1. Case Study
GI Tract: Hiatus Hernia, GERD and Obesity
Fall 2016
Assignment 2
Due date: Sep 26, 2016
Yeyan Jin
CSUID:829840439
FSHN 450
I pledge on my honor that I have not given or received any unauthorized assistance on this
assignment

2. Case Study
GI Tract: Hiatus Hernia, GERD and Obesity
Fall 2016
AJ is a 57 yo Caucasian male, admitted from ES with fever and upper R quadrant pain.. US
revealed thickening of gall bladder wall and presence of stones. Hospitalized for removal of gall
bladder. D/C to home. Readmitted 2 days later c/o epigastric pain, poor appetite and nausea and
vomiting. pH study, barium swallow, endoscopy with biopsy for H. Pylori conducted. Diagnosis:
hiatus hernia, GERD, esophagitis and gastric ulcer
Medical History: Hiatus hernia, mild Htn, and arthritis of the spine.
Family History: Mother, 77 yo has COPD. Father, died at age 65 from CHF. 4 living siblings:
brother 53 had PCI last year, brother 40 and sister 46 in apparent good health, sister age 48 is
obese.
Social History: Divorced for past 16 years. 2 adult married children. Currently employed part-
time in human resources. Non-smoker, moderate alcohol consumption (1 Beer/day)
Physical: Ht. 5'7” Wt 190 # BP 128/80 Pulse 90 RR 16 Temp 98.9
Nutrition History:
Patient reports he experiences heartburn frequently, especially when he eats certain foods such as
Big Macs, potato chips or nachos. Reports that he is “taking TUMS constantly”. Takes Advil
regularly to alleviate arthritis pain in back. Received diabetes education after diagnosis of T2DM
but does not do self-blood glucose monitoring. Has made some dietary changes: eats whole grains,
avoids fruit juice and sweets. Drinks diet soda, regular coffee and water. Patient states that he has
been moderately lactose intolerant for over 10 years. Drinks no milk, but eats ice cream and
limited amounts of hard cheese and yoghurt. Last 2 days intake has been limited to clear liquids
due to post-operative status and epigastric pain.
Diet history reveals a typical day consisting of:
Morning:
1 cup oatmeal
½ c yoghurt (sweetened, low-fat, fruit flavor)
1 fruit (banana or peach or apple)
2 - 3 cups black coffee (caffeinated)
Lunch:
3 Tacos (beef with lettuce, tomatoes, hot salsa) or 6”Subway sandwich (variety varies),
Kentucky fried chicken or McDonald’s fried chicken sandwich
12 oz can diet Coke
Snack:
12 oz can diet Coke and about 6 oz potato chips
Dinner:
1 cup salad (mixed greens, tomatoes, carrots, cucumber) with 1 TBSP blue cheese dressing
4-6 oz steak, chicken or fish, usually grilled or broiled (sometimes fried)

3. 1 c. potatoes (french fries or baked with sour cream and butter) or rice with 1 tsp butter
Slice garlic toast (sometimes) otherwise doesn’t have bread with dinner
1 cup ice cream
Evening:
1 bag microwave buttered popcorn
12 oz Beer
Activity: 30 minute walk 4 – 5 times per week, walk replaced with 4-6 hours fly fishing 1 -2
time per week (walks a lot doing this) in season (about 6 months each year), gardening, hunting.
Watches about 6 hours of television each day/evening.
Home Medications: Metformin, TUMS, Zantac, Advil, Lisinopril, Centrum multivitamin
supplement
Hospital Mediations: lansoprazole, metronidazole, tetracycline for 28 days; continue daily
multivit, decrease ibuprofen to 200 mg three times per day with meals.
Admission Laboratory (non-fasted):
Glucose 110 mg/dl
BUN 17 mg/dl
Na+ 137 mEq/L
K+ 4.5 mEq/L
Cl- 98 mEq/L
Bilirubin 1.3 mg/dl
AST 30 U/L
ALT 22 U/L
Alk Phos 156 U/L
CBC:
Hgb 12.7 g/dl
Hct 37.9 %
WBC 11.1 x103
/mm3
RBC 4.8 x106
/mm3
% Lymph 51
1. How is gastric acid secretion controlled and produced (briefly) and how do each of the
anti-GERD anti-acid medications (home and newly prescribed) alter this?
Hormone gastrin stimulates the parietal cell to produce gastric acid. Hormone histamine is used
to inhibit gastric acid production.
Anti-GERD is to inhibit H2 receptors or inhibit H+/k+/ATP enzyme, to reduce production of
gastric acid.

4. Anti-acid medications are aluminum hydroxide. They can make chemical reaction with HCL to
product NCL and water. They increase pH level in the stomach to protect it from too much
gastric acid.
2. Identify the patient’s risk factors for 1) GERD, 2) peptic ulcer disease?
1) He had hiatus hernia which will increase the risk of getting GERD
2) H. pylori infection and removal of gall bladder are the risk factors for getting peptic ulcer
disease.
3. Describe each diagnostic test. What is H. Pylori and why was it measured in the biopsy?
1) GERD diagnosis: Endoscopic Esophagoscopy, Radiographic, pH study
2) Peptic ulcer disease diagnosis: Laboratory tests for H.pylori, endoscopic gastric
duodenoscopy , Xray
4. What is the probable reason for each abnormal laboratory value?
Alk phos higher than normal and Hgb lower than normal can be his liver problems. Gall bladder
has stones.
Hct lower than normal because of surgery.
WBC and %Lymph higher than normal because of his esophagitis
5. Document your nutrition assessment of this patient in ADIME format. Don’t forget to
evaluate BMI and interpretation, Kcal and protein needs and compare to intake.
Document only those medical conditions, lab values, etc which are pertinent to your
nutrition assessment.
See next page
6. List 3 high priority nutrition problems (pick one from each of the intake, behavioral
and clinical domains) and complete PES statements for each. For each of the PES
statements you have written, establish an ideal goal and appropriate intervention and
monitoring/evaluation plan.
See next page

