Samantha Jamieson

MNT 2 GI Case Study KEY 2017

Objectives:
KRDN 1.2: Use current information technologies to locate and apply evidence-based guidelines and protocols.
KRDN 1.3: Apply critical thinking skills.
KRDN 2.2: Describe the governance of nutrition and dietetics practice, such as the Scope of Nutrition and
Dietetics Practice and the Code of Ethics for the Profession of Nutrition and Dietetics; and describe
interprofessional relationships in various practice settings.
KRDN 3.3: Demonstrate counseling and education methods to facilitate behavior change for diverse individuals
and groups.
KRDN 3.1: Use the Nutrition Care Process to make decisions, identify nutrition-related problems and determine
and evaluate nutrition interventions.

Mr. Lopez is a 44 y/o Hispanic male s/p Billroth I surgery due to perforation of the pyloric sphincter due PUD. Prior to
Billroth I surgery, pt was admitted from ER with epigastric pain, elevated WBC count, and reported blood in stools and in
vomit. Pt underwent an EGD was found to have perforated pyloric sphincter. Tissue biopsy revealed H. Pylori infection.

Medical Hx: Impaired fasting glucose (3 years)

Social Hx: Single father of 2, wife deceased. Quit smoking 1 pack cigarettes per day about 2 years ago. Pt denies illicit
drug use.

Sx: epigastric pain, n/v, indigestion, bloody stools, weight loss

Medications: Omeprazole (20 mg bid), Clarithromycin (500 mg bid) and amoxicillin (1 g bid), Lortab

Ht: 62/74. Wt: 198#/90

Diet Rx: NPO advance to clear liquid (NCS -no concentrated sweets) tomorrow.

Mr. Lopezs lab values upon admit were:

Test Result Reference Value Test Result Reference Value

Glucose 99 mg/dL 70-99 mg/dL Na 140 mEq/L 136-145 mEq/L
BUN 20 mg/dL 10-20 mg/dL K 4.6 mEq/L 3.5-5.0 mEq/L
Cr 1.1 mg/dL 0.6-1.2 mg/dL Cl 102mEq/L 98-106 mEq/L
Ca 8.4 mg/dL 8.4-10.2 mg/dL Mg 2.0 mEq/L 1.3-2.1 mEq/L
Serum 3.2 g/dL 3.5-5.0 g/dL PO4 3.9 mg/dL 3.0-4.5 mg/dL
Albumin
Transferrin 400 mg/dl 212-360 mg/dl RBC 4.2 x106/ mm3 4.7-6.1 x106/ mm3
Hgb 12.2 g/dl 14-18 g/dl WBC 16,200 / mm3 5,800-11,000/
mm3
Hct 38% 41-51% MCV 70 um3/RBC 78-93um3/RBC

You are the dietitian at the University Hospital. You are consulted to educate pt re: post-gastrectomy and PUD diet.
During your initial visit with pt for assessment, you learn that..

This is where you will interview your pt. You will meet with Mr. Lopez with a group of about 6 students during class
time and you should have questions prepared to ask him. You may use your PES template to help guide you (to make
sure you ask all the questions you need to). You may discuss these questions with your group before the interview.
Diet hx:
Breakfast:
4 cups of coffee, black, regular/brewed

Mid-morning:
2 cups of coffee with 1 small powdered doughnut (200-220 kcals/2-3 g pro)

Lunch:
Double cheeseburger from McDonalds or Burger King and medium Diet Coke (BK 450 kcals; 27 g protein) or (McD 440
kcals; 25 g protein)
OR large bowl of Chili from Wendys with medium Diet Coke (330 kcals; 28 g protein w/8g fiber)

Dinner:
Homemade Mexican food such as:
Beef Enchiladas (1-2) (330-660; 14-28 g protein)
~ cup refried beans (106 kcals; 9 g protein)
cup salad (lettuce and diced tomatoes) (3-10 kcals; < 1 g protein)

Beer (mostly in the evenings and late afternoon) (105*4 = 420kcals)

1. Discuss Billroth 1
Explain a Billroth I procedure.
What different conditions is it
used to treat?
Gastroduodenostomy= a surgical procedure that makes a new connection
between the stomach and the duodenum (small intestine)
Stomach cancer, malfunctioning pyloric valve, gastric obstruction, and
stomach ulcers

What nutrient deficiencies are B12, Iron

possible after a Billroth I?

