ACHALASIA WITH ASPIRATION PNEUMONIAClinical Site Case Study PresentationDTC 471 Nutrition Therapy III ExperiencePresented by Thomas BoschApril 7th, 2016

Objectives

Provide an overview of patient profile and historyExplore the disease backgrounds of achalasia and aspiration pneumoniaTrace the patient’s disease progress and treatmentsHighlight the Nutrition Care Process including assessment, diagnosis, intervention, monitoring and evaluationDraw conclusions with a focus on the connections between bulimia and achalasiaExplore the topic for 45-minutes with subsequent opportunity for Q & A

Patient68-year old female, retired nurse, lived with familyrecent 3-week hospital stay for MRSA pneumoniasubsequent 2-month stay in SNFsmoker of 3-4 packs per day, but quit in 1984

Reason for Admissionhigh-spiking fever of 101°Fincreasing dyspnea and hypoxia for past several days

Admission DiagnosesACUTE HYPOXIC RESPIRATORY FAILURE RELATED TO ASPIRATION PNEUMONIAacute-on-chronic diastolic heart failurechronic COPD exacerbationGERDCHRONIC ASPIRATION DUE TO ACHALASIAodontoid fracture

Medical/Client History - GIRoux-en-Y gastric bypass surgery in 2000appendectomy in 2000gastric bypass revision with subtotal gastrectomy in 2003revision of the Roux-en-Y gastric bypass in 2005cholecystectomy

Medical History/Client - GI2 x laparascopic lysis of adhesions to resolve small-bowel obstructionsGERD - significant nightly acid reflux with multiple episodes of small emesis and chokinggastric stent placed in 2013achalasiaendoscopic Heller myotomy with a gastrojejunal stricturoplasty in 2014 to relieve GERD

Medical History/Client - Skeletaltotal right hip replacement (osteoarthritis) in 2012kyphosisfell and fractured right humerus 2014odontoid neck fracture - respiratory, swallowing, balance, and cardiac problems are associated with this type of fracture (dysphagia and aspiration)

Medical/Client History - Pulmonaryearly, heavy smoking significant nightly acid reflux (GERD) with multiple episodes of small emesis and chokingrecurrent admissions for aspiration pneumoniasrecent 3-week hospital stay for the treatment of MRSA pneumonia

Medical/Client History - Nutritionmorbid obesityweight loss of 260 lbs after bypassbulimiachronic malnutrition

Disease Background – AchalasiaPathophysiology

achalasia is a motility disorder in which the peristalsis of the esophagus is absent or weakenedpressure of the lower esophageal sphincter (LES) is elevated and the ability of the LES to relax is impairedoccurrence of one per 100,000 individuals in the United Statesno gender predominance in its occurrence

megaeasophagus / end-stage achalasia

Disease Background – AchalasiaTwo Types

primary achalasia is the more common type and develops due to a loss of ganglion cells (inhibitory neurons) in the myenteric plexus of the lower part of the esophagussecondary achalasia is caused by other diseases such as esophageal cancer, Chagas disease (infectious disease common in South America), and diabetes mellitus

Disease Background – AchalasiaEtiology

viral infections (most significantly varicella zoster virus infections), as well as allergic and autoimmune disorders (most significantly psoriasis and Sjögren's syndrome) sometime precede achalasia onset

Disease Background – AchalasiaTreatments

primary pharmacological approach consists of calcium channel blockers such as nifedipine or nitrates that help relax the smooth muscle tissueBotulinum toxin has also been employed to block acetylcholine, which prolongs the release of nitric oxide and thus the relaxation of the LESthrough pneumatic dilatation, the LES can be mechanically dilatedesophageal myotomy, a surgical procedure that divides the muscle fiber of the LES

Disease Background – AchalasiaSymptoms

dysphagia, vomiting, and substernal pain upon swallowingfoods and fluids collect in the lower esophagus, which loses its muscle tone and becomes stretched/dilated over timetypical symptoms of this process are poor oral intake with subsequent weight loss

Disease Background – AchalasiaNutritional Interventions

texture-modified diets that have increased caloric and protein densityextremely hot, cold or spicy foods should be avoided as to not damage the esophageal mucosasmall, more frequent meals are tolerated bestafter a myotomy or dilatation, patients do well with a texture-modified diet such as the National Dysphagia Diet 3 (NDD-3) “Dysphagia Advanced”

Disease Background – AchalasiaPrognosis

treating achalasia aggressively is to prevent the formation of megaeasophagus/end-stage achalasiaabout 10 – 15 % of patients who have undergone treatment for achalasia have progressive dilation of the esophageal diameterefficacy of both pneumatic dilatation (PD) and Heller myotomy decreases over time and repeat treatment is required by a good proportion of patients after 5 years

Disease Background – Aspiration Pneumonia

these substances become the breeding ground for bacterial infectionsthese bacteria types are often more difficult to treat than those seen in more common types of pneumonia

as achalasia progresses, aspiration of food and saliva into the lungs can cause pneumonia or lung abscessesaspiration pneumonia occurs when food, saliva, liquids, or vomit is breathed into the lungs or airways leading to the lungs

Present Illness and Medical Treatmentadmitted with a diagnosis of acute aspiration pneumonia, acute respiratory failure with hypoxia, COPD, GERD, achalasia, and odontoid fractureput on broad-spectrum antibiotic therapyInitial oxygen requirement of 5l/minuteanemia and chronic malnutrition in combination with repeat aspirations were cited as the greatest challenges to her recovery

