Major case study presentation

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Clinical Major Case Study Presentation on Biliopancreatic Diversion with Duodenal Switch Bypass Surgery

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  • Calorie needs based on minimum needs
    Protein based on maximum
  • Bariatric procedures aim to reduce food volume consumed, but there is no effort to assure only healthy food and beverages are consumed.
  • This includes the pre and post-op nutritional counseling and ensuring compliance with vitamin intake to supplement diet.
  • Major case study presentation

    1. 1. Medical and Nutrition Therapy for Malnutrition and Malabsorption Status Post Gastric Bypass Surgery Lauren Wathen, Dietetic Intern University of Maryland, College Park
    2. 2. Objectives • Overview of malnutrition status post biliopancreatic diversion with duodenal switch gastric bypass surgery • Review medical and nutritional complications associated with chronic alcoholic pancreatitis and liver cirrhosis • Understand the medical and nutrition treatment of a patient with all of these medical issues
    3. 3. Gastric Bypass Procedures • More than 1/3 of the U.S. adult population is obese • Surgery has become increasingly common – 1998: 7.0 per 100,000 patients – 2002: 38.6 per 100,000 patients 31.6% increase in 4 years
    4. 4. Biliopancreatic Diversion with Duodenal Switch Mayo Clinic Video
    5. 5. Patient Report - SS • 40 yo Caucasian female • Ht: 162.6 cm • Wt: 48 kg • BMI: 18 • IBW: 54.5 kg • % IBW: 88% • Lives at home alone • Former smoker • History of EHOH abuse and heavy dependence on narcotics for chronic pain • Past Medical History – Gastric bypass performed ten years ago – Chronic alcoholic pancreatitis – Liver cirrhosis – GERD – Anemia – Anxiety disorder – Deep vein thrombosis (DVT) – Chronic abdominal pain – MRSA
    6. 6. Hospital Course • SS presented to the ED requiring PICC line placement for Total Parenteral Nutrition (TPN) secondary to malnutrition and long-standing failure to thrive from liver cirrhosis. • Emaciated with temporal and clavicle wasting • Had flat affect and generalized weakness • Generalized abdominal tenderness and increased bowel sounds • Afebrile with a normal pulse and blood pressure of 98/60. Alert and oriented x3
    7. 7. Hospital Course • Day 1- 3/25/14: Patient admitted from Emergency Room for malnutrition, intractable abdominal pain, nausea with vomiting. Admission lab results showed hyponatremia and hypomagnesemia which may be related to poor intake and nausea with vomiting admission as serum potassium level was normal. Gastroenterology recommended PICC line placement and consultation with nutrition for initiation of TPN after line placement. Diet – No order placed. • Day 2 – 3/26/14: PICC line placement. Diet – Regular; minimal intake. • Day 3 – 3/27/14 – Patient seen by nutrition for initial assessment. TPN dosed by pharmacist and initiated. Diet – Regular; minimal intake.
    8. 8. Hospital Course • Day 4 – 3/28/14: Patient underwent ultrasound guided paracentesis due to ascites. The physician removed 6.8 L of ascetic fluid from peritoneal cavity. Diet – NPO for procedure then Regular; minimal intake. • Day 5, 6 – 3/29/14-3/30/14: Patient continues on TPN. Patient continues to experience chronic abdominal pain that is being treated with IV narcotics. No other complaints currently. Diet – Regular; minimal intake. • Day 7 – 3/31/14: Patient discharged home to continue with home TPN and home health services arranged by case management. Patient’s urine grew MRSA which was deemed to be colonization not infection as per infectious disease consult; they recommended Bactrim-DS x 1 week which was prescribed. SS has remained hemodynamically stable and afebrile. Follow up with primary care provider planned within 3-5 days and follow up with her usual gastroenterologist as instructed.