Explain the pathophysiology
behind the possible deficient
status of each of these
nutrients.
Explain the appropriate
diet/meal plan for patients
after this surgery in both the
acute phase and long term.
Iron gets absorbed in the duodenum of the small intestine making it hard
to absorb if the duodenum is tampered with or even bypassed. B12 is a
common deficiency in gastric surgeries because of the intrinsic factor
being interfered with which is the substance secreted by the stomach
that enables the body to absorb Vitamin B12.
No acidic foods, low caffeine, and high levels of fruits and vegetables.

Why is this diet prescribed? The acidic foods should be avoided so that

2. Discuss H. Pylori infection

What are the risk factors? Peptic ulcers,

What is the recommended Antibiotics such as amoxicillin, tetracycline, metronidazole, or

treatment for H. Pylori? clarithromycin.
 What are the dietary Avoid spicy foods, high fat foods, refined sugar foods, caffeine, acidic foods,
restrictions that are
recommended for patients
with this infection?

ASSESSMENT
3. Calculate pts BMI, %IBW, %UBW, and % weight change.

BMI 25.4 IBW 105+ (60)=165 %IBW 165/198=83%

UBW 230 %UBW 198/230=86% % wt change: loss of 30 pounds in 3

months

Is wt change cause for concern? Why or why not?

Yes, the patient has lost 30 pounds in 3 months which is a rate of 2.5 pounds a week. The safe amount

of weight to lose each week is between 1.5-2.0 pounds.

4. Thoroughly evaluate the abnormal lab values. Investigate potential causes and discuss the causes that are
applicable to this patient.

Low Serum Albumin Low albumin levels are seen with edema, hepatic disease, malabsorption,
diarrhea, burns, eclampsia, ESRD, malnutrition, low protein intake, stress,
over hydration, and cancer. Mr. Lopez is most likely having low serum
albumin levels due to malabsorption, malnutrition, and low protein intake
due to his Billroth 1 surgery. The absorption of protein, B12, and many other
vitamins/minerals get absorbed by Small Intestine which is recovering from
surgery along with the stomach.
High Transferrin High transferrin levels are seen with inadequate iron stores, iron deficiency
anemia, acute hepatitis, polycythemia, oral contraceptive use, pregnancy.
Mr. Lopez most likely has low iron levels due to the new opening in the
duodenum causing the iron to not be absorbed as highly as it should.
Low HgB Low HgB levels are seen with anemia, hyperthyroidism, cirrhosis, many
systematic diseases, HIV/AIDS. Mr. Lopez is having many symptoms of
anemia so the low HgB for him might be from this possibility of anemia.
Low Hct Low hematocrit is found with anemia, blood loss, hemolysis, leukemia,
hyperthyroidism, cirrhosis, over hydration. Mr. Lopez is showing symptoms
of anemia and is also having blood loss with the blood found in his stool and
vomit.
Low RBC Low RBC is found in anemia, hemorrhage, Iron deficiency, systematic
disease. Mr. Lopez has other blood levels that are consistent with anemia
and has also shown symptoms that are consistent with iron deficiency which
is another piece of low RBC.
High WBC High white blood cell levels are seen with leukemia, bacterial infection,
hemorrhage, trauma or tissue injury, and cancer. Mr. Lopez has a bacterial
 infection (H Pylori) so the high white blood cell level is consistent with his
body trying to fight off this bacteria infection.
Low MCV Low MCV is seen with Iron deficiency anemia, hereditary spherocytes,
thalassemia minor, sideroblastic anemia, pyr-responsive anemia, lead
poisoning. Mr. Lopez has Iron Deficiency and anemia so that explains the
low MCV levels.

5. Discuss the issues that have contributed to pts symptoms

.
Blood in stools and vomit Mr. Lopez has lab values that are consistent with a
stomach ulcer and anemia that both result in blood in
stool and vomit.
Epigastric pain Mr. Lopez has symptoms such as epigastric pain that is
consistent with Peptic Ulcer.
N/V N/V is consistent with the peptic ulcer and high
amounts of acid.

6. Investigate pts medications. Create a chart detailing: drug generic & brand name, drug function/classification,
nutrition-related symptoms, food/nutrient interactions and any other considerations that are applicable to this
patient. Why is pt being placed on these medications? After discharge, should pt continue to take Tums? Why
or why not?

