Nikki Finkenthal

KNH 413
Professor Matuszak
PUD Case Study
1. List all the food items that may contribute to GGs condition and explain
why.
-All the food items that may contribute to GGs condition were the fried foods,
fast foods with high fat content and frozen dinners. All of her meals are very
unhealthy and have high fat/ sodium content. She also is consuming a lot of coffee
and alcohol, but no water is listed so she could also be extremely dehydrated.

2. List any additional oral intake that may have contributed to GGs condition
and explain why.
-GGs consumption of black coffee and alcohol with no intake of water can leave
her very dehydrated and cause a burning pain in her stomach. The consumption of
alcohol decreases the mucosal integrity (Nelms 2016, p. 365).

3. List the non-oral stimulants (physical or psychological stress) that could

contribute to GGs condition and what she could do to change them.
-Some stimulants and stress factors in her life that could contribute to her
condition was the admittance back into school, reenrolling after taking a large
amount of time of could be very shocking and stressful for her mental and
physical health. She also has the demands of working part time and also being a
supportive parent to her son. She also is possibly going through a divorce and
custody battle with her ex-husband. Some of the changes that she could make are
to use better time management skills and find activities that calm her and make
her feel at peace. By limiting some of the stressful stimulants in her life, the
condition she had could have been subsided or not occurred if she managed them
better.

4. List the symptoms of GGs gastritis.

-Some symptoms of GGs gastritis are the increase in burning she experienced
and severe pain in the RLQ of her stomach. Epigastric pain is the most common
symptom related to PUD. She also admitted to having stress headaches and
indigestion (Nelms 2016, p. 366).

5. Was a bland diet necessary? Explain and list the principles of the diet plan
that you think GG should follow.
-I think the bland diet was necessary for GG. Based on her symptoms and pain
this diet plan can help minimize the further development of the ulcer and also
prevent any future development. By restricting certain foods that she currently has
in her diet it can help decrease the acid secretion and irritation she was having. By
eliminating foods with black/ red pepper, fried foods, coffee and alcohol she can
truly help decrease her pain (Nelms 2016, p. 366).
6. What is the mechanism of action of the following medications GG is
receiving: Carafate, AlternaGel and Pepcid?
-Carafate is used to treat and prevent the return of duodenal ulcers. It sticks to
damaged ulcer tissues and protects against acids/ enzymes so healing can occur
-AlternaGel is used for relief of heartburn, sour stomach and peptic ulcer pain and
is used to promote the healing of ulcers.
-Pepcid is used to treat ulcers, GERD and other conditions where the stomach
produces too much acid
(www.medlineplus.gov)

7. List the nutrient-drug interactions that are associated with these medications
-AlternaGel has a nutrient drug interaction if the patient consumes citric acid
based food products. Citric acid can increase absorption of aluminum hydroxide,
which can elevate blood levels of aluminum and reduce kidney function.
-Carafate has no nutrient drug interactions associated when patients are taking this
medication
-Pepcid has the ability to prevent nutrient absorption by changing the GI
environment. H2- receptor antagonists are antisecretory drugs inhibit gastric acid
secretion and raise gastric pH which may impair absorption of Vitamin B12 by
reducing cleavage from dietary sources (Krause 2012, p. 215)
(www.medlineplus.gov)

8. What are GGs IBW and percent of IBW?

-Based on the fact that GG is 52 her IBW is 110
100 lbs + 5 lbs per inch above 5 feet = 110 IBW
98 lbs/ 110 lbs x 100 = 89% of her IBW

9. Estimate her daily energy needs using the Harris-Benedict equation and
appropriate stress factor.
REE for females =655.1 + 9.6 (kg) + 1.9 (cm) 4.7 (years)
Weight = 110 lb/ 2.2 kg = 50. kg
Height = 62 inches x 2.54 cm= 157.5 cm
Age= 27

655.1 + 9.6 (50 kg) + 1.9 (157.5 cm) 4.7 (27 yrs) = 1316 x stress factor
of 1.2 = 1568 kcal
GG should consume 1550-1650 kcals per day

10. What might be the cause of the LUQ pain along with her usual pain?
-The LUQ pain that GG is experiencing can be related to her consumption of
alcohol. Her lab tests showed that she had high levels of ALP, which is used to
measure liver function, high levels can be associated with alcoholic liver disease.
The consumption of alcohol decreases mucosal integrity due to the reduction of
protective prostaglandis, which occurs in the LUQ (Nelms 2016, p. 365).
11. In the second set of lab values, glu, BUN, Cr, ser alb, Na, K, Cl, hgb and hct
all dropped. This probably means that GG was:
a. bleeding
b. eating poorly in the hospital
c. dehydrated when the first labs were drawn
d. over hydrated when the second set of labs was drawn

12. In the second set of lab values, serum amylase, AST and ALT all dropped.
This probably means that:
a. enzymes were elevated due to alcohol
b. her medications caused them to drop
c. GG was dehydrated when the first labs were drawn
d. GG was over hydrated when the second set of labs was drawn

13. Refer to the two lab tables again, and note that two days after admission,
GGs Alk Phos and CPK remained essentially unchanged. Why?
a. these enzymes are not affected by alcohol or hydration
b. her medications caused them to drop
c. dehydrated when the first labs were drawn
d. over hydrated when the second set of labs was drawn

14. What diagnostic test(s) indicate(s) that GG has an ulcer?

-An endoscopy can be performed when coupled with a tissue biopsy to see
a visualization of the ulcer. Other less invasive testing options include the
C-urea breath test, stool antigen test and serum testing for antibodies
(Nelms 2016, p. 366).

