Natalie Rohr

KNH 413
Professor Matuszak
Case Study #14: Peptic Ulcer Disease
1.

List all of the food items that may contribute to GGs condition and explain

why.
Many of the foods that GG has been ingesting, contribute to her condition. Foods that
increase acid secretion or cause direct irritation to gastric mucosa are the caffeine and
alcohol that she consumes regularly. The milk that she was using to treat her stomach
pain has also been shown to contribute to both gastric and pepsin secretion. The high fat
content foods, as well as the chocolate, may also increase the acid secretion (Nelms 366).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal
Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston,
MA: Cengage Learning.
2.

List any additional oral intake that may have contributed to GGs condition

and explain why.

GGs use of ASA medications for her headaches decreases mucosal integrity, such as the
reduction of protective prostaglandins. Smoking also decreases blood supply as well as
decreases mucosal integrity as well (Nelms 365). These two factors help lead to GGs
condition.
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal
Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston,
MA: Cengage Learning.
3.

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

contribute to GGs condition and what she could do to change them.

GG is undergoing a lot of stress in her life. Shes going through a divorce, shes having
trouble finding a good income, shes back in school, and she has to balance being a mom
for a child who was recently diagnosed with ADHD. Stress decreases blood supply as
well as decreases mucosal integrity, similarly to the effects of smoking (Nelms 365). In
order to help relieve some of the stress, GG could go talk to a counselor about how to
balance and manage all the different aspects in her life. By doing this, she would come up
with a plan on how to effectively manage her life.
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal
Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston,
MA: Cengage Learning.
4.

List the symptoms of GGs gastritis.

Gastritis is inflammation of the gastric mucosa. The symptoms for gastritis can include
belching, anorexia, abdominal pain, vomiting, and in more severe cases, bleeding and
hematemesis (Nelms 365). GG has only experienced abdominal pain.
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal
Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston,
MA: Cengage Learning.
5.

Was a bland diet necessary? Explain and list the principals of the diet plan that

you think GG should follow.

No, a bland diet was not necessary for GG to follow. Research has been done to show
that a bland diet is not required when reducing the symptoms of gastritis. However, GG
should change her diet plan so that she is eating less acidic foods and recue her black
coffee consumption. It is also important for GG to obtain a high nutrition diet with
adequate amounts of fruits and vegetables as well as fiber. It has also been shown that the
cessation of smoking and drinking alcohol can help relieve symptoms. If her gastritis is
caused by infection, then her doctor will prescribe antibiotics.
Cited: Gastritis. (n.d.). Retrieved February 08, 2016, from
https://umm.edu/health/medical/altmed/condition/gastritis

6.

What is the mechanism of action of the following medications GG is receiving:

Carafate, AlternaGel, and Pepcid?

Carafate, also known as a sucralfate, is used to treat and prevent duodenal ulcers. It works
by forming a barrier or coating over the ulcer and protects it from acid of the
stomach, allowing it to heal. AlternaGel acts as an antacid. It helps to relieve heartburn,
acid indigestion, sour stomach, and an upset stomach due to these symptoms. Pepcid, also
known as a famotidine, works in decreasing the amount of acid the stomach produces.
Pepcid is used to treat and prevent ulcers in the stomach and intestines.
Cited: Pepcid: Uses, Dosage, Side Effects - Drugs.org. (n.d.). Retrieved February 08,
2016, from http://www.drugs.org/pepcid.html
Sucralfate (Oral Route). (n.d.). Retrieved February 08, 2016, from
http://www.mayoclinic.org/drugs-supplements/sucralfate-oral-route/description/drg20066120
Active Ingredients (in each 5 mL teaspoon). (n.d.). Retrieved February 08, 2016, from
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=99955
7.

List the nutrient-drug interactions that are associated with these medications.

With the use of Pepcid, the drug can decrease the absorption of vitamin B12.
1.6therefore one should not smoke when taking it. AlternaGel may interfere with normal
calcium metabolism. You should always talk with your doctor when prescribed a drug,
regarding drug-nutrient interactions and possible complications if the drug is taken at
meals, at certain times, etc.
Cited: Bobroff, L. B. (n.d.). Food/Drug and Nutritent/Drug Interactions. Retrieved from
http://edis.ifas.ufl.edu/pdffiles/He/HE77600.pdf

Marks, J. (2014). What is Sucralfate? Retrieved from

http://www.everydayhealth.com/drugs/sucralfate#avoid
Drug and Nutrient Reactions. (n.d.). Retrieved from
http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf
8.

