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Rebekah Vukovich Dietetic Intern
CASE STUDY
Introduction to patientPast medical history Primary diseases/conditions Short bowel syndrome Patient’s current hospital admissions
Nutrition Care Process
OUTLINE
Female Age: 63Weight:
First admission: 44kg Second admission: 49kg 28% wt. loss in past 10 months
Height: 152.4 cmBMI: 18.9 (first admission) Social history: Married, retired, previously
residing in extended care facility, home health care
Primary problem: Multiple abdominal surgeries with complications, malnutrition, long-term TPN
INTRODUCTION
Partial gastrectomy RNY gastrojejunostomy Colostomy G-tube GI bleed GERD Ulcers HTN Tracheostomy (December) MI COPD Depression CAD TIA Cardiac stents Rheumatoid arthritis
PAST MEDICAL HISTORY
3/2011 Cardiac arrest, myocardial infarction
6/2012 Perforated duodenal ulcer, peritonitis, graham patch over ulcer
7/2012 Small bowel obstruction
3/2014 Hematemesis, hiatal hernia, chronic gastritis, gastric ulcer
5/2014 GI bleed, hiatal hernia, gastric ulcer
7/2014 Upper GI bleed, peptic ulcer, anemia, partial gastrectomy, RNY
gastrojejunostomy, G-tube placed10/2014
Chronic antral ulcer, gangrene, colectomy, ileostomy12/2014
Hyperkalemia, dehydration, AKI
PREVIOUS HOSPITAL ADMISSIONS
Open sores or lesions, disrupt mucosal integrity Gastric ulcer Esophageal ulcer Duodenal ulcer
Causes: Stomach acid Helicobacter pylori infection Long-term NSAIDs use
Symptoms: Burning stomach pain Starts between meals or during the night May come and go, duration varies Less common: N/V, belching, poor appetite, weight loss
PEPTIC ULCER
Complications Bleeding Perforation Obstruction
Treatment Worsen if not treated Acid-suppressing medication Antibiotics Surgery
Nutrition Therapy Alcohol Coffee and caffeine Spices Probiotics Omega 3, 6
PEPTIC ULCERS
Billroth II Due to recurrent GI bleeds Chronic antral ulcer Procedure Nutritional complications
Obstruction, dumping, abdominal discomfort, diarrhea, weight loss, impaired digestion and absorption
Micronutrient defi ciencies: iron, calcium, Vit. D, ribofl avin, folate, Vit. B12
Diet Avoid: concentrated sweets Lactose Small, frequent meals Lying down after meals Emphasize protein and fat Fiber
GASTRECTOMY WITH RNY GASTROJEJUNOSTOMY
Anatomy Diet recommendations:
High-calorie high-protein Low residue Foods that cause gas and odor
Malabsorption Bile acid Fat Vitamin B12
Increased loss Fluid Sodium Potassium
ILEOSTOMY
>40-50% small intestine removed Particularly ileum and ileocecal valveLoss of small bowel absorptive area Complications
Diarrhea, dehydration, steatorrhea, weight loss, muscle wasting, bone disease
Malabsorption with loss of absorptive areaPrognosis:
Adaption of remaining bowel Length of residual bowel Ileocecal valve Small and large bowel continuity
SHORT BOWEL SYNDROME
Post-op feedings If >1/2 removed, start TPN Elemental formula MCT triglycerides 6-10 small meals/day
Supplements/Medications Initially, control hydroelectrolitic
disturbances/rehydrate PN started earlyPN essential for long-term survival
SHORT BOWEL SYNDROME
Long-term TPN Complications Systemic recurrent infections (vein catheter
contamination), thrombosis of two or more central veins, and hepatic malfunction
Satisfactory results with the use of EN To reduce/eliminate PN
Antimotility agents Oral diet: iso-osmolar, hypercaloric, fractionated
form, addition of soluble fibers Restriction of lipids, lactose, and calcium oxalate. Oral rehydration Vitamin/mineral supplement
DIET AND SHORT BOWEL SYNDROME
Long-term retrospective clinical study10 patients with severe SBS after intestinal surgery
resection No chronic conditions Examined every 12 months Measured: body weight, height, BMI, basal energy
expenditure, percentage of involuntary loss of usual body weight (%UWL), fat-free mass, fat mass, total protein, albumin, total lymphocyte count
Calculated home parenteral nutrition (HPN) and home enteral nutrition (HEN) provided
RESEARCH STUDY
Signifi cant and progressive increase in %UWL 20% of body weight loss by the end FFM and FM signifi cant decrease Serum albumin, total protein, and total lymphocyte count
did NOT change signifi cantly HPN withdrawn in 8 patients (permanently in 5, and
temporarily in 3) Most frequent complications: infection from central venous
catheter (at least 1x in each patient, 30 total instances) Bone disease in 7 pt., deep vein thrombosis in 3 pt., chronic
calculous cholelithiasis in 5 pt. Bone disease: use of cyclic HPN, may contribute to urinary calcium
loss All patients survived for 2 years, seven for 5 yrs., and six for
7 years of more
RESULTS
References a study of 124 patients with SBS, survival of 94% at 1 year, 86% at 2 years, and 75% at 5 years Death rate: 22% r/t HPN
Duration of PN correlates significantly with length of RSB (length of the residual small bowel after the Treitz angle)
Long-term Enteral Nutrition + Oral Intake achieved the minimal energy requirement at only 2 periods of the study
Inability to use EN exclusively in severe SBSPatients who reduced PN, survived for longer periodsUse of HEN + OI reduced complications of prolonged
PN
RESULTS
Slow and progressive introduction of oral diet Control electrolytes No benefit to restricting lipids and oxalate if there is
no colon Intestinal absorption up to 50% in SBS Hypercaloric: 1.5-2.0 of BEE
Factors impairing intake: bacterial overgrowth, nausea, flatulence, poor appetite, fear of eating outside the home
Consider intermittent use of PN throughout the year.
