Case 7

Gastroesophageal Reflux Disease

Krishna Gupta, a 48-year-old male, visited his physician for evaluation of increasing complaints of
severe indigestion. He was scheduled for a variety of tests—including intraesophageal pH monitoring
and a barium esophagram—that support a diagnosis of gastroesophageal reflux disease.

Objectives
After completing this case, the student will be 5. Interpret pertinent laboratory parameters
able to: for nutritional implications and significance.
1. Apply knowledge of the pathophysiology 6. Analyze nutrition assessment data to evalu-
of gastroesophageal reflux disease (GERD) ate nutritional status and identify specific
in order to identify and explain common nutrition problems.
nutritional problems associated with this 7. Determine nutrition diagnoses and write
disease. appropriate PES statements.
2. Describe basic principles of drug action 8. Develop a nutrition care plan—with appro-
required for medical treatment of GERD. priate measurable goals, interventions, and
3. Understand the potential complications of strategies for monitoring and evaluation—
untreated GERD. that addresses the nutrition diagnoses of
4. Discuss the rationale for nutrition recom- this case.
mendations to minimize adverse symptoms
of GERD.

77

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78 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Gupta, Krishna, Male, 48 y.o.

Allergies: NKA
Pt. Location: University Gastroenterology Clinic Physician: Jen Li Date: 11/1

Ranta Images/Shutterstock.com Patient Summary: 48-y.o. male here for evaluation and treatment for increased
and recurrent symptoms of indigestion.

History:
Onset of disease: Patient has been experiencing increased indigestion over
last year. Previously it was only at night but now he experiences indigestion
almost constantly. He has been taking Tums several times daily and has tried the herb fenugreek
and turmeric for relief of symptoms. Mr. Gupta has gained almost 30 lbs since he had knee
surgery 3 years ago, which he attributes to a decrease in his ability to run and not being able to find
a consistent replacement for this form of exercise. Patient states he plays with his children on the
weekends, but that is the extent of his physical activity. He states he probably has been eating and
drinking more over the last year, which he attributes to stress. He is worried about his family history
of heart disease, which is why he takes an aspirin each day. He has not changed his diet in any way
except for the addition of fenugreek and turmeric.
Medical history: Essential HTN—Dx 1 year ago
Surgical history: s/p R knee arthroplasty 5 years ago
Medications at home: Metoprolol 50 mg daily; 325 mg aspirin daily; multivitamin daily; 500 mg
ibuprofen twice daily for last month
Tobacco use: No
Alcohol use: Yes; 1–2 beers 1–2 times/week
Family history: What? CAD. Who? Father.

Demographics:
Marital status: Married—lives with wife and 2 sons
Spouse name: Saanvi
Number of children: 2 (ages 8 and 12)
Years education: BA
Language: English and Hindi
Occupation: Retail manager of local department store
Hours of work: M–F, works consistently in evenings and on weekends as well
Ethnicity: Indian
Religious affiliation: Hinduism

MD Progress Note:
General/Constitutional: Well-developed, overweight 48-year-old Indian male in mild distress.
HEENT: Head: normocephalic and atraumatic
Eyes: anicteric sclera, noninjected conjunctiva
Mouth: oral mucosa pink, dentition in good repair
Throat: pharynx pink without exudates
Neck: soft, supple, no palpable masses. No lymphadenopathy.

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 Case 7 Gastroesophageal Reflux Disease 79

Gupta, Krishna, Male, 48 y.o.

Allergies: NKA
Pt. Location: University Gastroenterology Clinic Physician: Jen Li Date: 11/1

Cardiac: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.
Pulmonary/Chest: Lungs are clear to auscultation bilaterally.
Abdominal: Abdomen soft, nontender, with normoactive bowel sounds in all four quadrants. Liver
percusses approx 8 cm at the midclavicular line, one fingerbreadth below the right costal margin.
Epigastric tenderness without rebound or guarding.
Extremities: Normal range of motion in all four extremities. No cyanosis or clubbing or peripheral
edema.
Neurological: Conscious, alert, and oriented. Cranial nerves II through XII are intact grossly and
symmetrically. No focal neurologic deficit.
Skin: Skin is warm and dry. No rashes or ulcerations noted.

