Cairo, Justin C.

GIT Disorder

I. General Information of patient

Name of Patient: Px 007 Date of Birth: 11/09/1972 Code: FULL

Attending Physician: Dr. Josie Oyacab Date of Admission: 11/10 Discharged: N/A

II. Medical History

Review and relate relevant clinical history of assigned patient. Present illness and chief complaints

• History of hospitalization: Initially diagnosed with HTN (hypertension) 1 year ago.

• Surgery: s/p R knee arthroplasty 5 years ago
• Allergies: NKA
• Past Illness: Essential HTN—Dx a year ago.
• Physical state of health: GERD; increased indigestion and HTN (hypertension)
• Family History: CAD, Father

• Disease condition GERD (Gastroesophageal Reflux Disease)

▪ Definition and classification
▪ GERD
Gastroesophageal Reflux Disease (GERD) is a condition in which partially-digested food
in the stomach backs up into the esophagus. GERD is a term recognized for commonly
called acid indigestion, heartburn and reflux esophagitis.
Gastroesophageal reflux occurs when the lower esophageal sphincter is weak or relaxed
allowing the stomach contents to flow up into the esophagus.
▪ Etiology
Reduced LES pressure (hypotensive) with a resting pressure of 5mmHg which is
influenced by a 2-cm hiatal hernia. Smoking also contributes to the condition.
▪ Epidemiology
Epidemiological data have shown that the prevalence of symptomatic GERD has been
rising in the Asia Pacific Region. In 2005, the prevalence of GERD in Eastern Asia was
approximately 2.5-4.8% and has increased to 5.2-8.5% by 2010.
A similar gradual rising trend of EE has been noted at St. Luke’s Medical Center – Global
City Institute of Digestive and Liver Diseases (IDLD) since 2010. In most cases, the
grading of severity of Erosive Esophagitis remains mild. Unfortunately, bothersome
symptoms of GERD and the associated morbidities have resulted to a significant loss in
one’s productivity due to work absences and diminished quality of life.
 ▪ Pathophysiology

▪ Clinical Manifestations
▪ Burning Sensation in chest (Heartburn) usually after eating which might
be worse at night
▪ Chest Pain (substernal)
▪ Difficulty in swallowing
▪ Regurgitation of food or sour liquid
▪ Sensation of a lump in your throat
▪ Pharyngeal irritation
▪ Frequent throat clearing
▪ Hoorness
▪ Worsening of asthmatic symptoms
▪ Belching
▪ Esophageal spasm
▪ Prognosis
Most patients with GERD do well with medications, although a relapse after cessation of
medical therapy is common and indicates the need for long-term maintenance therapy.
Identifying the subgroup of patients who may develop the most serious complications of
GERD and treating them aggressively is important. Surgery at an early stage is most
likely indicated in these patients. After a laparoscopic Nissen fundoplication, symptoms
resolve in approximately 92% of patients.
III. Socio-economic history
 • Composition of the family: Married—lives with wife and 2 sons
• Educational background: BA
• Type of residence: None
• Occupation Retail manager of local department store
• Lifestyle
 Smoking: None
 Drinking: Yes; 1–2 beers 3–4 times/week
 Exercise: Occasional
• Religion: Seventh Day Adventist
• House of work: M–F, works consistently in evenings and on weekends as well
• Cultural influences and others: None

IV. Assessment of Nutritional status

Anthropometry
Usual Body Weight: 180 lbs. (82 kg)
Weight Gain: 35 lbs since knee surgery (5 yrs. ago)
Height: 5’9” (175.26 cm)
Desirable Body Weight: [Tanhausser] (175.26 – 100) – 7.526 = 68 kg
Admitted Weight: 215 lbs. (98 kg)
BMI: 98/1.75262 = 31.91 kg/m2 [WHO; Obese Class 1]
Biochemical Assessment
Lab. results Ref. Range Results Interpret Indication
Cholesterol (mg/dL) 120 – 199 220 High CVD
LDL (mg/dL) <130 165 High CVD
LDL/HDL ratio <3.22 8.25 High CVD

