicine.org/healthlibrary/conditions/digestive_disorders/stomach_and_duodenal_ulcers_peptic_ulcers_85,P00394/ Accessed December 15, 2013. Vaidya BB, Garg CP, Shah JB. Laparoscopic Repair of Perforated Peptic Ulcer with Delayed Presentation. J Laparoendosc Adv Surg Tech A. 2009; 19: 153-156. Peritonitis. John Hopkins Medicine. http://www.hopkinsmedicine.org/healthlibrary/conditions/adult/digestive_disorders/peritonitis_85,P00391/ Accessed December 15, 2013. Ehrlich SD. Peritonitis. University of Maryland Medical Center. http://umm.edu/health/medical/altmed/condition/peritonitis Updated on May 7, 2013. Accessed December 15, 2013. CIU: Initiation of Enteral Nutrition. Academy of Nutrition and Dietetics Evidence Analysis Library. http://andevidencelibrary.com/template.cfm?template=guide_summary&key=3205&auth=1 Accessed December 15, 2013. McClave SA, Marindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in the Adult Critically Ill Patients. J Parenter Enteral Nutr. 2009: 33 (3): 277-316. http://www.nutritioncare.org//Professional_Resources/Guidelines_and_Standards/Guidelines/2009_Adult_Critical_Care__Initiate_Enteral_Feeding/ Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med. 2009; 35: 2018-2027 Montejo JC, Minambres E, Bordeje L, et al. Gastric residula volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med. 2010; 36: 1386-1393. Guillaume A, Seres DS. Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis. Nutr Clin Pract. 2012;27:513-520 American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 4th ed. Chicago, IL. 2012. McClave SA, Marindale RG, Vanek VW, et al. Guidelines for the Provision and Assessment of Nutrition Therapy in the Adult Critically Ill Patients. J Parenter Enteral Nutr. 2009: 33 (3): 2009. http://www.nutritioncare.org//Professional_Resources/Guidelines_and_Standards/Guidelines/2009_Clinical_Guidelines__Renal_Failure/