What are GGs IBW and percent of IBW?

IBW 100 + 5(2) = 110 lbs

%IBW (98/110) x 100 = 89%
9.

Estimate her daily energy needs using the Harris-Benedict equation and

appropriate stress factor.

BMR = 655.1 + (9.563 x weight in kg) + (1.850 x height in cm) (4.676 x age)
655.1 + (9.563 x 44.5 kg) + (1.850 x 157.5 cm) (4.676 x 27) = 1250 kcal
1250 kcal x 1.6 stress factor = 2000 kcal
A stress factor of 1.6 was used because GG is experience moderate to heavy stress in her
life.
10. What might the cause of the LUQ pain along with her usual pain?
Pain in the LUQ is usually indicative of something wrong with the organs and/or tissue
structures located on that area of the torso. There are many organs located in that area of
the torso, one of them being the left side of the liver. Before GG was admitted into the
hospital for the second time, she had a binge-drinking episode the night before. As
previously stated, alcohol can induce mucosal inflammation. Because of her binge
drinking after abstinence, her liver was likely overworked, causing mucosal inflammation
and pain in the LUQ. The enzyme ALP, which shows damage to the liver, was also out of
the normal range (122 U/L when the normal range is 25-100 U/L). This is indicative of
her binge drinking and her overworked liver.
Cited: Upper Left Abdominal Pain | MD-Health.com. (n.d.). Retrieved February 08,
2016, from http://www.md-health.com/Upper-Left-Abdominal-Pain.html

Bode, C. (n.d.). Alcohol's Role In Gastrointestinal Disorders. Retrieved from

http://pubs.niaaa.nih.gov/publications/arh21-1/76.pdf
ALP. (n.d.). Retrieved February 08, 2016, from
https://labtestsonline.org/understanding/analytes/alp/tab/test/
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:
Since GGs BUN, Na, K, and Cl all dropped from the first lab to the second that is
indicative of over hydration when the second labs were drawn (dehydration when the first
labs were taken). Her lowered hgb and hct show that she is bleeding (answers A and D).
12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This
probably means that:
Enzymes were elevated due to alcohol. When GG first had the lab tests done, it was right
after she had binge drank. When the second set of lab values were taken, her bloodalcohol level had returned to normal and she was more hydrated.
13. Refer to the two lab tables again, and note that two days after admission, GGs
Alk, Phos, and CPK remained essentially unchanged. Why?
GG was dehydrated when the first labs were drawn.
14. What diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?
In order to test for H pylori, the cause behind the ulcer, there are multiple diagnostic tests
that can be done. Tests can be done to test for H. pylori the use the patients blood, breath,
and stool. An endoscopy can also be done in which a hollow tube equipped with a lens is
put down the throat and into the stomach to look for ulcers. Lastly, an x-ray of the upper
digestive system can be taken. The patient will swallow a white liquid (containing
barium) that coats the digestive tract and makes an ulcer more visible.

Cited: Peptic ulcer. (n.d.). Retrieved February 08, 2016, from

http://www.mayoclinic.org/diseases-conditions/peptic-ulcer/basics/tests-diagnosis/con20028643
15. Briefly sketch the anatomical position where GGs ulcer can be found.

16. Define:

H2 antagonist blocks histamine receptors that are a component of one of the

stimulatory paths for acid secretion

Proton pump inhibitor class of medications that block H+, K+ -ATPase
enzyme, a component in HCl production, thus reducing acid secretion in the
stomach
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper
Gastrointestinal Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp.
344-377). Boston, MA: Cengage Learning.

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

Nexium, amoxicillin, and clarithromycin?