Clinical Assessment

Normal Range Indications Results Implications/Remarks

Barium Abnormal Endoscopy with GERD
esophagram biopsy to r/o H.
pylori infection

• Dietary assessment
▪ Usual Dietary Intake
Food Amount CHO (g) CHON (g) FAT (g) Energy (kcal)
Fried Chicken 3 pcs - 24 33 393
(Wings)
White Coffee 1 sachet 26 1 - 108
(3n1)
 Banana 2 pcs 20 - - 80
Beef Steak (chuck) 4 mbs - 32 44 524
String beans 1 cup 6 2 10 122
(Guisado)
Magosteen 8 pcs 40 - - 160
Rice 8 cups 184 16 - 800
Orange Juice 1 cup 30 - - 120
Fish Escabeche 2 slices - 32 4 164
(Tilapia)
Ubod Guisado 1 cup 6 2 10 122
Orange kiat-kiat 6 pcs 20 - - 80
Lemon Juice 1 cup 20 - - 80
French Fries 1 ½ cup 48.5 - 20 400
Ice Cream 1 ½ cup 69 12 30 594
Strawberry
Popcorn 2 cups 28 - 5 166
(sweetened)
Total 497.5 119 156 3853
TER 375 100 90 2700
Adequacy 132.67% 119% 173.33% 142.70%
Interpretati Over Over adequate Over adequate Over adequate
on adequate
TER: Harris-Benedict
BEE = 66.47 + 13.75 (98) + 5 (175) – 4.67 (48)
= 66.47 + 1347.5 + 875 – 224.16
= 2064.81 x 1.3
= 2684.25 ≈ 2700 kcal

CHO: 2700 x .55/4 = 371.25 ≈ 370 g

CHON: 2700 x .15/4 = 101.25 ≈ 100g
FAT: 2700 x .30/9 = 90 g 2700 – 375 – 100 – 90

 24-hour Food Recall

FOOD AMOUNT CHO CHON FAT KCAL
Cornflakes 2 cups 92 8 - 400
Milk low-fat (goat) 1 cup 12 8 5 125
Orange Juice 3 cups 90 - - 360
12oz Coca-Cola 3 cans 15 - - 100
Chocolate Cake 2 slices 46 4 10 290
Chocolate Chip Cookie 9 pcs 69 6 22.5 504
Roasted Peanuts w/ 2 cups 30 40 137.5 935
skin
Beer regular 2 bottles - - 35 280
 Fried Chicken 3 pcs - 24 18 258
(drumstick)
Rice 5 ½ cup 253 22 - 1100
Beef Nilaga (plate) 3 mbs - 24 30 366
Fried Fish (karpa) 1 pc - 8 6 86
Toge Guisado 1 cup 6 2 10 122
Litchi 8 pcs 20 - - 80
Pinakbet 1 cup 6 2 10 122
Coconut Water 1 cup 10 - - 40
Ice Cream Mango 2 cups 92 16 40 792
Milk, skim 1 cup 12 8 - 80
TOTAL 753 172 324 6040
TER 375 100 90 2700
Adequacy 200.8% 172% 360% 223.70%
Interpretatio Over Over Over Over
n adequate adequate adequate adequate

• Drug-Nutrient Interaction of possible administration effect

Table 1. Relevant drug and nutrient interaction/Food and Drug Interaction
Name of Drug Indication Possible Interaction Management Strategy
Atenolol Lowers high blood pressure Dolesetron, fingolimod, apple Take medication by mouth
(hypertension), prevent stroke juice and orange juice with or without food. Limit
and heart attacks. salt intake and other
preventatives for
hypertension.
Aspirin Reduces the risk of stroke and Mifepristone, acetazolamide, Medication by mouth, do
heart attack "blood thinners" (such as not lie down for at least 10
warfarin, heparin), corticosteroids minutes after taken the
(such as prednisone), drug.
dichlorphenamide, methotrexate,
valproic acid, herbal medications
(such as ginkgo biloba).
Ibuprofen
Omeprazole Treats esophagus problems Cilostazol, clopidogrel, Medication by mouth as
(acid reflux) methotrexate (especially high- directed, usually once daily
dose treatment), rifampin, St before a meal. The dosage
John's wort. and length of treatment are
based on your medical
condition and response to
treatment.