Vital Signs: Temp: 98.6°F Pulse: 90 Resp rate: 16

BP: 119/75 Height: 5'9" Weight: 215 lbs

Assessment and Plan:

Dx: Gastroesophageal reflux disease, HTN

Medical Tx plan: Hematology, Chem 24, Ambulatory 48-hour pH monitoring with Bravo™ pH moni-
toring system, Barium esophagram—request radiologist to attempt to demonstrate reflux using
abdominal pressure and positional changes; Endoscopy with biopsy to r/o H. pylori infection; Begin
omeprazole 30 mg every am; Decrease aspirin to 75 mg daily; D/C self-medication of ibuprofen
daily; Nutrition consult.
J. Li, MD

Nutrition:
History: Patient relates he has gained almost 30 lbs since his knee surgery. He attributes
this to a decrease in his ability to run, and he has not found a consistent replacement for this
form of exercise. He plays with his children on weekends, but that is the extent of his physical
activity. He states he probably has been eating and drinking more over the last year, which he
attributes to stress with his busy lifestyle and long work hours. He is worried about his family
history of heart disease, which is why he takes an aspirin each day. He has not really followed
any diet restrictions for health concerns. He eats a combination of traditional Indian foods
along with more American-style food choices. He has lived in the United States since his high
school years, so he does not follow any strict dietary practices related to his religious back-
ground of Hinduism.

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80 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Gupta, Krishna, Male, 48 y.o.

Allergies: NKA
Pt. Location: University Gastroenterology Clinic Physician: Jen Li Date: 11/1

Usual dietary intake:

AM: 1½ c hot cereal; 2¾ c skim milk on cereal; sometimes egg
and naan
16 oz orange juice
Hot tea with milk and sugar
Lunch: Fast food chicken sandwich with fries, Diet Coke—or leftovers
from previous evening
Snack when he comes home: Handful of crackers, cookies, or chips, 1 12-oz beer
PM: Typically eats traditional Indian foods at home for evening meal:
3–4 oz of meat (chicken primarily) or tofu (grilled or cooked on top
of stove) cooked with rice and vegetables; chapattis; hot chai or
black tea.
Relates that his family’s schedule has been increasingly busy, so
they sometimes (1–2 times per week) order pizza or stop for fast
food instead of cooking.
Late PM: Ice cream, popcorn, or crackers. Drinks 3–4 12-oz diet sodas daily
as well as hot tea.

24-hr recall:
(At home PTA): 2 scrambled eggs, naan; hot black tea
At work: 3 12-oz Diet Pepsis
Lunch: Leftover curry with spinach, chickpeas, rice—2 c
Hot black tea
Late afternoon: 2 c chips, 1 beer
Dinner: Lentil dal—2 c. over approx. 2 c rice
2 slices naan
2 c hot chai tea
Bedtime: 2 c ice cream

Food allergies/intolerances/aversions: Fried foods seem to make the indigestion worse

Previous nutrition therapy? No
Food purchase/preparation: Wife or eats out
Vit/min intake: One-A-Day for Men multivitamin daily

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 Case 7 Gastroesophageal Reflux Disease 81

Gupta, Krishna, Male, 48 y.o.

Allergies: NKA
Pt. Location: University Gastroenterology Clinic Physician: Jen Li Date: 11/1

Laboratory Results
Ref. Range 11/1 0700
Chemistry
Sodium (mEq/L) 136–145 144
Potassium (mEq/L) 3.5–5.1 4.5
Chloride (mEq/L) 98–107 102
Carbon dioxide (mEq/L) 23–29 25
BUN (mg/dL) 6–20 8
Creatinine serum (mg/dL) 0.6–1.1 F 0.9
0.9–1.3 M
Uric acid (mg/dL) 2.8–8.8 F 5.1
4.0–9.0 M
Est GFR, non-Afr Amer >60 117
(mL/min/1.73 m2)
Glucose (mg/dL) 70–99 91
Phosphate, inorganic (mg/dL) 2.2–4.6 3.8
Magnesium (mg/dL) 1.5–2.4 1.9
Calcium (mg/dL) 8.6–10.2 8.9
Bilirubin total (mg/dL) ≤1.2 0.9
Bilirubin, direct (mg/dL) <0.3 0.05
Protein, total (g/dL) 6–7.8 6.3
Albumin (g/dL) 3.5–5.5 4.5
Prealbumin (mg/dL) 18–35 31
Alkaline phosphatase (U/L) 30–120 83
ALT (U/L) 4–36 11
AST (U/L) 0–35 9
CPK (U/L) 30–135 F 71
55–170 M
Lactate dehydrogenase (U/L) 208–378 210
Cholesterol (mg/dL) <200 245 !
HDL-C (mg/dL) >50 F, >40 M 52
VLDL (mg/dL) 7–32 35 !
LDL (mg/dL) 0–99 157 !

(Continued)

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82 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Gupta, Krishna, Male, 48 y.o.

