CaseStudy1:PepticUlcerDiseaseResultinginGastrectomy

SamBallard
KNH413
2.11.2016

1. ListallthefooditemsthatmaycontributetoGGsconditionandexplainwhy.
Fastfoodswithhighfatcontent
Frozendinners
Friedfoods
Blackcoffee
Milk
Chocolate
Alcohol
Soda/Carbonatedbeverages

ThesefoodandbeverageitemsmaybecontributingtoGGscondition,mainly
becausetheyallstimulateanincreasedsecretionofstomachacids.Friedfoods,fast
foods,andfrozendinnerscommonlyhaveahighfatcontentthatcausesstomach
acidsecretionfordigestion.Coffee,chocolate,andsoda/carbonatedbeverages
containcaffeine,whichalsohasthiseffect(JohnsHopkinsMedicine,n.d.).Milkand
dairyproductsmayatfirstprovideulcerreliefbycoatingthestomachlining,but
theyalsostimulatethestomachtoproducemoreacidanddigestivejuices
(ClevelandClinic,2016).Lastly,alcoholcanirritateanderodethestomachlining
anditalsoincreasesacidsecretion(MayoClinic,2016).

2. ListanyadditionaloralintakethatmayhavecontributedtoGGsconditionand
explainwhy.

GGsexcessiveintakeofaspirinandsmokinghabitmayhavealsocontributedtoher
condition.Aspirin,andotherNSAIDs,causeulcersbyinterruptingthenatural
abilityofthestomachandtheduodenumtoprotectthemselvesfromstomachacid.
NSAIDscanalsointerferewithbloodclotting,whichhasobviousimportancewhen
ulcersbleed(AmericanCollegeofGastroenterology,2016).Smokingdoesnot
necessarilyincreasestomachacidsecretion,butitdoeshaveasignificanteffecton
upperGIfunction,whichcouldcontributetopepticulcerdisease.Smoking
interfereswithH2antagonistsandtheirabilitytodecreasetheproductionof

stomachacids,acceleratethegastricemptyingoffluids,promoteduodenogastric
reflux,inhibitpancreaticbicarbonatesecretion,reducemucosalbloodflow,and
inhibitmucosalprostaglandinproduction(Eastwood,1988).
1


3. Listthenonoralstimulants(physicalorpsychologicalstress)thatcouldcontribute
toGGsconditionandwhatshecoulddotochangethem.

GGhasenduredasignificantamountofphysicalandpsychologicalstress.Sheis27
andwasmarriedafteroneyearofcollege.Shehasnojobskillsandhasdependedon
herhusbandtosupportherforeightyears.Herhusbandleftherandher4yearold
sonsixmonthsagoandnowhastheresponsibilityofsupportingherselfandherson
withoutanyfinancialsupportfromherfamily.Itwouldbecostlyforhertopursuea
divorcesettlement,whichwouldbenecessaryforhertoobtainchildsupport.She
wasencouragedtoreturntoschoolinordertogainadegreeandskillstopursuea
job,whichwouldrelievesomeofherfinancialstress.Hermotheragreedtohelp
babysitsoGGappliedforandreceivedaGuaranteedStudentLoan,startedschool,
obtainedaparttimejoboncampus,andispursuingadegreeinaccounting.She
nowhasthestressofmaintaininggoodgradesinordertokeepherloanand
workingparttimewhilebeingasingleparenthasbeenverydemanding.GGsbusy
schedulehascausedhertohavealackofsleep,whichonlyaddstoherphysicaland
psychologicalstress.Hermethodsofcopingwithherbusyscheduleandlackofsleep
arealsocausingherphysicaldiscomfortandstressheadaches,whichonlyfurther
preventherfromperformingherresponsibilities.Hersonwasalsodiagnosedwith
ADHDandrequirespsychologicalintervention,whichaddstoherpsychological
stressandpackedschedule.Allofthesephysicalandpsychologicalstressorsmay
havehelpedtoexacerbateGGspepticulcerdisease.