V. Nutrition Diagnosis (PES)

 • Increased indigestion and possible heartburn related to GERD as evidence by gathered
assessment information.
• Insufficient knowledge related to religious dietary restrictions as evidenced by usual
food intake and food recall and poor lifestyle choices occasional drinking 3-4 times/week.
• Unintended weight gain and excessive calorie intake related to obesity class 1 as
evidenced by elevated adequacy level of macronutrients and micronutrients.

VI. Nutrition Care Plan/Intervention

Table 2. Identification of nutrition and other related problems
Parameters Nutrition Related Problems Other Related Problems
Anthropometry Unintended Wt. gain Obesity Class 1
Calculated BMI Overnutrition
Biochemical High: Cholesterol, LDL, LDL/HDL At risk of CVD
Ratio
Clinical Barium Esophagram; Endoscopy GERD
with biopsy to r/o H. pylori
infection
Dietary Over Adequate Level of Nutrient Overnutrition, Obesity
and Calorie Intake
Drug-Nutrient Interaction ---- ----
Others Stress Eating and Drinking Overnutrition, Obesity

Table 4. Identification of Goals and Expected Outcomes

Nutrition Related Problem Goals Expected Outcome

Indigestion Can appropriately digest Satisfied while eating foods.

food normally
Overnutrition; Obesity decreased food consumption Few months of appropriate regular diet,
in slow progression he can return to normal weight.
Unintended weight gain Slowly returning to normal Return normal weight with slow
weight for a few weeks of progression of balanced calorie intake
appropriate food
consumption
Alcoholism Decreased or no alcohol Normal complete blood count w/ supplied
intake as recommended for nutrients of the prescribed diet given for
the body the body
Table 5. Recommendation
Management Short Term Rationale Long Term Rationale
Parameter Recommendation Recommendation
Nutrition • Educate Giving  Ensure that the • To address and
deficiency and patient on his awareness to patient’s wife correct
over adequate total energy the patient establish a malnourishment
caloric intake requirement on her daily sufficient and to promote
and show energy needs knowledge and a full and
food models and the understanding as balanced diet
estimating specifics of to why adequate adequate to the
how much he the quantity and appropriate patient’s dietary
should eat, and quality food intake are needs.
taking note of of food she important and
his religion needs to eat why • To address any
related dietary will help her supplementation vitamin and
restrictions. to reach her is needed. mineral
ideal caloric deficiencies.
• Create a meal
intake goals • To encourage
plan with
(given that the patient to
appropriate she can work
macronutrient follow the
with what
quantity and guidelines on
she can eat
distribution according to their own
that the her religious voluntary will.
patient can beliefs and
easily follow. within the
dietary
restrictions).

GERD; increased  Nutrition Alcohol is an  Limit alcohol Until the patient

indigestion education on irritant and intake commits to a
the effects of causes long- total lifestyle
smoking and term and dietary
excessive inflammatio change and
alcohol intake n to the LES applies the
in the GIT and mucosa and learnings from
how it impairs the nutrition
contributes in LES’s ability education,
the gastric acid to contract, there is a
reflux and or close, possibility that
burning which may acid reflux
sensation in cause symptoms will
the chest. regurgitation arise again.
of acid back
 Educate into the
patient about esophagus.
 the risks
involved in
smoking and
alcoholism and
then advise to
slowly lessen
smoking habits
and alcohol
consumption.

Recommended Nutrition Care Plan

1500 – 265 – 30 – 35
Diet Restriction: Oral Feeding; Soft Diet 1500 kcal – 265g –
30g – 35g, 300 mg cholesterol, low oxalate, non-irritant and
acidic foods, low fat, low uric acid, no simple sugar in 3 meals and 2 snacks each meal plan.

Note: Patient is Seventh Day Adventist and dietary restrictions/modifications should be

followed.