Allergies: NKA
Pt. Location: University Gastroenterology Clinic Physician: Jen Li Date: 11/1

Laboratory Results (Continued)

Ref. Range 11/1 0700
LDL/HDL ratio <4.5 3.02
Triglycerides (mg/dL) <150 178 !
HbA1C (%) <5.7 5.1
Hematology
WBC (×103/mm3) 3.9–10.7 5.6
RBC (×106/mm3) 4.2–5.4 F 5.2
4.5–6.2 M
Hemoglobin (Hgb, g/dL) 12–16 F 14.0
14–17 M
Hematocrit (Hct, %) 37–47 F 43
41–51 M
Mean cell volume (µm3) 80–96 85
Mean cell Hgb (pg) 28–32 28
Mean cell Hgb content (g/dL) 32–36 32
RBC distribution (%) 11.6–16.5 15.5
Platelet count (×103/mm3) 150–350 345
Hematology, Manual Diff
Neutrophil (%) 40–70 55
Lymphocyte (%) 22–44 28
Monocyte (%) 0–7 6
Eosinophil (%) 0–5 0
Basophil (%) 0–2 0
Blasts (%) 3–10 3
Urinalysis
Collection method — Clean
catch
Color — Pale
yellow
Appearance — Clear
Specific gravity 1.001–1.035 1.006
pH 5–7 6.1
Protein (mg/dL) Neg Neg
Glucose (mg/dL) Neg Neg

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 Case 7 Gastroesophageal Reflux Disease 83

Gupta, Krishna, Male, 48 y.o.

Allergies: NKA
Pt. Location: University Gastroenterology Clinic Physician: Jen Li Date: 11/1

Laboratory Results (Continued)

Ref. Range 11/1 0700
Ketones Neg Neg
Blood Neg Neg
Bilirubin Neg Neg
Nitrites Neg Neg
Urobilinogen (EU/dL) <1.0 0.009
Leukocyte esterase Neg Neg
Prot chk Neg Neg
WBCs (/HPF) 0–5 1
RBCs (/HPF) 0–2 0.5
Bact 0 0
Mucus 0 0
Crys 0 0
Casts (/LPF) 0 0
Yeast 0 0

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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84 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

Case Questions
I. Understanding the Disease and Pathophysiology
1. How and where is acid produced in the stomach and how is acid production controlled
within the gastrointestinal tract?

2. What role does lower esophageal sphincter (LES) pressure play in the etiology of
gastroesophageal reflux disease? What factors affect LES pressure?

3. What are the complications of gastroesophageal reflux disease?

4. The physician biopsied for H. pylori. What is this?

5. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease.

6. Describe the diagnostic tests performed for this patient.

7. What risk factors does the patient present with that might contribute to his diagnosis?
(Be sure to consider lifestyle, medical, and nutritional factors.)

8. The MD has decreased the patient’s dose of daily aspirin and recommended
discontinuing his ibuprofen. Why? How might aspirin and other NSAIDs affect
gastroesophageal disease?

9. The MD has prescribed omeprazole. What class of medication is this? What is the basic
mechanism of the drug? What other drugs are available in this class? What other groups of
medications are used to treat GERD?

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 Case 7 Gastroesophageal Reflux Disease 85

II. Understanding the Nutrition Therapy

10. Summarize the current recommendations for nutrition therapy for GERD.

III. Nutrition Assessment

11. Calculate the patient’s %UBW and BMI. What does this assessment of weight tell you?
In what ways may this contribute to his diagnosis?

12. Calculate energy and protein requirements for Mr. Gupta. How would this recommen-
dation be modified to support a gradual weight loss?

13. Mr. Gupta and his wife are originally from India. Are there components of their traditional
diet that may aggravate his symptoms of GERD?

14. What considerations related to Hinduism should you keep in mind when assessing
Mr. Gupta’s diet?

15. Estimate his caloric intake from his 24-hour recall. How does this compare to your
calculated energy requirements?

16. Are there any abnormal labs that should be addressed to improve Mr. Gupta’s overall
health? Explain.

17. Mr. Gupta’s history includes the use of fenugreek and turmeric as alternative treatments for
his symptoms of GERD. Examine the evidence regarding these supplements. What could
you tell Mr. Gupta? Are there any concerns with the ingestion of these supplements?

18. What other components of lifestyle modification would you address to help treat his
diagnosis?

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86 Unit Three Nutrition Therapy for Upper Gastrointestinal Disorders

IV. Nutrition Diagnosis

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

V. Nutrition Intervention
20. Determine the appropriate intervention for each nutrition diagnosis.

21. Does the long-term use of proton pump inhibitors have nutritional or other health
consequences? Are there specific interventions that you might implement to address
these effects?

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 Case 7 Gastroesophageal Reflux Disease 87

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