Case 9

Ulcer Disease: Medical and Surgical Treatment

Objectives
After completing this case, the student will be 7. Calculate enteral nutrition prescriptions.
able to: 8. Evaluate a standard enteral nutritional
1. Discuss the etiology and risk factors for regimen.
development of ulcer disease. 9. Develop a nutrition care plan—with
2. Identify classes of medications used to treat appropriate measurable goals, interventions,
ulcer disease and determine possible drug– and strategies for monitoring and
nutrient interactions. evaluation—that addresses the nutrition
3. Describe surgical procedures used to treat diagnoses of this case.
refractory ulcer disease and explain com-
mon nutritional problems associated with Maria Rodriguez is a 38-year-old female who
this treatment. has been treated as an outpatient for her gastro-
4. Apply knowledge of nutrition therapy esophageal reflux disease. Her increasing symp-
guidelines for ulcer disease and gastric toms of hematemesis, vomiting, and diarrhea
surgery. lead her to be admitted for further gastrointesti-
5. Analyze nutrition assessment data to evalu- nal workup. She undergoes a gastrojejunostomy
ate nutritional status and identify specific to treat her perforated duodenal ulcer.
nutrition problems.
6. Determine nutrition diagnoses and write
appropriate PES statements.

95

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96 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Rodriguez, Maria, Female, 38 y.o.

Allergies: Codeine causes N/V Code: FULL Isolation: None
Pt. Location: RM 1145 Physician: S. Sharma Admit Date: 8/30

Patient Summary: Maria Rodriguez is a 38-year-old female admitted through ED for a surgical
consult for possible perforated duodenal ulcer.

History:
Onset of disease: Diagnosed with GERD approx. 11 months ago; diagnosed with duodenal ulcer
2 weeks ago
Medical history: Gravida 2 para 2. No other significant history except history of GERD.
Surgical history: She is s/p endoscopy (2 weeks ago as an outpatient) that revealed 2-cm duodenal
ulcer with generalized gastritis and a positive biopsy for Helicobacter pylori.
Medications at home: She has completed 10 days of a 14-day course of bismuth subsalicylate
525 mg 4 × daily, metronidazole 250 mg 4 × daily, tetracycline 500 mg 4 × daily, and omeprazole
20 mg 2 × daily, prescribed for total of 28 days
Tobacco use: Yes
Alcohol use: No
Family history: What? DM, PUD. Who? DM: maternal grandmother; PUD: father and grandfather.

Demographics:
Marital status: Widowed—lives with 2 daughters ages 12 and 14
Number of children: 2
Years education: Associate’s degree
Language: English and Spanish
Occupation: Computer programmer
Hours of work: M–F 9–5
Ethnicity: Hispanic
Religious affiliation: Catholic

MD Note 9/2 POD#2: s/p gastrojejunostomy secondary to perforated duodenal ulcer.

General appearance: 38-year-old Hispanic female—thin, pale, and in acute distress
Physical exam:
Heart: Regular rate and rhythm, heart sounds normal
HEENT: Noncontributory
Genitalia: WNL
Neurologic: Oriented × 4
Extremities: Noncontributory
Skin: Warm and dry to touch
Chest/lungs: Rapid breath sounds, lungs clear
Peripheral vascular: Pulses full—no bruits
Abdomen: Tender with guarding, absent bowel sounds

24 hr. Vital Signs: Temp: 99 Pulse: 78 Resp rate: 32

BP: 101/72 Height: 5'2" Weight: 110 lbs

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 Case 9 Ulcer Disease: Medical and Surgical Treatment 97

Rodriguez, Maria, Female, 38 y.o.

Allergies: Codeine causes N/V Code: FULL Isolation: None
Pt. Location: RM 1145 Physician: S. Sharma Admit Date: 8/30

Assessment and Plan:

38-yo female 2 days post-op gastrojejunostomy secondary to perforated duodenal ulcer. Pain well
controlled.

Plan:
NPO with ice chips
Enteral nutrition via jejunostomy feeding tube placed during surgery. Receiving Pivot 1.5@25 mL/hr
via continuous drip.
Continue with PT for ambulation.
Wound care.
S. Sharma, MD

Nutrition:
History: Patient relates that she understands about the feeding she is receiving through her tube.
She explains that she has eaten very little since her ulcer was diagnosed and wonders how long it
will be before she can eat again. Her physicians have told her they might like her to try something
by mouth in the next few days.

Usual dietary intake (prior to current illness):

AM: Coffee, 1 slice dry toast. On weekends, cooked large breakfasts for family, which included
omelets, rice, pozole, or pancakes, waffles, fruit.
Lunch: Sandwich from home (2 oz turkey on whole-wheat bread with mustard); 1 piece of raw fruit,
cookies (2–3 Chips Ahoy)
Dinner: 2 c rice, some type of meat (2–3 oz chicken), fresh vegetables (steamed tomatoes, peppers,
and onions—1 c), coffee
Usual intake includes 8–10 c coffee and 1–2 soft drinks (12-oz cans) daily

24-hr recall: Has been NPO since admission.