5. 8. Suggest specific modifications to his usual intake. (Table format is appreciated):
Food Eaten Modification Reason
2-3 cups of coffee 1 cup of coffee Reduce risk of GERD
Ice cream No ice cream Reduce risk of obesity
and diabetes
1 cup salad for dinner Breakfast and lunch
also need 1 cup
vegetables
Reduce risk of heart
diesase
9. Provide a recent journal reference (published within the last 5 years) to support one
part of your plan. Provide the reference in acceptable reference format (JAMA or JAND)
and a copy of the abstract.
I would like to let him lower the intake of caffeine. Based on the article below, high intake of
caffeine will decrease basal LES pressure and distal esophageal contraction which will promote
the reflux of gastric contents up into the esophagus. Hiatus Hernia is one of the risk factor for
GERD, he may get GERD in the future.
Lohsiriwat S, Puengna N, Leelakusolvong S. Effect of caffeine on lower esophageal sphincter
pressure in Thai healthy volunteers. Diseases Of The Esophagus [serial online]. 2013;19(3):183-
188.
Abstract
Caffeine affects many aspects of body function including the gastrointestinal system. A single-
blinded experimental study was performed to evaluate the effect of caffeine on lower esophageal
sphincter (LES) and esophageal peristaltic contractions in healthy Thai adults. The volunteers
were six men and six women aged 19–31 years. Subjects drank 100 mL of water. Five wet
swallows were performed 30 min after the drink. The basal LES pressure was continuously
measured using esophageal manometric technique. They then consumed another 100 mL of
water containing caffeine at the dose of 3.5 mg/kg body weight. The swallows and basal LES
pressure monitoring were repeated. The results showed no change in basal LES pressure after a
water drink while caffeine consumption significantly lowered the pressure at 10, 15, 20 and
25 min. The mean amplitude of contractions and peristaltic velocity were decreased at the distal
esophagus at 3 and 8 cm above LES. The mean duration of contraction was decreased at the
distal part but increased at the more proximal esophagus. The heart rate, systolic and diastolic
blood pressures were increased significantly at 10–20 min after caffeine ingestion. This study
indicated that caffeine 3.5 mg/kg affected esophageal function, resulting in a decrease in basal
LES pressure and distal esophageal contraction, which is known to promote the reflux of gastric
contents up into the esophagus.

6. ADIME
Assessment
Patients Value Normal Range Probable reason for variance
Glucose 110 mg/dl Less than 140 mg/dl Normal
BUN 17 mg/dl 7 to 20 mg/dl Normal
Na+ 137 mEq/L 135 to 145 mEq/L Normal
K+ 4.5 mEq/L 3.5 to 5.0 mEq/L Normal
Cl- 98 mEq/L 96 to 106 mEq/L Normal
Bilirubin 1.3 mg/dl 0.3 to 1.9 mg/dl Normal
AST 30 U/L 10 to 34 U/L Normal
Alk Phos 156 U/L 25 to 100 U/L Higher than normal. Caused by
liver problems, gallstones
Hgb 12.7 g/dl 13.5 to 17.5 g/dl Lower than normal. Caused by
liver problems.
Hct 37.9 % 38.8 to 50 % Lower than normal. Caused by
surgery.
WBC 11.1 x103
/mm3
4500 to 11,000 Higher than normal. Caused by
esophagitis
RBC 4.8x106
/mm3
4.7 to 6.1*10^6/mm^3 Normal
% Lymph 51 18 to 44 Higher than normal. Caused by
esophagitis
BMI 86.18/170/170=29.8 25 to 29.9 is overweight. He needs weight control.
BP 128/80 120/80 is ideal blood pressure. He is pre-high pressure.
BMR=66.47+ (13.75 x 86.18) + (5.0 x 170) - (6.75 x 57) =1717 calories/day
Protien needs per day= 86.18*1.4=120 gm/day
He has poor appetite and nausea and vomiting.
Medical: He had hiatus hernia, mild Htn, and arthritis of the spine. And hiatus hernia wasn’t cure.
He didn’t do self-blood glucose monitoring.
Social: Divorced 16 years, all his children are married. Working in human resource. Not much
activities he can do. Activity level is low. Watching TV more than six hours everyday.
Diet: Too much coffee he drinks every morning that my increase risk to get GERD. Not enough
vegetables intake. He has lactose intolerant and diabetes, so he should not eat ice cream.

7. Diagnosis
Behavioral
Low activity level r/t watches tv more than 6 hours everyday AEB overweight and about to be
obesity.
Clinical
Obesity r/t increases risk of hiatus hernia AEB he has hiatus Hernia
Intake
High intake of caffeine r/t lack of knowledge about risk factor GERD AEB GERD
Intervention
Only drink one cup of coffee in the morning, and do 30 mints walking everyday after dinner
instead of watching TV.
Mornitoring/Evaluation
Have a 3 day’s food intake recall, I want to see if he changes his food intake. And measure his
weight weekly.
The expected outcome is he start weight losing.