Nexium, also known as esomeprazole magnesium, is indicated for the reduction in the
occurrence of gastric ulcers associated with continuous NSAID therapy in patients at risk
for developing gastric ulcers. When paired with amoxicillin and clarithromycin (which is
true for GGs case), it is indicated for the treatment of patients with H. pylori infection
and duodenal ulcer disease to eradicate H. pylori.
Amoxicillin is an extended spectrum penicillin group of antibiotic. It acts by inhibiting
bacterial cell wall synthesis. The lack of bacterial cell wall results in death due to lysis of
bacteria. Clarythromycin is a bacteriostatic drug that acts by inhibiting protein synthesis.
It interferes with transpeptidation and translocation thus there is inhibition of protein
synthesis and hence inhibition of cell growth.
Cited: Label: NEXIUM- esomeprazole magnesium capsule, delayed release. (n.d.).
Retrieved February 08, 2016, from http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?
setid=9af7a792-d38a-4b2a-b5d6-855d2183b029
Amoxicillin. (n.d.). Retrieved February 08, 2016, from http://www.antibioticsinfo.org/amoxicillin.html
Clarithromycin. (n.d.). Retrieved February 08, 2016, from http://www.antibioticsinfo.org/clarithromycin.html

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 able to provide assistance to someone
like GG.
Being a dietetics major, I would feel competent in counseling her about her diet. I would
be able to help her chose which foods work for her and which foods do not. Educating
her on the importance of when to eat meals, how much, and which foods, are very
important when dealing with the gastric mucosa of the stomach. I would also help with

nutritional intervention therapy, which helps improve and maintain nutritional quality as
well as helping lessen symptoms of the ulcer.
I would want to refer her to a counselor to help manage her drinking, relationship issues,
stress, and financial concerns. There are a few centers nearby that would work for GG
such as the student-counseling center at Miami University and the Community
Counseling and Crisis Center in Oxford, Ohio.
19. What is the significance of dark stools?
A stomach/intestinal bleed can be the cause of black stool. Black color is an indication
that he bleeding is caused from higher up in the intestine or in the stomach itself (an
ulcer). Since GGs stool was black and she was experiencing bleeding, it solidifies the
fact that she has a stomach ulcer.
Cited: Black stool(diarrhea). (n.d.). Retrieved February 08, 2016, from
http://www.drugs.com/forum/need-talk/black-stool-diarrhea-50988.html
20. Give the pathophysiology for the cause of the following abnormal values: BUN,
NH3, and WBC.
A high BUN value, such as GGs, suggests impaired kidney function. This may be due to
chronic kidney disease, or to a condition that results in decreased blood flow to the
kidneys such as heart failure, shock, stress, dehydration, or severe burns. GGs high BUN
value most likely was contributed to her stress level and dehydration. An abnormal NH3
value is indicative of liver failure, GI bleeding (usually in the upper GI tract such as the
stomach, severe muscle exertion, or heart failure. This abnormal value would show GGs
bleeding and possible liver damage from the binge drinking. A high WBC count may be
due to certain drugs or medications, smoking, infections, or severe mental or physical
stress. GGs high WBC count may be due to her smoking and her high level of stress
Cited: Blood Urea Nitrogen. (n.d.). Retrieved February 08, 2016, from
https://labtestsonline.org/understanding/analytes/bun/tab/test/

Ammonia blood test: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved February 08,
2016, from https://www.nlm.nih.gov/medlineplus/ency/article/003506.htm
WBC count: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved February 08, 2016,
from https://www.nlm.nih.gov/medlineplus/ency/article/003643.htm

21. GG was probably dehydrated on admission since she has been drinking. This
means that some of her lab values were probably higher/lower (circle one) than
indicated.
HIGHER. When someone is dehydrated, there are more concentrated amounts of
electrolytes and other substances in the blood. These concentrated levels help try and pull
water in the blood.
Cited: Dehydration: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved February 08,
2016, from https://www.nlm.nih.gov/medlineplus/ency/article/000982.htm
22. After admission GG received packed cells and IV fluids. How would that affect
the next set of lab values?
For GGs next set of lab values, she will not be dehydrated. As she starts to receive more
fluids, her lab values should start to return to normal. Her Hgb and Hct levels were very
low upon her admission to the hospital, due to bleeding. The addition of the packed cells
should help her numbers rise to a normal range.
23. Define the following terms:

Packed cells- red blood cells that have been collected, processed, and stored in

bags as blood product units available for blood transfusion

Abdominal tap- a test done in order to remove fluid from the area between the

stomach wall and the spine

Perforated ulcer- a condition where an untreated ulcer can burn through the wall
of the stomach (or other areas of the GI tract), 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

