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Major Case StudyV. A.Melissa Hughey, Dietetic InternThe University of Southern Mississippi

+Primary Diagnosis: Gastroparesis Etiology

Slow gastric motility Decreased amount or absent interstitial cells of Cajal Increased gastric retention

Occurrence: 36%-40% of unknown origin Increase in number of hospitalizations Men: 0.01% Women: 0.04%

+Primary Diagnosis: Gastroparesis Symptoms

Weight loss Vomiting Abdominal pain

Prognosis Mortality between 4% and 38% Nutrition support Diet restrictions Surgical treatment

+Nutritional Treatment

Low fat diet versus high fat diet Smaller, more frequent meals Liquid diet, mechanical soft diet Nutritional supplements, where appropriate

+ Surgical and Medical Treatment

Gastric stimulation developed by Dr. Thomas Abell at the University of Mississippi Medical Center

First implantation: 1992

+About V. A.

73 year old white female From Semmes, Alabama Homemaker, lives with her husband Admitted to the University of Mississippi Medical Center

from February 11 to February 15 Admitted to have gastric stimulator placed after being

diagnosed with gastroparesis in 2003 Past medical history of GERD with Nissen

fundlipliocation, fibromyalgia, thyroid disease

+Symptoms

Vomiting without nausea “It just comes up.”

40 pound unintentional weight loss over 10 year period Increased difficulty with high fat foods

+Anthropometrics

Weight: 53.5 kg (118 lbs) Height: 63 inches (5’3”) IBW: 54.5 kg (120 lbs) %IBW: 103% BMI of 20.9

*Anthropometric measurements were taken on only one occasion

+MedicationsMedication Justification

Dicyclomine (Bentyl) Bentyl is used to treat irritable bowel syndrome (IBS). It helps to reduce cramping and pain associated with IBS by reducing movement in the muscles of the intestines. Bentyl should be taken before food is consumed. It may cause dry mouth, nausea, and constipation.

Famotidine (Pepcid) Pepcid is used in the treatment of GERD by reducing the amount of acid in the stomach. By reducing the amount of acid available in the stomach to flow back into the esophagus, Pepcid allows the esophagus time to heal. Pepcid may cause constipation or diarrhea in some instances.

Insulin (Humulin R, Novolin R) Humulin R, Novolin R is a type of synthetic injectable insulin that is used in the treatment of diabetes. It helps to reduce high blood sugar by allowing insulin to enter the cells. Insulin should be taken in relation to the amount of food consumed. Insulin may cause an increase in weight.

+MedicationsMedication Justification

Pantoprazole (Protonix) Protonix is used in the treatment of acid reflux. It works to decrease the amount of acid in the stomach that is available to flow back into the esophagus. It helps to prevent further erosion to the esophagus and stomach.

Ondansetron (Zofran)Zofran is used to treat nausea and vomiting after surgical procedures by blocking the release of serotonin in the body. Zofran may cause dry mouth, abdominal pain, and diarrhea.

Promethazine (Phenergan) Phenergan is used in the prevention and treatment of nausea and vomiting following surgical procedures and narcotic pain use. Phenergan may also be used to calm patients prior to a surgical procedure. Phenergan may cause dry mouth and nausea. Alcohol should be avoided while taking Phenergan.

+LabsLab Value ExplanationGlucose: 122 (H), 117 (H), 113 (H) Glucose is monitored to determine the levels of

blood sugar in the body. High blood sugar (hyperglycemia) and low blood sugar (hypoglycemia) can both cause patient discomfort, organ damage, and death. Although her gastroparesis is of the idiopathic nature, V. A. had high blood glucose levels before and after her surgery.

BUN: 5.0 (L), 6.0 (L) Blood urea nitrogen (BUN) is tested as part of a basic metabolic panel in acutely ill patients to determine kidney function. V. A. most likely had a lower than normal BUN due to malnutrition related to her weight loss from years of gastroparesis. Because V. A. has previously been unable to keep food down, she has not been able to absorb proper nutrients, leading to malnutrition.

Calcium: 8.4 (L), 8.5 (L) Calcium in the blood is usually ordered as part of a basic metabolic panel in acutely ill patients during hospitalization. The test will determine if the patient has too much or too little calcium in the blood. V. A.’s lower calcium value may be related to her lower than normal albumin level. Her thyroid disease or her inability to consume dairy products may also cause a low calcium value.

+LabsLab Value ExplanationAlbumin: 2.9 (L) Albumin is measured to determine a patient’s

nutritional status or disease progression. Low albumin levels, such as those seen in V. A.’s case, can indicate malnutrition. Because of V. A.’s inability to digest adequate amounts of food, she is at a greater risk of being malnourished.

Red Blood Cells: 2.46 (L), 2.39 (L), 3.40 (L)

A red blood cell count is ordered when a patient feels weak or has become pale. Red blood cells are responsible for transporting oxygen to muscle tissues. When the number of red blood cells is decreased, a patient may appear fatigued. A low red blood cell count can indicate anemia, for which V. A. was given two units of packed red blood cells. A low red blood cell count may also indicate nutritional insufficiency of vitamin B12, as well.