Present Illness and Medical TreatmentCT scan revealed diffuse bilateral ground glass disease with significant dilation of the esophaguspatient had newly diagnosed MAC (mycobacterium avium complex) Patient had been offered placement of a G-tube or J-tube during her most recent 3-week hospital visit, but had declined that option

Present Illness and Medical Treatmentplacement of a feeding jejunostomy tube was discussed, since the pouch from the gastric bypass surgery was not suitable to a PEG tube placement or open G-tube placementpatient had short gut syndrome contributing to malnutritiontolerance of esophageal stenting or feeding tube placement was not optimisticdecided against the placement of a J-tube, since she would also continue aspirating on saliva

Present Illness and Medical Treatmentpatient declined mechanical ventilation and rejected any interventions except for comfort care medspatient passed away during the night from March 2nd to the 3rd after a 9-day hospital stay

Nutrition Care Process – Anthropometric Measurements

Height: 4 feet 11 inches (59 inches or 150 cm)Weight: 56.2 kg (124 lbs)IBW: 49 kg (107 lbs)BMI: 25% IBW: 115%4-year average weight/UBW: 59 kg (130 lbs)% UBW: 95%

Nutrition Care Process – Food/Nutrition-Related History

Poor oral intake/appetite for yearsPO 50% at mealtimeshad lost 6.8 kg (15 lbs) in 2 months d/t poor food quality at SNF and not having dentureswas taking multivitamin, calcium and vitamin D supplements dailyput on a regular diet with soft solids d/t no denturespatient had declined additional supplements/snacks

Nutrition Care Process – Food/Nutrition-Related History

Estimated energy needs: 1125-1405 kcal (20-25 kcal/kg CBW) Protein needs: 60-69 g (1.4-1.6 g/kg IBW)Fluid needs: 1405-1680 ml (25-30 ml/kg CBW)patient was increasingly aspiratingonly 5% of PO actually got digestedpatient was put on NPO SLP added that the patient had a history of bulimia

Nutrition Care Process – Biochemical Databiochemical lab findings were rather unremarkablecalcium levels were slightly reduced most likely d/t current and long-term antibiotic treatmentsBUN slightly elevated possibly d/t dehydrationelevated glucose value on 2/25 possibly d/t prednisone regimen (no T2DM)

Nutrition Care Process – Nutrition-Related Physical Findings

poor oral intake & chronic poor appetite for years15 lbs weight loss (10.9%) in two months at SNFno access to denturesPO intakes of 50% at mealtimes ate very slowlysevere, protein calorie malnutrition in the context of chronic illness was identified through nutrition focused physical examnutrition risk was high due to prolonged poor appetite prior to admit, acute, involuntary weight loss, and malnutrition

Nutrition Diagnoses1. Inadequate protein-energy intake related to

altered GI function as evidenced by PO intakes of less than 50% of energy needs for over a month and a 10.9% weight loss over the preceding two months

2. Acute disease or injury related malnutrition related to altered GI function as evidenced by PO intakes of 0-50% and frequent aspirations due to food not clearing the esophagus

3. Inadequate oral intake and malnutrition related to altered GI function as evidenced by necessity of NPO due to frequent aspirations from stagnant food in the esophagus

Nutrition Intervention For Achalasiasmall frequent meals for intake to clear the esophagus and avoid aspirationchewing food well and eating slowlyliquid nutritional supplements in order to make nutrient intake easierspacing meals and achieving relaxation before and during eatingfoods only to be consumed at moderate temperatureselevating the head of the bed for 30-45 minutes after meals and at bedtime to prevent both GERD and aspirations

Nutrition Interventionlarger volumes of liquids with each meal to help propel food more easily into the stomach (except with dysphagia restrictions)PEG and G-J tube feeding

Nutrition Monitoring and Evaluationpatient was monitored for further weight decline, PO intake, any changing lab values and medications, as well as BMsafter the possibility of a PEG/G-J placement had been discussed, RD monitored for implementation of G-J tube nutrition support and made recs for ENdue to high nutrition risk follow-ups were scheduled 3 x within 1-3 days or as consulted

Conclusionachalasia can mimic the food avoidance and vomiting behavior of anorexia nervosa or bulimia nervosa1

a diagnosis of bulimia nervosa can also detract from the discovery and diagnosis of achalasia2

we won’t know in this patient, which condition existed first, but it is possible that the developing achalasia was misinterpreted as an eating disorder3

ConclusionI agree with the following statement by gastric

surgeons at the Mayo Clinic in Arizona: “Ultimately, bariatric surgery is not a cure for

obesity. Nor is it the solution to the epidemic of obesity, given the increasing prevalence of obesity and an insufficient supply of surgeons. Prevention via education and public awareness will be critical

over the next several decades to reverse an epidemic that has been decades in the making.”4

References1) GI Disorders May Signal Underlying Eating Disorders. Eating

Disorders Review.com website. http://eatingdisordersreview.com/nl/nl_edr_23_6_5.html. Accessed March 26, 2016.

2) Teufel M, Lamprecht G, Zipfel S, et al. Vomiting and feeling fat – coincidence of achalasia and bulimia nervosa. Int J Eat Disord. 2009; 42(1): 90-92.

3) Däbritz J, Domagk D, Monninger M, Foell D. Achalasia mistaken as eating disorders: report of two children and review of the literature. Eur J Gastroenterol Hepatol. 2010; 22: 775-778.

4) Madura, J, DiBaise J. Quick fix or long-term cure? Pros and cons of bariatric surgery. F1000 Med Rep. 2012; 4: 19.

Questions?

Thank you!

Contact:Thomas Bosch, Ph.D.541-505-7758thomas@eatwelltoheal.com