Drug Function Nutr-related sx Food/Drug intx Other NB info/SE

Brand/generic

Omeprazole Antiulcer, Acid reflux May lower Nausea

antigerd, absorption of iron,
antisecretory may lower
absorption of B12,
may lower calcium
absorption by 61%
Clarithromyci Antibiotic, H N/A Caution with alcohol Headache, rash
n Pylori
Treatment
amoxicillin Antibiotic, Prebiotics may Do not drink alcohol Rash, rare allergic
pencillin lower GI side reaction
effects
Lortab Narcotic, Anorexia, delays Take with food Reduces cough,
opioid digestion drowsiness, sedation,
confusion, headache

Why is the pt being placed on these medications? After discharge, should Mr. Lopez continue to take Tums?
Why or why not?
 The patient is on the antibiotics, clarithromycin and amoxicillin, due to the H. Pylori infection and the
risk of infection/bacteria getting in the body after surgery is very high. The Patient is on omezaprole
due to his epigastric pain which could be significant with his ulcer that he has having symptoms for.
The Lortab that Mr. Lopez is on is consistent with recovering from surgery because it is a pain reliever
that allows for Mr. Lopez to be more comfortable. Mr. Lopez should not continue to take tums
because he is already on an antiacid medicine (omeprazole).

7. Evaluate pts usual intake. Evaluate his overall diet and intake of vitamins/minerals/calories/protein based upon
the information provided above. What nutrients are lacking? Explain.

4 cups of coffee + 2 Cups Coffee with
small powdered doughnut
Double cheeseburger from McDonalds
or Burger King and medium Diet Coke
Beef enchiladas, refried beans, and salad
Beer
This meal is severely lacking protein and all vitamins and
minerals. This meal truly has no nutritional
This meal is not lacking in protein but is way too high in
saturated fats.
This meal is decent in protein, probably high in fat, but has
some vitamins and minerals being added with the salad
addition. This is best meal of the day regarding vitamins
and minerals.
Alcohol does not give any kind of nutrient value so these
beers each night are just adding calories.

8. Estimate pts kcal (use Mifflin) , protein, and fluid needs. Explain how you determined each of the needs.

Kcals Show work Why you used these factors

2147.5 10 (90) + 6.25 (74)-5 (44) +5 = I used 1.3 as a factor because the
with activity factor: 2492 1147.5 kcal (1.3)= 1492 major surgery factors are 1.2-1.6

Protein
Pro Show work Why you used these factors
1.2 (90kg)=108 I used the 1.2 factor because the
108 g patient is recovering from surgery
and needs more protein to recover
faster.

Fluid Show work Why you used these factors

198 (1)= 198 mL The body need 1 mL of water per 1
198 mL pound of body weight

DIAGNOSIS
9. Discuss the problems/ issues that you have identified for Mr. Lopez. Include all including those from his
history/social etc. as well as those that you have identified answering the previous questions.
 Hint see case study 1 to include pertinent categories. Do not write a paragraph. Add rows as needed.
Highlight those that you think are the most important to address.
DIAGNOSIS- HINT- Use these in your ADIME note to follow

Altered GI function Pt has altered GI function due to bilroth 1 procedure

Unintended weight loss Pt has lost weight due to nausea and lack of desire to eat

Malnutrition Chronic disease (anemia) due to bilroth 1 procedure

Inadequate oral intake Pt is not eating proper amounts of vitamins and minerals

Increased protein-energy Pt needs more protein because of healing process from surgery

intake

Increased nutrient needs Pt has a deficiency in iron and B12

10. Prioritize the problems from the previous question. Choose the top three and write a PES statement for each
one. Brainstorm one or more intervention for each nutrition diagnosis.
Use the NCP standardized language and list your interventions under each nutrition diagnosis. Include in your
intervention potential professionals or agencies that may be beneficial for patient.
Use the NCP standardized language and list the Monitoring/Evaluation criteria that you will use to measure,
monitor and evaluate progress. Use measurable, objective language.