AlthoughGGmayhavelittlecontroloverthelackofsupportshehasfromher
husband,herfinancialsituation,andhersonspsychologicalneeds,therearesome
thingsshecanchangeaboutherlifestyle.Sheisalreadytryingtogainjobskillsby
goingbacktocollege,whichwilleventuallyimproveherfinancialstatusifshecan
earnastablecareeronceshehasherdegree.Workingparttimewhileshegoesto
schoolshouldalsohelphercurrentfinancialstrain.GGneedstofindalternative
waystocopewiththestressofherbusyschedule.Ratherthandrinkingalcohol,
drinkingcaffeine,losingsleep,andtakinganexcessiveamountofaspirin,GGshould
exploremorepositivecopingmethods.Shecouldtakeupamentallyandphysically
calmingactivity,likeyoga,orpreparehealthymealsaheadoftimesoshecangrab
andgothroughouttheweekandavoideatingfastfood.Itisalsohelpfultohave
peoplewhocanwatchhersonandtakesomeofthatpressureoffofheraswell.So
althoughshemaynotbeabletoimmediatelychangeherlifesituation,shedoeshave
fullcontrolofhowshedealswithherstress.

4. ListthesymptomsofGGsgastritis.

GGsabdominalpainandanincreasedburningsensationinherstomachare
importantinitialindicatorsthatsheissufferingfromgastritis.Herstomachpain
occursabout30minutesaftereatingandsubsideswithantacids,butsoonreturns.
AfterGGtookthemedicationsherphysicianprescribedandstartedtomakelifestyle
changes,shewentbacktoheroldways,whichresultedinherthrowingupblood.
ThisindicatesthatGGwasexperiencingadditionalsymptomsindicativeofanulcer:
vomitingandhematemesis(throwingupblood).ItisalsolaterdiscoveredthatGGs
stooltestedpositiveforoccultblood.Thebloodinthestoolindicatesthatgut
bleedingisanothersymptomofhergastritis.OthersymptomsofgastritisthatGG
hasntreportedexperiencingincludebelchingandanorexia(Nelms,Sucher,&
Lacey,2014).

5. Wasablanddietnecessary?Explainandlisttheprinciplesofthedietplanthatyou
thinkGGshouldfollow.

ItwasnotnecessaryforGGtobeprescribedablanddiet.Instead,GGshould
consumeadietrichinfruitsandvegetables.Thiswillprovideherwithappropriate
fiberandcanreducetheriskofdevelopingulcersinthefirstplace.Sheshouldalso
consumefoodsthatcontainflavonoidstoinhibitthegrowthofH.pylori.Thesefoods
mayincludeapples,cranberries,celery,onions,andgarlic(UniversityofMaryland
MedicalCenter,2013).Ratherthancoffee,alcohol,andsoda,GGshoulddrink
noncolacarbonatedbeveragesandherbalteas.Ifshewantsdairyproducts,she
shouldchooseskimor1%milkandlowfatyogurt.Sheshouldavoidusinghighfat
cookingmethodsorfryingfoodswhenconsumingeggs,starches,meats,ordesserts.
Hermeatsshouldbebaked,roasted,broiled,grilled,orstewedwithnovisiblefat.
Sheshouldavoidspicyseasoningsorpepperastheseareoftennottoleratedby
ulcerpatientsandcanexacerbatesymptoms.Outsideofdiet,howandwhenGGeats
willalsoaffecthermedicalnutritiontherapy.GGshouldconsumesmaller,more
frequentmealsandshouldnotliedownaftereatingorconsumelargemealscloseto
bedtime.MicronutrientsofconcernforGGmayincludeiron,calcium,andB12and

herneedforadditionalsupplementationshouldbeevaluated(Nelms,Sucher,&
Lacey,2014).

6. WhatisthemechanismofactionofthefollowingmedicationsGGisreceiving:
Carafate,AlternaGel,andPepcid?

Carafate

Antiulcermedication;notgreatlyabsorbedintothebody
throughthedigestivetract;worksmainlyintheliningofthe
stomachbyadheringtoulcersitesandprotectingthemfrom
acids,enzymes,andbilesalts(Drugs.com,2016).

AlternaGel

Aluminumhydroxide;antacidthatworkstoneutralize
hydrochloricacidsingastricsecretions(DrugBank,2010).