CHO CHON FAT KCAL

Diet RX 265 30 35 1500
FOOD EX CHO CHON FAT Kcal B AM L PM D MS
VEG 6 18 6 96 2 2 2

FRUIT 4 40 160 1 1 2

MILK
(Skim)
RICE A 3 69 276 2 1

RICE B 6 138 12 600 2 2 2

Meat 2 16 2 82 1 1
(LF)
FAT 7 35 315 1 2 2 2

Total 265 34 37 1529

Breakfast
 Steamed Broccoli 1 cup
Red apple, no skins ½ pc
Lugaw, thick consistency 3 cups
Salad dressing for broccoli 2 tsp
AM Snack
Buko Pie 1/8 pc 22cm diameter
Lunch
Sauteed Squash 1 cup
Banana, lakatan 1 pc
Lugaw, thick consistency 3 cups
Bangus fish Steak 1 slice
PM Snack
Boiled Sweet Potato Yellow 1 pc
Dinner
Papaya 2 slices
Steamed Carrots 1 cup
Chicken cut stir-fry (70g)
Lugaw, thick consistency 3 cups

VII. Monitoring and Evaluation

Table 6. Nutrition Monitoring and Evaluation

Nutrition Related Problem Parameter Parameter for Success Time Frame for
Measurement
Weight changes Evaluate weight change to Weight gain appropriate 2-3 weeks/18 days
ensure there is not for patient’s age.
additional weight gain
Regularly check BMI in 2-3
days interval for
progression.
Energy intake Monitor patient dietary Achieved normal nutrition 1-2 months/48 days
recall to ensure patient is status with appropriate
reaching her calories diet.
goals, and make sure pt. is
following GERD nutritional
guideline of enhance fiber
consumption.
Indigestion Monitor barium Normal digestion 1-2 weeks/12 days
esophagram for any
positional changes of
reflux in the
gastroesophageal.
VIII. Glossary of medical terms and abbreviations used

BMI Body Mass Index

BEE Basal energy expenditure

GERD Gastroesophageal Reflux disease

GIT Gastrointestinal Tract

HDL High-density Lipoprotein

Kcal Kilocalories

LDL Low-density Lipoprotein

LES Lower Esophageal Sphincter

TER Total Energy Requirement

Total Cholesterol The total amount of cholesterol in your blood;

includes low-density lipoprotein (LDL)
cholesterol and high-density lipoprotein (HDL)
cholesterol.

Px Patient

IX. References
Literature:
Krause’s Food and the Nutrition Care Process 13th Edition (2014), L. K. Mahan, S.Escott-
Stump, J.L.Raymond, Elsevier Inc.

Medical Nutrition Therapy A Case Study Approach 4th Edition (2014) ,M.N. Nelms, S.L.
Roth, Cengage Learning

Nutrition and Diagnosis-Related Care 7th Edition (2012), Sylvia Escott-Stump, Lippincott
Williams & Wilkins
Medical Nutrition Therapy for Filipinos 6th Edition (2011), A.Jamorabo-Ruiz, V.S.Caludio,
E.E. de Castro, Merriam and Webster Bookstore Inc.

Food Exchange Lists for Meal Planning, DOST FNRI Publication No. 57-ND8(3) 3rd
Revision (1994), Reprinted May 2012

Online Resources:
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Chen CL, Robert JJ, Orr WC. Sleep symptoms and gastroesophageal reflux. J Clin Gastroenterol.
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DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal
reflux disease. Am J Gastroenterol. 2005 Jan. 100(1):190-200.

Dial MS. Proton pump inhibitor use and enteric infections. Am J Gastroenterol. 2009 Mar. 104
Suppl 2: S10-6.

Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut. 2009
Feb. 58(2):295-309.

Fass R. Proton pump inhibitor failure--what are the therapeutic options? Am J Gastroenterol.
2009 Mar. 104 Suppl 2: S33-8.

Gallup Organization. Heartburn Across America: A Gallup Organization National Survey.

Princeton, NJ: Gallup Organization; 1988.

Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V. Management strategy for
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Heidelbaugh JJ, Goldberg KL, Inadomi JM. Overutilization of proton pump inhibitors: a review of
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Richter JE. Surgery for reflux disease: reflections of a gastroenterologist. N Engl J Med. 1992 Mar
19. 326(12):825-7.

Answer the following:

a. How is acid produced and controlled within the gastrointestinal tract?