Food allergies/intolerances/aversions: See nutrition history.
Previous nutrition therapy? No
Food purchase/preparation: Self and daughters
Vit/min intake: None

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98 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Rodriguez, Maria, Female, 38 y.o.

Allergies: Codeine causes N/V Code: FULL Isolation: None
Pt. Location: RM 1145 Physician: S. Sharma Admit Date: 8/30

Intake/Output
Date 9/2 0701 – 9/3 0700
Time 0701–1500 1501–2300 2301–0700 Daily total
Tube feeding: Formula 150 100 200 450
Tube feeding: Flush 50 50 50 150
(mL/kg/hr) (0.5) (0.38) (0.63) (0.5)
I.V. 400 400 380 1180
IN (mL/kg/hr) (1) (1) (0.95) (0.98)
I.V. piggyback
TPN
Total intake 600 550 630 1780
(mL/kg) (12) (11) (12.6) (35.6)
Urine 550 200 480 1230
(mL/kg/hr) (1.38) (0.5) (1.2) (1.03)
Emesis output
OUT Other: Drains 275 320 220 815
Stool 200 128 328
Total output 1025 520 828 2373
(mL/kg) (20.5) (10.4) (16.56) (47.46)
Net I/O 2425 130 2198 2593
Net since admission (8/30) 2425 2395 2593 2593

Laboratory Results
Ref. Range 8/30 0800 9/2 0600
Chemistry
Sodium (mEq/L) 136–145 141 140
Potassium (mEq/L) 3.5–5.1 4.5 4.2
Chloride (mEq/L) 98–107 103 101
Carbon dioxide (CO2, mEq/L) 23–29 26 24
Bicarbonate (mEq/L) 23–28 24 23
BUN (mg/dL) 6–20 18 15
Creatinine serum (mg/dL) 0.6–1.1 F 1.1 0.9
0.9–1.3 M
BUN/Crea ratio 10.0–20.0 16.3 16.6
Uric acid (mg/dL) 2.8–8.8 F 3.2 4.4
4.0–9.0 M

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 Case 9 Ulcer Disease: Medical and Surgical Treatment 99

Rodriguez, Maria, Female, 38 y.o.

Allergies: Codeine causes N/V Code: FULL Isolation: None
Pt. Location: RM 1145 Physician: S. Sharma Admit Date: 8/30

Laboratory Results (Continued)

Ref. Range 8/30 0800 9/2 0600
Est GFR, non-Afr Amer .60 56 ! 70
(mL/min/1.73 m2)
Glucose (mg/dL) 70–99 80 128 !
Phosphate, inorganic (mg/dL) 2.2–4.6 3.7 3.5
Magnesium (mg/dL) 1.5–2.4 1.9 1.7
Calcium (mg/dL) 8.6–10.2 9.0 8.7
Osmolality (mmol/kg/H2O) 275–295 293 292
Bilirubin total (mg/dL) #1.2 1.7 ! 1.0
Bilirubin, direct (mg/dL) ,0.3 1.3 ! 0.6 !
Protein, total (g/dL) 6–7.8 5.7 ! 5.8 !
Albumin (g/dL) 3.5–5.5 3.0 ! 3.3 !
Prealbumin (mg/dL) 18–35 15 ! 14 !
Ammonia (NH3, µg/L) 6–47 11 10
Alkaline phosphatase (U/L) 30–120 98 90
ALT (U/L) 4–36 30 24
AST (U/L) 0–35 30 17
CPK (U/L) 30–135 F 155 ! 135
55–170 M
Lactate dehydrogenase (U/L) 208–378 351 321
Coagulation (Coag)
PT (sec) 11–13 11.5 12.1
PTT (sec) 24–34 25.5 24
Hematology
WBC (3 103/mm3) 3.9–10.7 16.3 ! 12.5 !
RBC (3 106/mm3) 4.2–5.4 F 4.9 5.0
4.5–6.2 M
Hemoglobin (Hgb, g/dL) 12–16 F 11.2 ! 10.2 !
14–17 M
Hematocrit (Hct, %) 37–47 F 33 ! 31 !
41–51 M
Mean cell volume (µm3) 80–96 91 86
Mean cell Hgb (pg) 28–32 25.9 ! 25.5 !
Mean cell Hgb content (g/dL) 32–36 31 ! 28.5 !
RBC distribution (%) 11.6–16.5 17.2 !

(Continued)

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100 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Rodriguez, Maria, Female, 38 y.o.