Pepcid

Ahistamine2blocker(H2antagonist);worksbydecreasingthe

amountofacidthestomachproduces(Drugs.com,2016).

7. Listthenutrientdruginteractionsthatareassociatedwiththesemedications.

Longtermuseofthesethreeacidblockingmedicationsmayleadtonutrient
deficienciesbecausestomachacidisimportantinthedigestionand/orabsorptionof
nutrients.LessstomachacidcanleadtolowabsorptionofvitaminB12and

supplementsmaybeneeded(especiallyinolderpeople)(Bobroff,Lentz,&Turner,
2009).

8. WhatareGGsIBWandpercentofIBW(AppendixA,Tables7and8)?

HamwiMethod
100+(5x#inchesover5)=IBW
100+(5x2)=110lbs
IBW=110lbs

%IBW=(Currentbodyweight/IBW)x100
%IBW=(98lbs/110lbs)x100
%IBW=89%

9. EstimateherdailyenergyneedsusingtheHarrisBenedictequationandappropriate
stressfactor(AppendixA,Table17).

Ht:52
(5ftx12in)+2in=62inx2.54cm=157.48cm
Wt:98lbs
98lbsx2.2kg=44.5kg

HarrisBenedict
655+(9.56xwt(kg))+(1.85xht(cm))(4.68xage(yrs))xSF
655+(9.56x44.5kg)+(1.85x157.48cm)(4.68x27yrs)x1.3
(655+425.42+291.338126.36)x1.3
1,245.398x1.3=1,619kcal/day1,6001,700kcal/day
4


Iwouldrecommendastressfactorof1.3toaccountforGGshospitalizationand
surgeryaswellasherbeing89%ofheridealbodyweight.Iwouldwanthertohave
adequateenergyforrecoveryandweightgain.Onceshebecomescloserto100%of
heridealbodyweight,IwouldreevaluateGGsenergyneeds.

10. WhatmightbethecauseoftheLUQpainalongwithherusualpain?(Hint:Consider
theenzymesthatareelevated).

GGselevatedALP(alkalinephosphatase)enzymesindicatethatdamagedlivercells
arereleasingincreasedALPintoherblood.HerlivercouldbethesourceofherLUQ
pain.ItispossiblethatGGsexcessivealcoholandaspirinintakehasalreadycaused
damagetoherliver,causingtheelevatedALPenzymes(MedlinePlus,2016).

11. Inthesecondsetoflabvalues,glu,BUN,Cr,seralb,Na,K,Cl,hgb,andhctall
dropped.ThisprobablymeansthatGGwas:
a. bleeding.
b. eatingpoorlyinthehospital
c. dehydratedwhenthefirstlabsweredrawn.
d. overhydratedwhenthesecondsetoflabswasdrawn.

12. Inthesecondsetoflabvalues,serumamylase,AST,andALTalldropped.This
probablymeansthat:
a. enzymeswereelevatedduetoalcohol.
b. hermedicationscausedthemtodrop.
c. GGwasdehydratedwhenthefirstlabsweredrawn.
d. GGwasoverhydratedwhenthesecondsetoflabswasdrawn.

13. Refertothetwolabtablesagain,andnotethattwodaysafteradmission,GGsAlk
PhosandCPKremainedessentiallyunchanged.Why?
a. theseenzymesarenotaffectedbyalcoholorhydration.
b. hermedicationscausedthemtodrop.
c. dehydratedwhenthefirstlabsweredrawn.
d. overhydratedwhenthesecondsetoflabswasdrawn.

14. Whatdiagnostictest(s)(notlabvalues)indicate(s)thatGGhasanulcer?

GGprovidedastoolsample,underwentanesophagogastroduodenoscopy,hada
biopsytakentoruleoutH.pyloriandcarcinoma,underwentgastricanalysis,hada
5

bloodtesttodetectserumIgGantibodytoH.pyloriasabackuptothebiopsy,and
hadanELISAtest.Herstoolsamplewaspositiveforoccultblood,indicatingthatshe
hasbleedinginherintestines.Theesophagogastroduodenoscopyrevealedgastritis
superiortothepyloricsphincterwithanulceronthedorsalwalloftheduodenum,
justbelowthepyloricsphincter.Thegastricanalysisindicatedhypersecretionof
HClandGGsbiopsywasnegativeforcarcinoma,butwaspositiveforH.pylori.GGs
positiveELISAtestalsoconfirmedthepresenceofH.pylori.
15. BrieflysketchtheanatomicalpositionwhereGGsulcercanbefound.