Exploratory Laparotomy- a surgical operation where the abdomen is opened

and the abdominal organs examined for injury or disease

Billroth I- a surgery in which the pylorus is removed and the proximal stomach is

anastomosed directly to the duodenum

Vagotomy- severing of the vagus nerve; often a component of gastric surgery
Cited: Blood Products. (n.d.). Retrieved February 08, 2016, from
http://library.med.utah.edu/WebPath/TUTORIAL/BLDBANK/BBPROD.html

Peptic ulcer: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved February 08, 2016,
from https://www.nlm.nih.gov/medlineplus/ency/article/000206.htm
Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal Tract.
In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston, MA:
Cengage Learning.
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, or gastroduodenostomy, a partial gastrectomy is performed
with a reconstruction that consists of an anastomosis of the proximal end of the

duodenum to the distal end of the stomach. In a Billroth II procedure, or

gastrojejunostomy, a partial gastrectomy is performed with a reconstruction that consists
of an anastomosis of the proximal end of the jejunum to the distal end of the stomach.
The nutritional risks due to these surgeries is caused by reduced capacity of the stomach
and potential changes in gastric emptying and transit time when the normal pathway for
digestion and absorption is interrupted. Vitamin and mineral deficiencies are common so
taking a supplement should help keep them in a normal range. Calcium and vitamin D
supplements are also usually prescribed to patients as well (Nelms 368).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal
Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston,
MA: Cengage Learning.
26. Calculate GGs energy and protein needs.
BMR = 655.1 + (9.563 x weight in kg) + (1.850 x height in cm) (4.676 x age)
655.1 + (9.563 x 44.5 kg) + (1.850 x 157.5 cm) (4.676 x 27) = 1250 kcal
1250 kcal x 1.6 stress factor = 2000 kcal
GGs total energy needs remain the same, however she may not be able to obtain that
amount of calories at first. As she slowly starts to add nutritious foods back into her diet,
her goal should be 2000 kcal.
1.5 g protein/kg/day (1.5 g protein)(44.5 kg) = 66.7 g protein/day
27. List the principles of a post-gastrectomy diet and briefly describe the scientific
basis for each principle.
A post-gastrectomy diet includes a well-balanced diet slightly higher in protein and fat
than what is recommended by the US Dietary Guidelines. Simple sugars (including clear
liquids) should be avoided in order to prevent hyperosmolality and hypoglycemia
associated with dumping syndrome. Lactose is often not tolerated. If the patient is lactose
intolerant, commercial products that provide lactase or are lactose-free can be
recommended. This is an additional reason to recommend calcium and vitamin D

supplements. Liquids should be consumed between meals to prevent their contribution to

dumping syndrome because they facilitate quick movement through the small intestine.
The patient is also encouraged to consume five to six small meals throughout the day and,
if necessary, lie down after meals. Advancing to solid foods should progress slowly
(Nelms 369).
Cited: Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper Gastrointestinal
Tract. In Nutrition Therapy and Pathophysiology (Third ed., pp. 344-377). Boston,
MA: Cengage Learning.
28. Is it possible that GGs diet will ever change or do you believe she will be on a
post-gastrectomy diet for the rest of her life? Explain your answer.
Since the surgery was a permanent fix, GG will have to be on the post-gastrectomy diet
for the rest of her life. As she heals from the surgery, she may be able to tolerate simple
sugars and dairy products more, but that is dependent on what her body can handle and
what it cannot. She will have to start off with liquid foods and then slowly start to
progress to solids, but the guidelines for the post-gastrectomy should be followed in order
to help aid in recovery and reduce the risk for dumping syndrome.
29. If GG were to be hospitalized for an extended period of time and require a tube
feeding via duodenum or jejunum, what characteristics would be appropriate or the
tube feeding you would use?
Characteristics for tube feedings that GG would use should be close to what her needs are
orally. Pivot 1.5 and Crucial are two supplements that I would recommend for GG
because both meet her caloric needs as well as her protein needs. They are also a
hydrolyzed formula with low amounts of carbohydrates.
30. Using the table below, compare several of the enteral nutritional supplements
that would be appropriate for GG.
Product

Producer

Cal/

Non-pro

g/L

Na

mOs

Vol

Free

mL

Crucial

Nestle

1.5

cal/g N

67:1

Pr

CH

94

Fat

134 68

mg

mg

m/

RDA

kg
50.