Acid is produced in the stomach where the gastric glands are located. The hydrochloric
acid is secreted from the parietal cells within the gastric gland. The hydrochloric acid
activates the pepsinogen, kills microorganisms, and denaturizes proteins. It is produced
and secreted during the first phase, called cephalic phase where the HCL and
pepsinogen are released when stimulated by tasting, smelling, or even seeing food.
b. What role does lower esophageal sphincter (LES) pressure play in the etiology of
gastroesophageal reflux disease? What factors affect LES pressure?
Normally, the atmospheric pressure is greater in the esophagus than in the stomach, and
this prevents reflux of gastric contents. The LES stops serves as a barrier between the
esophagus and the stomach. The etiology of reflux is affected by many factors including
physical and lifestyle factors. Things that lower LES pressure include increased
hormones, other bodily conditions like a hernia, cigarette smoking, medications, and
foods high in fat among others.
c. What are the complications of gastroesophageal reflux disease?
Complications of untreated or unresponsive GERD may include impaired swallowing,
aspiration of gastric contents into the lungs, ulceration, and perforation or stricture of
the esophagus. Barrett’s Esophagus or Barrett’s metaplasia, has the cells change in the
esophagus going from normal squamous cell epithelium to metaplastic columnar cell
epithelium.
d. The physician biopsied for H. pylori. What is this?
H. pylori or heliocobacter pylori is the bacteria responsible for most ulcers and stomach
inflammation. It can weaken the protective coating of the stomach. Many of the
symptoms of carrying H. pylori are similar to GERD.
e. Identify the patient’s signs and symptoms that could suggest the diagnosis of
gastroesophageal reflux disease.
The patient has severe indigestion, and was afraid he was having a heart attack or
having some heartburn.
f. Describe the diagnostic tests performed for this patient.
Empe Rador was admitted to the hospital and an intraesophageal pH monitoring and
barium esophagram support a diagnosis of gastroesophageal reflux disease. pH
monitoring is placing a capsule that has an acid sensing probe, battery and a transmitter
inside. The probe monitors the acid in the esophagus and transmits the information to a
recorder that is worn by the patient on a belt. The capsule transmits for two days and
then the battery dies. Within a week, the capsule is passed in the stool. Information is
taken and put into the computer to figure out the pH.
g. What risk factors does the patient present with that might contribute to his diagnosis? (Be
sure to consider lifestyle, medical, and nutritional factors.)
Empe Rador is considered obese due to his high BMI. He has a very low activity rate due
to his past knee surgery and now his shoulder injury. He does not smoke but does take
many different pills each day such as atenolol, aspirin, and ibuprofen. His 24-hour
dietary recall contains many foods that are very high in fat such as fried chicken, potato
salad, French fries, and ice cream. He also has alcohol 3-4 times a week, which can
decrease LES pressure as well leading to GERD.
h. The MD has decreased the patient’s dose of daily aspirin and recommended
discontinuing his ibuprofen. Why? How do aspirin and NSAIDs affect gastroesophageal
disease?
Certain medications can control the gastric secretions certain ways, while others can
interfere with control of gastric secretions by blocking several of those control pathways.
Ibuprofen and aspirin can block these pathways. These drugs can provide short-term
relief, but over-the-counter drugs should not be used more than a few weeks at a time,
not every day. Aspirin and ibuprofen can weaken the LES causing GERD to become
more prevalent.
i. The MD has prescribed omeprazole. What class of medication is this? What is the basic
mechanism of the drug? What other drugs are available in this class? What other groups
of medications are used to treat GERD?
 Lansoprazole is a proton pump inhibitor that works by suppressing the molecules that
release the stomach acid. They block the H+, K+-ATPase ezyme, a component in HCL
production. Other proton pump inhibitors include omeprazole, pantoprazole,
rabeprazole, and esomeprazole which are all only available by prescription only. Over-
the-counter strength Prilosec is also available. Other groups of medications that are
used to treat GERD include antacids, foaming agents, H2antagonists, and prokinetics.
j. Summarize the current recommendations for nutrition therapy for GERD.
The current recommendations for nutrition therapy include avoiding black and red
pepper, coffee, and alcohol as well as reducing the amount of food eaten at each meal.
Avoiding foods such as chocolate, mint, and high fat foods is also recommended.
Increasing calcium and iron may help as well. Reducing the number of carbonated
beverages may also help.

X. Realizations: How did the case study relate to your chosen field of endeavour?

It stimulates our minds in assessing the patient’s nutritional status and health through practical
cases that enriches our opinions and logic behind the arguments. This will give us an understanding
on how to educate the patient with right eating habits as well as planning the food to meet their
nutritional programs and supervise the preparation and serving of meals.