16. Define:
a. H2antagonist:
medicationsthatinterrupttheproductionofacidinthe

stomach
b. Protonpumpinhibitor:classofmedicationsthatblocktheH+,K+,ATPase
enzyme,acomponentinHClproduction,thusreducingacidsecretioninthe
stomach

17. WhatisthemechanismofactionofthefollowingmedicationsGGisreceiving:
Nexium,amoxicillin,andclarithromycin?

Nexium

Protonpumpinhibitor;worksbydecreasingtheamountof
acidmadeinthestomachtoallowulcertoheal;
delayedreleasecapsuletopreventbreakdownofthe
medicationbystomachacid(MedlinePlus,2016).

Amoxicillin

Antibiotic;worksbystoppingthegrowthofthebacteriathat
maycauseulcers(H.pylori)(MedlinePlus,2016).
6

Clarithromycin

Antibiotic;worksbystoppingthegrowthofthebacteriathat
maycauseulcers(H.pylori)(MedlinePlus,2016).

18. GGwasnotreceivingcounselatthetimethemajorbleedingstarted.Ifyouhadthe
opportunitytocounselGGjustbeforethebleeding,whatareaswouldyoufeel
competenttocounselherandinwhatareaswouldyoureferhertosomeoneelse?
Investigatetheagenciesinyourareathatareavailabletoprovideassistanceto
someonelikeGG.

IwouldonlyfeelcompetenttocounselGGonhowherdietandlifestylechoices
(smoking,alcohol,aspirinuse)isaffectingherpepticulcerdiseaseandoverall
nutritionstatus.GGhasalotoffamilyandpersonallifecrisesgoingonandbecause
ofthis,Iwouldconsiderreferringhertoasocialworker,apsychologist,an
alcoholicsanonymousgroup,andafamilycounselor.Asocialworkermaybeableto
adviseGGonherseparation/divorce,financialtroubles,andbeingasingleparent.
Shewouldbenefitfromtakingadvantageoflocalprogramsforsinglemoms,suchas
theButlerCountyWICprogramortheOxfordFamilyResourceCenter.A
psychologistmayhelpGGcopewithherstress.AllowingGGtoexpressherfeelings
andtalktosomeoneaboutwhatsheisgoingthroughwouldallowherto
periodicallyreleasestressandfindalternativewaysofcopingwithherstress,rather
thandrinking.IfthepsychologistfindsthatGGsalcoholuseismoresevere,thenan
alcoholicsanonymousgroupmaybemorehelpfultoher.Meetingwithafamily
counselormayalsohelptoprovidestructureandorganizationtoGGsentirefamily.
HavingGG,hermom,andherhusband,onthesamepageregardingthecareofher
sonwouldallowGGtomaintainproperpersonalcare,performherschoolandwork
responsibilities,andwouldcreateasolidsupportsystemforhersonwhosuffers
fromADHDandhasbeencaughtinthemiddleofthefamilysstressandproblems.I
wouldalsosuggestthatGGspeakwithanothercollegeguidancecounselortoseeif
therearealternativewaysforhertocompleteherdegreethatwouldbemore
flexibletoherlifesituation.

19. Whatisthesignificanceofthedarkstools?

Darkorblackstoolsindicateamorerapidintestinalorgutbleedandshowupas
melenaoralargeamountofdarkredormaroonbloodinthestool(American
CollegeofGastroenterology,2016).Thiscouldindicateableedingulceror
inflammationofthestomachlining(gastritis)(MedlinePlus,2016).

20. Givethepathophysiologyforthecauseofthefollowingabnormalvalues:BUN,NH3,
andWBC.

BUN

Bloodureanitrogen;affectedbyfluidstatus;artificiallyhighwhen
dehydratedandartificiallylowwhenoverhydrated;levelsalso
increasedwithexcessiveproteinlevelsintheGItractandGIbleeding;
levelsalsodecreasedwithliverfailure,lowproteindiet,or
malnutrition(MedlinePlus,2015).