Allergies: Codeine causes N/V Code: FULL Isolation: None
Pt. Location: RM 1145 Physician: S. Sharma Admit Date: 8/30

Laboratory Results (Continued)

Ref. Range 8/30 0800 9/2 0600
Platelet count (3 10 /mm ) 3 3
150–350 267
Transferrin (mg/dL) 250–380 F 401 !
215–365 M
Ferritin (mg/mL) 20–120 F 15 !
20–300 M
Iron (µg/dL) 65–165 F 63 !
75–175 M
Vitamin B12 (ng/dL) 24.4–100 45
Folate (ng/dL) 5–25 15
Hematology, Manual Diff
Neutrophil (%) 40–70 45 55
Lymphocyte (%) 22–44 22 30
Monocyte (%) 0–7 5 4
Eosinophil (%) 0–5 2 3
Basophil (%) 0–2 0 1
Blasts (%) 3–10 4 5
Segs (%) 0–60 87 ! 78 !

Note: Values and units of measurement listed in these tables are derived from several resources. Substantial variation
exists in the ranges quoted as “normal” and these may vary depending on the assay used by different laboratories.

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 Case 9 Ulcer Disease: Medical and Surgical Treatment 101

Case Questions
I. Understanding the Disease and Pathophysiology
1. Identify the patient’s risk factors for ulcer disease.

2. How is smoking related to ulcer disease?

3. What role does H. pylori play in ulcer disease?

4. Four different medications were prescribed for treatment of this patient’s H. pylori infec-
tion: metronidazole, tetracycline, bismuth subsalicylate, and omeprazole. Identify the drug
functions/mechanisms of each.

5. What are the possible drug–nutrient side effects from Mrs. Rodriguez’s prescribed regi-
men? (See question #4.) Which drug–nutrient side effects are most pertinent to her current
nutritional status?

6. Explain the surgical procedure the patient received.

7. How may the normal digestive process change with this procedure?

II. Understanding the Nutrition Therapy

8. The most common physical side effects from this surgery are development of early or late
dumping syndrome. Describe each of these syndromes, including symptoms the patient
might experience, etiology of the symptoms, and standard interventions for preventing/
treating the symptoms.

9. What potential nutritional deficiencies may occur after this surgical procedure? Why might
Mrs. Rodriguez be at risk for iron-deficiency anemia, pernicious anemia, and/or megalo-
blastic anemia?

10. Should Mrs. Rodriguez be on any type of vitamin/mineral supplementation at home when
she is discharged? Would you make any recommendations for specific types? Explain.

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102 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

III. Nutrition Assessment

11. Prior to being diagnosed with GERD, Mrs. Rodriguez weighed 145 lbs. Calculate %UBW
and BMI. Which of these is the most pertinent in identifying the patient’s nutrition risk?
Why?

12. What other anthropometric measures could be used to further confirm her nutritional
status?

13. Calculate energy and protein requirements for Mrs. Rodriguez.

14. This patient was started on an enteral feeding postoperatively. What type of enteral formula
is Pivot 1.5? Using the current ASPEN guidelines for initiation of nutrition support, state
whether you agree with this choice and provide a rationale for your response.

15. Why was the enteral formula started at 25 mL/hr?

16. Is the current enteral prescription meeting this patient’s nutritional needs? Compare her
energy and protein requirements to what is provided by the formula. If her needs are not
being met, what should be the goal for her enteral support?

17. What would the RD assess to monitor tolerance to the enteral feeding?

18. Using the intake/output record for 9/2, how much enteral nutrition did the patient receive?
How does this compare to what was prescribed?

19. As the patient is advanced to solid food, what modifications in diet would the RD address?
Why? What would be a typical first meal for this patient?

20. What other advice would you give to Mrs. Rodriguez to maximize her tolerance of solid
food?

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 Case 9 Ulcer Disease: Medical and Surgical Treatment 103

21. Using her admission chemistry and hematology values, which biochemical measures are
abnormal?

a. Which values can be used to further assess her nutritional status? Explain.

b. Which laboratory measures are related to her diagnosis of a duodenal ulcer? Why
would they be abnormal?

22. Do you think this patient is malnourished? If so, what criteria can be used to support a
diagnosis of malnutrition? Using the guidelines proposed by ASPEN and AND, what type
of malnutrition can be suggested as the diagnosis for this patient?

IV. Nutrition Diagnosis

23. Select two nutrition problems and complete the PES statement for each.

V. Nutrition Intervention
24. For each of the PES statements that you have written, establish an ideal goal (based on the
signs and symptoms) and an appropriate intervention (based on the etiology).

25. Mrs. Rodriguez asks to speak with you because she is concerned about having to follow a
special diet forever. What might you tell her? What nutrition education should this patient
receive prior to discharge?

26. Do any lifestyle issues need to be addressed with this patient? Explain.

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