Nutr dx 1 Altered GI Altered GI function related to Bilroth 1 procedure as evidenced by

perforated pyloric sphincter.
PES Function

Intervention

FND Follow low acidic diet with high protein

NE/NC Needs education on healthy eating

CC Must see doctor to make sure healing properly

M/E Come back in 3 weeks to check on lab values and bilroth procedure
 Nutr dx 2 Unintended weight loss related to nausea/vomiting as evidenced by
weight loss of 30 pounds in 3 months
PES

Intervention

FND Still on low acidic diet but following a higher protein need due to
weight loss
NE/NC Need education on healthy eating

CC See dietitian to discuss a plan to gain weight but maintain a helathy

diet
M/E Come back in a month after eating healthy to check lab values and
weight status.

Nutr dx 3 Increased nutrient needs related to low iron and b12 levels as
evidenced by lab values.
PES

Intervention

FND Add high iron and b12 foods. Supplements if necessary.

NE/NC Nutrition education on gastric surgeries and vitamin/mineral

deficiencies
CC Coordination of care to a gastric surgeon to make sure bilroth
procedure is still working
M/E Come back in 3-4 weeks to see if iron and b12 levels have increased

INTERVENTION

11. Outline a nutrition education plan specific for this patient that combines the post-gastrectomy diet, H. Pylori
treatment and PUD. Include topics related to specific nutrients, foods/food groups and dining out.

Patient needs to learn about vitamin/mineral deficiencies post gastric surgery. Information on iron and
b12 rich sources should be advised. Also needs to learn about low acidic foods due to the possible
peptic ulcer that caused the H. Pylori. Patient currently has no knowledge about healthy eating and how
the amount of caffeine he is drinking is hurting his stomach.

DOCUMENTATION
12. Write a chart note in the ADIME format.
Assessment: 44 year old male with perforated pyloric sphincter, H. Pylori infection, and post bilroth 1
procedure
Ht: 64 Wt: 298 BMI: 25.4
Medication: omezaprole, Lortab, amoxicillin
Estimated energy intake: 2492
Diet related behaviors: client wife died so does not cook. Drinks 6 cups of coffee and eats out most of
the time. Does not have any water in diet and relies on mother to help cook dinner.
 Diagnosis: Inadequate intake of vitamins and minerals, altered GI function, and unintended wt loss.

Intervention: Add iron and b12 to diet along with nutrition education on post bilroth 1 procedure. Get
on meal plan/teach about healthy eating to gain weight but also get back lost vitamins and minerals.

Monitoring and evaluation:

Will follow up with client in 1 month to asses diet changes.

ADA EVIDENCE ANALYSIS LIBRARY (EAL)

13. During your education, Mr. Lopez mentions that his parents both have a history of heart disease. He asks you if
alcohol is beneficial to decrease the risk of developing heart disease and if so, should he continue to consume
alcohol. Using the ADA EAL, investigate if drinking alcohol reduces the risk of CVD. What does the research
show? What is the overall strength of the statement according to the AND EAL? What is your response to his
question?

Studies show that drinking 1-2 drinks of alcohol are associated with reduced risks of cardiovascular
disease. Excessive intakes are associated with increased all-cause mortality. Grade 2 rating=fair.

What is your response to his question?

The patient could drink 1-2 alcoholic beverages a night but not go over that. Suggest healthier
alcoholic beverages than beer such as red wine or vodka with club soda. Tell pt this is not a for sure
study but there have been some benefits.

Scope of Dietetics Framework, Scope of Professional Practice and Code of Ethics

After his first few days in the hospital, Mr. Lopezs diet has advanced to post-gastrectomy diet. When going to
see him for a follow-up visit, you realize that a hospital staff member from the dietary department that is also
his personal friend is bringing him foods from the cafeteria that are not appropriate for his current diet order.
The patient and staff member ask you to please not report it to anyone else as it could potentially get the
staff member in trouble.

14. Explain in detail how this situation should be handled as a professional. Include in your discussion your
evaluation of the Code of Ethics as it applies to this situation.
This is a very inappropriate issue from both parties. The staff member should not be interfering the first
place and they should not be asking you as the nutrition expert to not report something that is clearly
wrong. As a nutrition expert, you must step in and possibly get the doctor involved because the patient
will not heal if his prescribed diet is not being followed as it should.
15. After evaluating these resources, how do you plan to respond to this request?
I plan on getting the doctor involved and having a meeting with the patient and doctor together to go
over the risks of what could happen if the patient continues to eat these foods.