NH3

Alcoholmayaffectammonialevels;increasedammonialevelsmaybe
causedbyGIbleeding,liverfailure,lowbloodpotassiumlevels,anda
highproteindiet(MedlinePlus,2015).

WBC

Whitebloodcellcount;decreasedlevelsmaybeduetoliverdisease
orcertainviralorbacterialinfections;increasedlevelsmaybedueto
anemia,certaindrugsormedicines,cigarettesmoking,bacterial
infections,inflammatorydiseasesorseverementalorphysicalstress
(MedlinePlus,2015).

21. GGwasprobablydehydratedonadmissionsinceshehadbeendrinking.Thismeans
thatsomeofherlabvalueswereprobablylowerthanindicated(theywere
artificiallyhigh).

22. AfteradmissionGGreceivedpackedcellsandIVfluids.Howwouldthataffectthe
nextsetoflabvalues?

AdministeringpackedcellsmeansthatGGreceivedaconcentratedamountofred
bloodcells.Thiswouldincreasehemoglobin,hematocrit,iron,andotherredblood
cellrelatedlabvalues.Thesevaluesmayreadasbeingextremelyhighifshewas
testedrightafterthepackedcellswereadministeredandamoreaccuratetestcould
beconductedsometimeafteradministration.AdministeringIVfluidswould
improveGGshydrationstatus.Shewasdehydratedatadmission,whichiswhat
causedherlabvaluestobeartificiallyhigh.AfterreceivingIVfluids,GGslabvalues
wouldbecomedilutedandwouldhavethempossiblyreadartificiallylower(ifover
hydrated)oraccurately(ifproperlyhydrated).

23. Definethefollowingterms:
a. Packedcells:apreparationofbloodcellsseparatedfromliquidplasma,
oftenadministeredinsevereanemiatorestoreadequatelevelsof
hemoglobinandredbloodcellswithoutoverloadingthevascularsystem
withexcessfluids(TheFreeDictionary,2009).
8

b. Abdominaltap:usedtoremovefluidfromtheareabetweenthebellywall
andthespine(abdominalcavity)todiagnosethecauseoffluidbuilduporthe
presenceofaninfection(MedlinePlus,2016).
c. Perforatedulcer:atearorholewheretheulcerislocated,whichcanallow
blood,digestivejuices,food,andbacteriatoleakoutoftheGItract
(MedlinePlus,2016).
d. Fistula:anabnormalopeningorpassagebetweentwointernalorgansor
fromaninternalorgantothesurfaceofthebody(Nelms,Sucher,&Lacey,
2014).
e. ExploratoryLaparotomy:asurgerythatopenstheabdomentoexaminethe
abdominalorgans(MedlinePlus,2014).
f. BillrothI:gastroduodenostomy;apartialgastrectomyorpyloroplastythat
consistsofananastomosis[surgicalconnection]oftheproximalendofthe
duodenumtothedistalendofthestomach(Nelms,Sucher,&Lacey,2014).
g. Vagotomy:severingofthevagusnerve;oftenacomponentofgastricsurgery
(Nelms,Sucher,&Lacey,2014).

24. SketchaBillrothI.

25. CompareaBillrothItoaBillrothIIastoanatomicalchangesaswellastodietary
changes,ifany.

ABillrothI,oragastroduodenostomy,isapartialgastrectomyorpyloroplastythat
consistsofananastomosis[surgicalconnection]oftheproximalendofthe
9

duodenumtothedistalendofthestomach(Nelms,Sucher,&Lacey,2014).A
BillrothII,oragastrojejunostomy,isapartialgastrectomywithreconstructionthat
connectstheproximalendofthejejunumtothedistalendofthestomachanda
blindloopoftheduodenumiscreated(Nelms,Sucher,&Lacey,2014).Becausethe
normalpathwayfordigestionandabsorptionisinterruptedwiththesetypesof
gastricsurgery,therearealsomanynutritionalimplications.Patientsmay
experiencechangesingastricemptying,transittime,decreasedoralintake,
maldigestion,and/ormalabsorption.VitaminB12deficiencyismostcommonamong

gastricsurgerypatients.Othervitaminandmineraldeficienciesincludethiamin,
vitaminB12,vitaminD,iron,andcopper(Nelms,Sucher,&Lacey,2014).