48

water
490
1000

8
Pivot 1.5

Abbott

1.5

75:1

94

172 51

330

of

water

fibe

mL

r
N/

772

A
475

595

Cited: Pivot 1.5 Cal. (n.d.). Retrieved February 09, 2016, from
http://abbottnutrition.com/brands/products/pivot-1_5-cal

1500

1.8

692

References
Active Ingredients (in each 5 mL teaspoon). (n.d.). Retrieved February
08, 2016, from

http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?
archiveid=99955
ALP. (n.d.). Retrieved February 08, 2016, from
https://labtestsonline.org/understanding/analytes/alp/tab/test/
Ammonia blood test: MedlinePlus Medical Encyclopedia. (n.d.).
Retrieved February 08, 2016, from
https://www.nlm.nih.gov/medlineplus/ency/article/003506.htm
Amoxicillin. (n.d.). Retrieved February 08, 2016, from
http://www.antibiotics-info.org/amoxicillin.html
Black stool(diarrhea). (n.d.). Retrieved February 08, 2016, from
http://www.drugs.com/forum/need-talk/black-stool-diarrhea-50988.html
Blood Products. (n.d.). Retrieved February 08, 2016, from
http://library.med.utah.edu/WebPath/TUTORIAL/BLDBANK/BBPROD.html
Blood Urea Nitrogen. (n.d.). Retrieved February 08, 2016, from
https://labtestsonline.org/understanding/analytes/bun/tab/test/
Bobroff, L. B. (n.d.). Food/Drug and Nutritent/Drug Interactions.
Retrieved from http://edis.ifas.ufl.edu/pdffiles/He/HE77600.pdf
Bode, C. (n.d.). Alcohol's Role In Gastrointestinal Disorders. Retrieved
from http://pubs.niaaa.nih.gov/publications/arh21-1/76.pdf
Clarithromycin. (n.d.). Retrieved February 08, 2016, from
http://www.antibiotics-info.org/clarithromycin.html
Dehydration: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved
February 08, 2016, from
https://www.nlm.nih.gov/medlineplus/ency/article/000982.htm
Drug and Nutrient Reactions. (n.d.). Retrieved from
http://www.healthcentral.com/static/pp/pdf_guides/nutrient.pdf
Gastritis. (n.d.). Retrieved February 08, 2016, from
https://umm.edu/health/medical/altmed/condition/gastritis
Label: NEXIUM- esomeprazole magnesium capsule, delayed release.
(n.d.). Retrieved February 08, 2016, from
http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=9af7a792d38a-4b2a-b5d6-855d2183b029

Marks, J. (2014). What is Sucralfate? Retrieved from

http://www.everydayhealth.com/drugs/sucralfate#avoid
Nelms, M., Sucher, K., & Lacey, K. (2016). Diseases of the Upper
Gastrointestinal Tract. In Nutrition Therapy and Pathophysiology (Third
ed., pp. 344-377). Boston, MA: Cengage Learning.
Pepcid: Uses, Dosage, Side Effects - Drugs.org. (n.d.). Retrieved
February 08, 2016, from http://www.drugs.org/pepcid.html
Peptic ulcer. (n.d.). Retrieved February 08, 2016, from
http://www.mayoclinic.org/diseases-conditions/pepticulcer/basics/tests-diagnosis/con-20028643
Peptic ulcer: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved
February 08, 2016, from
https://www.nlm.nih.gov/medlineplus/ency/article/000206.htm
Pivot1.5Cal.(n.d.).RetrievedFebruary09,2016,from
http://abbottnutrition.com/brands/products/pivot1_5cal
Sucralfate (Oral Route). (n.d.). Retrieved February 08, 2016, from
http://www.mayoclinic.org/drugs-supplements/sucralfate-oralroute/description/drg-20066120
Upper Left Abdominal Pain | MD-Health.com. (n.d.). Retrieved February
08, 2016, from http://www.md-health.com/Upper-Left-AbdominalPain.html
WBC count: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved
February 08, 2016, from
https://www.nlm.nih.gov/medlineplus/ency/article/003643.htm