Hemoglobin: 7.7 (L), 7.4 (L), 10.5 (L)

A hemoglobin test is used in the evaluation of red blood cells. Hemoglobin is involved in oxygen and carbon dioxide transport. A low value may be indicative of anemia or nutritional deficiency of vitamin B12.

Hematocrit: 23.0 (L), 22.4 (L), 31.4 (L)

Hematocrit is a measure of the percentage of red blood cells out of the total number of whole blood cells in the body. A hematocrit test will be ordered to evaluate red blood cell status. A low value may indicate anemia as well as nutritional insufficiency of vitamin B12.

+Labs Trend

+Estimated Energy Needs

1605-1873 kcal (30-35 kcal/kg) 64-80 g protein (1.2-1.5 g/kg) 1600-1900 mL fluid

+Diet

Day 1 (admission): NPO Day 2 (surgery): NPO Day 3: NPO Day 4: Clear liquid/Full liquid Day 5 (discharge): Full liquid

+Patient Encounter

24 hour recall Ice cream (!) Bedside education

+Nutrition Diagnosis

Harmful beliefs/attitudes about food or nutrition-related topics (NB-1.2) related to lack of prior exposure to accurate nutrition-related information about a low-fat diet as evidenced by patient verbalizing avoidance of all fat-containing foods.

+Nutrition Intervention

Nutrition education should be provided to V. A. about the components of a healthy diet

A focus should be placed on how to incorporate low-fat items such as fruits and vegetables into the diet

Since V. A. enjoys dairy products, she should be instructed about how to choose low-fat dairy products

Smaller, more frequent meals may also benefit V. A.

+Nutrition Monitoring and Evaluation V. A.’s weight and diet recall should be monitored to

ensure she is receiving the correct amount of carbohydrate, protein, and fat in her diet. Her fluid intake should also be monitored

The use of a journal between visits would help V. A. track her weight, food and fluid intake, and gastroparesis symptoms

Based on the food recall and gastroparesis symptoms, a correlation between what V. A. eats and when she has gastroparesis symptoms can be made

+V. A.’s Prognosis

Worldwide Anti-Vomiting Electrical Stimulation Study 50% of patients had normal gastric emptying at 1 year

post-op

Good prognosis Low-fat diet Stimulator maintenance

+References

Abell, T. I., Johnson, W. D., Kedar, A., Runnels, J. M., Thompson, J., Weeks, E. S., …& Griswold, M. E. (2011). A double-masked, randomized, placebo-controlled trial of temporary endoscopic mucosal gastric electrical stimulation for gastroparesis. Gastrointestinal endoscopy, 74(3), 496-503.

American Association for Clinical Chemistry. Albumin. (2013). Retrieved from http:// labtestsonline.org/understanding/analytes/albumin/tab/test

American Association for Clinical Chemistry. BUN. (2012). Retrieved from http://labtestsonline.org/understanding/analytes/bun/tab/test

American Association for Clinical Chemistry. Calcium. (2010). Retrieved from http:// labtestsonline.org/understanding/analytes/calcium/tab/test

American Association for Clinical Chemistry. Glucose. (2011a). Retrieved from http:// labtestsonline.org/understanding/analytes/glucose/tab/test

American Association for Clinical Chemistry. Hematocrit. (2012a). Retrieved from http://labtestsonline.org/understanding/analytes/hematocrit/tab/test

+References

American Association for Clinical Chemistry. Hemoglobin. (2012b). Retrieved from http://labtestsonline.org/understanding/ analytes/hemoglobin/tab/test

American Association for Clinical Chemistry. Red Blood Cell Count. (2011b). Retrieved from http://labtestsonline.org/understanding/ analytes/rbc/tab/test

Bielefeldt, K. (2012). Gastroparesis: concepts, controversies, and challenges. Scientifica, 2012. doi: 10.6064/2012/424802.

Buckles, D. C., Forster, J., & McCallum, R. W. (2003). The treatment of gastroparesis in the age of the gastric pacemaker: a review. Medscape general medicine, 5(4)

Centers for Disease Control and Prevention. BMI for Adults. (2011). Retrieved from http://www.cdc.gov/healthyweight /assessing/bmi/adult_bmi/ index.html

Escott-Stump, S. (2012). Nutrition and diagnosis-related care. Lippincott Williams & Wilkins. 7th edition. Keld, R., Kinsey, L., Athwal, V., & Lal, S. (2011). Pathogenesis, investigation and dietary and medical

management of gastroparesis. Journal of human nutrition and dietetics, 24, 421-430. doi: 10.1111/j.1365-277X.2011.01190.x

Tougas, G., Eaker, E. Y., Abell, T. L., Abrahamsson, H., Boivin, M., Chen, J., … & McCallum, R. W. (2000). Assessment of gastric emptying using a low fat meal: establishment of international control values. American journal of gastroenterology, 95(6), 1456-1465.

Wang, Y. R., Fisher, R. S., & Parkman, H. P. (2008). Gastroparesis-related hospitalizations in the United States: trends, characteristics, and outcomes, 1995-2004. American journal of gastroenterology, 103, 313-322. doi: 10.1111/j.1572-0241.2007.01658.x

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Thank you!