BillrothI

BillrothII

26. CalculateGGsenergyandproteinneeds.

HarrisBenedict
655+(9.56xwt(kg))+(1.85xht(cm))(4.68xage(yrs))xSF
655+(9.56x44.5kg)+(1.85x157.48cm)(4.68x27yrs)x1.3
(655+425.42+291.338126.36)x1.3
1,245.398x1.3=1,619kcal/day1,6001,700kcal/day

Protein
1.0g/kgx44.5kg=44.5g/kg/day
1.5g/kgx44.5kg=66.75g/kg/day4567g/kg/day

BecauseGGhasjusthadsurgery,isonapostgastrectomydiet,andthereisno
indicationthatherweightstatushaschanged/improved,shehasincreasedprotein
needs.Ifsheisreceivingadequatecalories,herproteinrequirementscanbemetby
consuming1.01.5gramsofproteinperkilogramperday(Nelms,Sucher,&Lacey,
2014).
10


27. Listtheprinciplesofapostgastrectomydietandbrieflydescribethescientificbasis
foreachprinciple.

Thepostgastrectomyorantidumpingdietencouragesawellbalanceddietslightly
higherinproteinandfatthanwhatisrecommendedbytheU.S.DietaryGuidelines
(Nelms,Sucher,&Lacey,2014).Inordertopreventhyperosmolalityand
hypoglycemiaassociatedwithdumpingsyndrome,patientsshouldavoidsimple
sugars,eventhoseinclearliquids.Lactoseisoftennottoleratedandtheseproducts
canbereplacedwithlactosefreeversions,calciumandvitaminDshouldbe
supplemented.Liquidsfacilitatequickmovementthroughthesmallintestine,which
contributestodumpingsyndrome,andshouldbeconsumedbetweenmeals(30
minutesto1houraftersolidfood).Patientsarerecommendedtoprogressto
consumingfivetosixsmallmealsinadayandisencouragedtoliedownaftermeals
ifitisnecessary(althoughthisrecommendationcontradictstherecommendation
forulcerpatientstonotliedownaftereating)(Nelms,Sucher,&Lacey,2014).

28. IsitpossiblethatGGsdietwilleverchangeordoyoubelieveshewillbeona
postgastrectomydietfortherestofherlife?Explainyouranswer.

IbelievethattherearesomeaspectsofthepostgastrectomydietthatGGwillbeon
fortherestofherlife.TheanatomyofherGItracthasbeenpermanentlyalteredand
willneverbeabletoregainitsfullcapacityfordigestionandabsorption.However,I
alsothinkthatherGItractwillslowlyandeventuallyadapttoitsnewform.GGmay
eventuallybeabletotoleratecertainfoodsbetter,suchasdairyproducts,andshe
willbeabletoslightlyadaptherdietbecauseoftheseincreasedtolerances.Ithink
thatitwouldbenefitGGtocontinuetoconsumefrequent,smallmealsthroughout
thedaybecauseofhernewGIanatomy.Eatingtoomuchatonetimecouldseverely
stressthehernewGIstructureandwouldpreventnutrientsfrombeingproperly
absorbed.Unfortunately,ifGGfallsbackintoheroldwaysofsmoking,drinking,and
eatingfatty,friedfoods,shewillmostlikelysuffercomplicationsandfurther
damageherGItract.

29. IfGGweretobehospitalizedforanextendedperiodoftimeandrequiredatube
feedingviaduodenumorjejunum,whatcharacteristicswouldbeappropriatefor
thetubefeedingyouwoulduse?

GGwouldwanttofollowthesamepostgastrectomyrecommendationsthatwere
providedforanoraldiet.Shewouldwanttochooseenteralformulathatishigherin
11

proteinandfat,freeofsimplesugars,lactosefree,andsupplementedwithvitamins
andminerals.Inthetablebelow,Nutren1.0isalactosefree,standardformula;
Nutren1.5isalactosefree,highkcalformula;PeptamenandOptimentalareboth
hydrolyzedformulasusedformalabsorption;andImpactisanimmunesystem
supportformula.AnyoftheseformulaswouldbebeneficialtoGGsnutritionstatus
andwouldbeappropriatechoicesforhertoreachherkcalorie,protein,andother
nutrientgoalsifatubefeedingweretobecomenecessary.Shewouldstillwantto
havefrequent,smallmealstopreventdumpingsyndrome.