NUTRITION RECOMMENDATIONS FROM STUDY
IV fluidsTPN M/VLasix Novolog LipitorFiberCon Lomotil Imodium Protonix Zofran Codeine Sulfate
ADMISSION 1 MEDICATIONS
Test Value Normal Range
Hemoglobin 10.4 g/dL 11.6–14.8 g/dL
WBC 15.6 K/mm3 3.8-10.4 K/mm3
Glucose 173 g/dL 60-110 mg/dL
Sodium 132 mmol/L 137-145 mmol/dL
Phosphorus 3.1 mg/dL 3.6–5.0 mg/dL
Free Triiodothyronine
2.26 pg/mL 2.77–5.27 pg/mL
ADMISSION 1 LABS
Severe sepsis due to abdominal abscess, complicated by septic shock r/t recent removal of duodenostomy tube
Advanced COPDRight lower quadrant fluid collectionAcute abdominal pain r/t mesenteric edemaPeritonitisLeukocytosisHypertension Treatment:
Guided drainage IV fluids IV antibiotics Oxygen
PRESENT MEDICAL STATUS AND TREATMENT
ADMISSION 1
Surgeon recommends complete bowel shut down and rest with minimum 2 weeks of TPN for malnutrition and duodenal leak.
Diet History: soft diet at nursing homeWeight History: Admission 44kg (22% in <3 months;
severe) 12/2/14 41.8kg 10/23/14 56.5kg 3/8/14 61.3kg
Nutrition-Focused Physical Assessment: Orbital Triceps Temporal Clavicle Shoulders Interosseous Hand-grip strength
ADMISSION 1NUTRITION ASSESSMENT
Diet order: Clear Liquids, NPO, TPNNutrition Needs:
Calories: BMR = 917; stress factor 1.4 (sepsis) = 1375 Protein: 1.2-2.0g/kg (sepsis, catabolic) = 52-88 Fluid: 30 ml/kg = 1200 ml/d
TPN: Clinimix 5/15 2L w/ 500 ml 20% lipids providing 1920 kcal and 100 gm
protein 1320mL w/ 250 ml 20% fat emulsion, providing 1437kcal
(104%) and 66g protein (75-127%)Nutrition Diagnosis: Malnutrition r/t chronic illness of
sepsis and altered GI function as evidenced by 22% wt. loss past 3 months, poor grip strength, subcutaneous fat loss, muscle atrophy and poor po intake for 3 days which meets the parameters for severe protein-calorie malnutrition (PCM).
ADMISSION 1NUTRITION ASSESSMENT
WeaknessHyponatremia Acute respiratory failureLeukocytosis UTI Sepsis
Polymicrobial septicemia Fungal septicemia
Short bowel syndrome Treatment
Normal saline Antibiotic 2 units packed red blood cells
PRESENT MEDICAL STATUS AND TREATMENT ADMISSION 2
Fatigue and weakness past 2 weeksTrigger: poor po >5 days and 10# wt. loss in past 6
months Weight: admission 49kg, Discharge 62.2kg I>O Diet history: since previous discharge
Regular diet: 2-3 meals/day Steak, potatoes, chicken, fish, mac & cheese, hamburger,
yogurt, oatmeal, pudding. No cottage cheese. Denies GI discomfort.
Eating less past 2 weeks Stated she was drinking adequate fluids (ginger-ale,
Pedialyte, Powerade, popsicles) TPN: 1320 ml with 250 ml 20% lipids
ADMISSION 2NUTRITION ASSESSMENT
Nutritional Needs: Calories: RMR = 971, stress factor 1.3 (infection, hx COPD)
= 1262 Protein: 1-1.3 g/kg (potential malabsorption, infection,
chronic illness) = 49-74 g Fluid: 30ml/kg = 1470 ml
Current diet: Purred diet, Clear Liquids, Full Liquids TPN: Clinimix 5/15 1320 ml w/ 250 ml 20% lipids,
which provides: 1437 kcal (114% of estimated needs) and 66 g protein (90-135% of estimated needs).
NUTRITION ASSESSMENT
Diagnosis Inadequate oral intake r/t poor appetite and fatigue as
evidenced by reported poor po intake >5 days. Intervention
Meals and Snacks: Encourage small, frequent meals. Decrease amount of fluid consumption with meals, have fluids between meals.
Nutrition Support: Continue TPN Supplement: Place order for Ensure TID.
Monitoring and Evaluation Meals and Snacks: Monitor for intake and tolerance. Nutrition Support: Monitor for tolerance and order change. Supplement: Monitor for consumption and need for lower-
sugar formula Anthropometrics: Maintain wt. +/- .5 to 1kg of admission wt. Biochemical: Monitor Hgb, Hct, sodium, BUN, glucose, and
iron.
ADMISSION 2NUTRITION CARE PROCESS
Two weeks of therapy for bacteremia and fungemia.
Long-term TPN Home health care
DISCHARGE
Questions?
THANK-YOU!