15. Briefly sketch the anatomical position where GGs ulcer can be found.

16. Define:
 H2 Antagonist: medications that interrupt the production of acid in the stomach
Proton pump inhibitor: class of medications that block the H+, K+ -ATPase
enzyme, a component in HCl production, thus reducing acid secretion in the
stomach (Nelms 2016, p. G-10 and G-19)

17. What is the mechanism of action of the following medications GG is

receiving: Nexium, amoxicillin and clarithromycin?
-Nexium is a proton pump inhibitor used to treat symptoms of GERD and other
conditions that involve excessive stomach acid; it can be given to prevent gastric
ulcer infections as well.
-Amoxicillin is a penicillin antibiotic that fights bacteria and can be used to treat
many different types of infections
-Clarithromycin is a macrolide antibiotic that fights bacteria in your body. It can
be used with other medicines to treat stomach ulcers (www.medlineplus.gov)

18. GG was not receiving counsel at the time the major bleeding started. If you
had the opportunity to counsel GG just before the bleeding, in what areas
would you feel competent to counsel her and in what areas would you refer
her to someone else? Investigate the agencies in your area that are available
to provide assistance to someone like GG.
-As a dietitian I would feel comfortable counseling GG in the aspects of her
condition related to nutrition, intervention and medical nutrition assessments. I
would feel comfortable creating a dietary plan for her that eases any discomfort of
her peptic ulcers and could also be a preventative dietary plan. I would discuss
healthier food options and the possibility of no longer consuming alcohol in her
diet. For further assistance in regards to cessation of alcohol and smoking, she
would need more help from a professional source that Im not educated in. Some
agencies she could go to for support and guidance would be Alcoholics
Anonymous, Community Counseling and Crisis Center in Oxford and other
psychological professions.

19. What is the significance of the dark stools?

-In the presence of peptic ulcer disease, melena, which refers to black, tarry stools
are very common with this diagnosis. The presence of melena may suggest that
the patient has either acute or chronic upper GI bleeding (Krause 2012, p. 602).

20. Give the pathophysiology for the cause of the following abnormal values:
BUN, NH3 and WBC.
-An increase in blood urea nitrogen is common in those with renal disease and
excessive protein catabolism. Its most likely that GG has an increase value of
BUN due to her dehydrated state when she was admitted into the hospital. Its
also possible that an elevated BUN level can be related to GI bleeding, which is
very likely due to the fact that she had a peptic ulcer within her GI
-An increase in NH3 or ammonia is common with a person who has an infection
or a traumatic injury, because this individual secretes more nitrogen than what is
 typically ingested. The presence of inflammatory cytokines causes nitrogen loss
and a negative nitrogen balance when these conditions are present.
-An increase in white blood cell count is common for patients fighting infections
and who also have elevated levels of stress. It makes sense that GG had abnormal
values for her white blood cell count due to the fact that she was in a high stress
time and was also fighting an internal infection from her peptic ulcer.
(Krause 2012, p. 53, 194, 195, 808, 819).

21. GG was probably dehydrated on admission since she had been drinking. This
means that some of her lab values were probably higher/ lower (circle one)
than indicated.

22. After admission GG received packed cells and IV fluids. How would that
affect the next set of lab values?
-Based on the fact that GG was dehydrated upon admittance into the hospital,
after receiving packed cells and IV fluids it should stabilize her body and raise her
lab values back to the normal range.

23. Define the following terms:

Packed cells: red blood cells that have been separated for blood
transfusion
Abdominal tap: used to remove fluid from the area between the belly
wall and the spine
Perforated ulcer: condition where an untreated ulcer can burn through
the wall of the stomach, allowing digestive juices and food to leach into
the abdominal cavity
Fistula: an abnormal opening or passage between two internal organs or
from an internal organ to the surface of the body (Nelms 2016, p. G-9)
Exploratory laparotomy: procedure completed under general anesthesia
when the surgeon makes a cut into the abdomen and examines the
abdominal organs
Billroth I: a reconstruction that consists of an anastomosis of the proximal
end of the duodenum near the end the distal end of the stomach.
Vagotomy: severing of the vagus nerve; often a component of gastric
surgery (Nelms 2016, p. G-23).
(www.medlineplus.gov)
24. Sketch a Billroth I