30. Usingthetablebelow,compareseveraloftheenteralnutritionalsupplementsthat
wouldbeappropriateforGG.

Product

Pro
(g/L
)

CHO
(g/L)

Fat
Namg
(g/L)

Nutren Nestle Liquid

1.5
Formula

1.5 60

169

68

Nutren Nestle Liquid

1.0
Formula

1.0 40

237

Pepta
men

Nestle Liquid
Formula

1.0 40

Optime
ntal

Abbott Liquid
Formula

Impact Nestle Liquid

Formula

Produce
r

Form

Cal/
ml

Kmg

mOsm
/kg
water

Volto
meet
RDAin
ml

gof
fibe
r/L

1,300 2,400 430

1,000

38

880

1,600 315

1,500

127

39

560

1,500 270

1,500

1.0 51

139

28

540

1,422

1.0 56

130

28

375

1,500

12

References

AmericanCollegeofGastroenterology.(2016).Pepticulcerdisease.Retrievedfrom
http://patients.gi.org/topics/pepticulcerdisease/

Bobroff,L.B.,Lentz,A.,&Turner,R.E.(2009).Food/druganddrug/nutrientinteractions:
Whatyoushouldknowaboutyourmedications.Retrievedfrom
http://edis.ifas.ufl.edu/pdffiles/He/HE77600.pdf

ClevelandClinic.(2016).Diseases&conditions.Retrievedfrom
https://my.clevelandclinic.org/health/diseases_conditions/hic_Peptic_Ulcer_Diseas
e

DrugBank.(2010).Aluminumhydroxide.Retrievedfrom
http://www.drugbank.ca/drugs/DB06723

Drugs.com.(2016).Carafate.Retrievedfromhttp://www.drugs.com/carafate.html

Drugs.com.(2016).Pepcid.Retrievedfromhttp://www.drugs.com/pepcid.html

Eastwood,G.L.(1988).Theroleofsmokinginpepticulcerdisease.JournalofClinical
Gastroenterology,10(Suppl1),S1923.

JohnsHopkinsMedicine.(n.d.)Stomachandduodenalulcers(pepticulcers).Retrievedfrom
http://www.hopkinsmedicine.org/healthlibrary/conditions/digestive_disorders/st
omach_and_duodenal_ulcers_peptic_ulcers_85,P00394/

MayoClinic.(2016).Pepticulcer.Retrievedfrom
http://www.mayoclinic.org/diseasesconditions/pepticulcer/basics/riskfactors/c
on20028643

MedlinePlus.(2014).Abdominalexploration.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/002928.htm

MedlinePlus.(2015).Ammoniabloodtest.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/003506.htm

MedlinePlus.(2015).BUNbloodtest.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/003474.htm
13


MedlinePlus.(2015).WBCcount.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/003643.htm

MedlinePlus.(2016).ALPbloodtest.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/003470.htm

MedlinePlus.(2016).Abdominaltap.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/003896.htm

MedlinePlus.(2016).Bloodyortarrystools.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/003130.htm

MedlinePlus.(2016).Lansoprazole,clarithromycin,andamoxicillin.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/druginfo/meds/a601067.html

MedlinePlus.(2016).Pepticulcer.Retrievedfrom
https://www.nlm.nih.gov/medlineplus/ency/article/000206.htm

Nelms,M.,Sucher,K.P.,&Lacey,K.(2014).Nutritiontherapyandpathophysiology.Boston,
MA:CengageLearning.

TheFreeDictionary.(2009).Packedcells.Retrievedfrom
http://medicaldictionary.thefreedictionary.com/packed+cells

UniversityofMarylandMedicalCenter.(2013).Pepticulcer.Retrievedfrom
http://umm.edu/health/medical/altmed/condition/pepticulcer

14