    9. 9. Nutrition Assessment – Diet History • SS reported poor appetite with limited intake and difficulty breathing prior to admission (PTA) due to symptomatic ascites • Reported some nausea with vomiting • Reported consuming 1-2 three oz. pre-digested whey protein shots per day based on tolerance. Was taking Vita4Life Bariatric MVI and Calcium (4 capsules/day). Reported not taking extra B12. • Denied ever having issues with dumping syndrome but did state she has always had loose stools since the bypass procedure • Food preferences included cottage cheese, yogurt, pudding, and peanut butter crackers
    10. 10. Laboratory Values Lab 3/25 3/26 3/27 3/28 Na 132 L 136 133 L 135 K 4.2 3.5 4.0 4.1 Cl 95 109 H 108 H 107 Creatinine 0.71 L 0.61 L 0.57 L 0.53 L BUN 11 7 5 L 6 L Glucose 97 78 75 90 Ca 10.1 8.1 8.0 7.9 L Mg 1.4 L 1.4 L 1.8 1.7 Phos 3.8 2.9 2.1 L 2.4 Albumin 3.6 2.5 L 2.4 L 2.2 L AST 31 24 24 32 ALT 23 18 19 21 Lactate 2.3 Hemoglobin 10.2 L 9.2 L 9.1 L 9.2 L
    11. 11. In-Patient Medications Medication Dosage Dates Received Benadryl 12.5 mg IV 3/25 Magnesium sulfate 1-2 g in 50-100 mL IV 3/26, 3/28, 3/29 Oxycodone 5-10 mg 3/25-3/31 Potassium chloride 10 mEq in 100 mL IV 3/26, 3/29 Rocephin 1 g 3/25-3/31 Colace 100 mg PRN 3/26-3/31 Lovenox 50 mg BID 3/26-3/31 Drisdol 50, 000 units weekly 3/26-3/31 Lasix 40 mg BID 3/28-3/31 Lactulose solution 10 g q 6 hours PRN 3/26-3/31 Morphine sulfate 2 mg q 4 hours PRN 3/26-3/31
    12. 12. Medication Dosage Dates Received Ocuvite 1 tablet daily 3/26-3/31 Zofran 4 mg q 6 hours PRN 3/26-3/31 Pancrelipase 5000 units TID with meals 3/26-3/31 Protonix 40 mg 3/25-3/31 Phenergan 12.5 mg IV 3/25-3/31 Inderal 10 mg 3/26-3/31 Xifaxan 550 mg 3/26-3/31 Mylicon 80 mg 3/26-3/31 Aldactone 50-100 mg 3/25-3/31 TPN 20-40 mL/hr 3/27-3/31 Vancomycin 750 mg 3/26-3/27 Vitamin B12 500 mcg tablet 3/26-3/31
    13. 13. TPN Orders Date 3/27/14 3/28/14 3/29/14 3/30/14 Protein (grams) 38.4 (0.8 g/kg) 67.2 (1.4 g/kg) 81.6 (1.7 g/kg) 81.6 (1.7 g/kg) Calories 416.5 kcal 792.21 kcal 1, 048.18 kcal 1, 048.18 kcal Lipids (grams) N/A N/A N/A N/A Dextrose (70%) 80 g/L 160 g/L 220 g/L 220 g/L Volume 960 mL (40 mL/hr) 960 mL (40 mL/hr) 960 mL (40 mL/hr) 960 mL (40 mL/hr) % Calorie Needs 29% 55% 73% 73% % Protein Needs 40% 70% 85% 85%
    14. 14. Nutrition Diagnosis • Inadequate oral intake (NI-2.1) related to cirrhosis with ascites, chronic pancreatitis, h/o gastric bypass, and poor PO intake PTA as evidenced by patient complaints of anorexia, nausea with vomiting, and consult for TPN for malnutrition.