25. Compare a Billroth I to a Billroth II as to anatomical changes as well as to

dietary changes, if any.
-In the Billroth I procedure, also known as the gastroduodenostomy, a partial
gastrectomy or a pyloroplasty, a reconstruction that consists of an anastomosis of
the proximal end of the duodenum near the end the distal end of the stomach. In a
Billroth II procedure a partial gastrectomy is performed that consists of an
anastomosis of the jejunum at the proximal end. In the Billroth II a blind loop of
the duodenum is created. The procedure completed during a Billroth II creates the
same effect as a Roux-en-Y procedure by creating a small pouch. In both
procedures the stomach has a reduced capacity and may cause changes in gastric
emptying and transit time within the digestion pathways and may interrupt
absorption. Other nutritional concerns are related to vitamin and mineral
deficiencies, specifically with thiamin, vitamin B12, vitamin D, iron and copper
(Nelms 2016, p. 368).

26. Calculate GGs energy and protein needs

REE for females =655.1 + 9.6 (kg) + 1.9 (cm) 4.7 (years)
Weight = 110 lb/ 2.2 kg = 50. kg
Height = 62 inches x 2.54 cm= 157.5 cm
Age= 27

655.1 + 9.6 (50 kg) + 1.9 (157.5 cm) 4.7 (27 years) = 1316 x stress
factor of 1.2 = 1568 kcal
GG should consume 1550-1650 kcals per day

Protein: 1.5g/ kg/ day x 50kg= 75g per day

27. List the principles of a postgastrectomy diet and briefly describe the
scientific basis for each principle.
-After a postgastrectomy diet the oral intake of foods and fluids is initiated as
soon as the patients GIT starts to function again. At first small frequent feedings
of ice and then followed by liquids and easily digested solid foods. If the patient
requires a longer timeframe for healing they can be placed on a feeding tube to
assist in the healing process. Depending on the surgery type the patient may be
faced with various nutritional complications such as obstruction, dumping,
diarrhea, abdominal pain and weight loss. Its beneficial for individuals to
consume six to eight small meals a day and consume fluids between the meals. If
a patient is having trouble during feeding administering pancreatic enzymes with
meals may help with the duodenal mixing of food and pancreatic juices due to the
inadequacy (Krause 2012, p. 605, 606 and 853)

28. Is it possible that GGs diet will ever change or do you believe she will be on a
postgastrectomy diet for the rest of her life? Explain your answer.
-It is possible that GG can return back to her normal diet after her
postgastrectomy surgery based diet, but she needs to be extremely cautious with
what she consumes in order to prevent a return of a peptic ulcer. Its stated that
dietary factors have gained or lost favor as a significant component in the cause
and treatment of peptic ulcers. There is little evidence that specific dietary factors
can exacerbate the disease. With this evidence it seems as if GG can return to her
normal diet as long as she is cautious and predominately follows a
postgastrectomy-based diet. She will most likely need to cut out alcohol, caffeine,
coffee and spicy foods for an extended period of time in order to allow her peptic
ulcer to properly heal and to prevent any future complications. Its recommended
for individuals who are treated with peptic ulcer disease to avoid foods that
exacerbate their symptoms and to consume a nutritionally complete diet (Krause
2012, p. 603)

29. If GG were to be hospitalized for an extended period of time and required a

tube feeding via duodenum or jejunum, what characteristics would be
appropriate for the tube feeding you would use?
-An appropriate tube feeding for GG would need to provide her with the same
nutrient values that she would normally consume via oral consumption. Due to
the fact that her digestion and absorption could possibly be impaired from surgery
of her ulcer, its best to give her a hydrolyzed formula for malabsorption. She also
just had a major surgery so her protein needs will be increased and her energy
needs will be higher as well, in order for proper healing and support. Giving her a
hydrolyzed, high protein, high calorie formula that also supports immune function
and metabolic stress would be the best choice for her if placed on a tube feeding
(Nelms 2016, p. 96).

30. Using the table below, compare several of the enteral nutritional supplements
that would be appropriate for GG.
 Produce Form Cal/ Pro CH Fat Na K Vol g of Free
Product r ml g/L O g/ mg mg to fiber H2O/
g/L L meet /L L in
RDA ml
in ml
NutriHep Nestle Hepatic 1.5 40 290 21 40 33 1000 - 190
Insufficiency 0 g 0 ml

Impact Nestle Immune 1.5 94 140 64 - - 1000 - -

Peptide support 0
1.5
Pivot 1.5 Abbott Immune 1.5 94 172 51 33 47 1000 1.8g 180
Cal support 0 0 5 g

Vital 1.0 Abbott Malabsorptio 1.0 40 130 38 25 33 1422 1.0 g 199

Cal n 0 0 g

Peptame Nestle Malabsorptio 1.0 40 128 39 14 37 1500 - 212

n n 0 0 5 ml