    15. 15. Nutrition Prescription Source Kcal Requirements Protein Requirements Fluid Requirements Facility Standards 1440-1920 kcal/day (30-40 kcal/kg/day) 57-96 gm/day (1.2-2 gm/kg/day) 1440-1920 mL/day (30-40 mL/kg/day) EAL N/A N/A N/A Nutrition Care Manual 1362.3 kcal/day (BEE (Mifflin-St. Jeor) x 20%) 38.4-57.6 gm/day (0.8-1.2 g/kg/day) Average healthy adult – 30-35 ml/kg/day* Height Weight BMI IBW % IBW 162.6 cm. (64 in.) 48 kg (106 lbs.) 18 54.5 kg 120 lbs. 88%
    16. 16. Nutrition Intervention • 1. General Healthful Diet (ND-1.1): Recommend continuing current diet with pancrelipase. Pt refused nutritional supplements. Will communicate pt food preferences and add snacks (cottage cheese, yogurt, peanut butter crackers). • 2. Parenteral Nutrition/IV Fluids (2.2): Provide 1080-1440 kcals and 43-72 gm protein to meet 75% of estimated needs. • 3. Collaboration with other providers (RC-1.4): Recommend appetite stimulant. Recommend increasing pancrelipase (2 caps pancrelipase 12,000 units with meals) and providing it with meals (current order is to be given 1 hour before meals). • 4. Referral to other providers (RC-1.5): Patient to follow-up with primary physician or GI specialist as instructed to monitor home IV infusion of TPN.
    17. 17. Nutrition Monitoring and Evaluation Indicator Criteria Total Energy Intake (FH-1.1.1.1) Oral intake >50% of estimated energy and protein needs. Parenteral Nutrition Intake (FH- 1.3.2.1) TPN solution to provide >75% of estimated energy and protein needs. Weight (AD-1.1.2) Weight gain of 0.5-1 lb/week Nutrition-related complementary/alterative medicine use (FH-3.2.1) Patient to continue using daily oral vitamin and mineral supplements due to risk of malabsorption/maldigestion s/p gastric bypass.
    18. 18. Case Discussion • It is evident that the patient understood some aspects of long- term nutritional care necessary since SS reported taking appropriate protein supplements and vitamins PTA. • A detailed diet history would have been very valuable to evaluate just what the patient was consuming and what may be contributing to the malnutrition. • Important to take into account the increased needs as well as being mindful of the possibility of refeeding syndrome with TPN since the patient was malnourished. • The origin of the cirrhosis could be a long-term complication of the BPD surgery, secondary to chronic alcohol abuse and/or a combination of these.
    19. 19. Case Discussion • Chronic abdominal pain also may be secondary to cirrhosis with ascites, pain associated with chronic pancreatitis, and/or generalized low pain tolerance. • Analgesic drugs continue to be a primary means to control chronic abdominal pain related to chronic pancreatitis. • The nausea with vomiting could be worsened by excessive opioid use that the patient required for pain control.
    20. 20. If Only I Had Asked… • How much weight was lost in total since the surgery? • What was the patient actually eating at home? • How long had the alcohol abuse been occurring and what was the extend of it?
    21. 21. Implication of Findings to Dietetics • Dietitians must be able to recognize and distinguish between normal and abnormal nutritional status following bariatric procedures to ensure patients are successful at weight loss while optimizing proper nutritional status. • This case highlights the importance of completing a thorough nutritional assessment to identify all contributing factors related to the patient’s condition.
    22. 22. References • "Bariatric Surgery." 2014. Nutrition Care Manual. Document. 16 May 2014. • Clinic, Mayo. Video: Biliopancreatic diversion with duodenal switch. 2014. http://www.mayoclinic.org/tests-procedures/bariatric- surgery/multimedia/biliopancreatic-diversion/vid-20084649. 16 May 2014. • Ertelt, Troy W., et al. "Alcohol abuse and dependence before and after bariatric surgery: A review of the literature and report of a new data set." Surgery for Obesity and Related Diseases (2008): 647-560. Document. • Flamm, Steven. "Rifaximin treatment for reduction of risk of overt hepatic encephalopathy recurrence." Therapeutic Advances in Gastroenterology (2011): 199-206. • Gachago, Cathia and Peter V Draganov. "Pain management in chronic pancreatitis." World Journal of Gastroenterology (2008): 3137-3148. • MedLinePlus. 14 May 2014. 19 May 14. <http://www.nlm.nih.gov/medlineplus/ency/imagepages/19500.htm>. • Story of Obesity Surgery - Biliopancreatic Diversion and Duodenal Switch. 2014. 16 May 2014. <http://asmbs.org/story-of-obesity-surgery-biliopancreatic- diversion-and-duodenal-switch/>.

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