NUTRITION CARE IN PATIENT ESOPHAGEAL CARCINOMA WITH RYLE'S TUBE FEEDING

NUTRITIONAL MANAGEMENT OF
ESOPHAGEAL CARCINOMA WITH RYLE’S
TUBE FEEDING
PRESENTED BY:
NUR FARAHIN SAADON
138524
GROUP A3
SUPERVISED BY:
MRS. MONALIZA AJID
COURSE COORDINATOR:
MADAM JULIANA SHAMSUDIN

CONTENT
INTRODUCTION
 DEFINITION
 TYPE
 RISK FACTORS
 CLINICAL PRESENTATIONS
NUTRITION CARE PROCESS DOCUMENTATION
 NUTRTION ASSESSMENT
 NUTRITION DIAGNOSIS
 NUTRITION INTERVENTION
 NUTRITION MONITORING & EVALUATION
CONCLUSION
DISCUSSION

DEFINITION
• Cancer cells that develop in esophagus that runs from throat to stomach
• Cancer starts at inner layer of esophagus and can spread throughout the layers of esophagus & other
parts of the body (Pichardo, 2020).
• According to American Cancer Society (2020) also, reported the cancer cells grow at anywhere along the
esophagus, starts in inner layer and growing outward through the other layer.

TYPE OF ESOPHAGEAL
CARCINOMA:
• The inner layer lined with squamous cells
which will be called squamous cells
carcinoma
• Most common in the neck region and
upper thoracic oesophagus
Squamous Cell
Carcinoma
Adenocarcinoma
• Cancer starts in gland cells
• Often found in lower of the thoracic
esophagus
• In Barret’s esophagus, gland cells begin
to replace he squamous cells in lower
part – lead to adenocarcinoma

RISK FACTORS OF ESOPHAGEAL CARCINOMA
Age
• Male more likely to have high risk getting
this cancer
Gender
Tobacco & Alcohol
Barrett’s esophagus
• The chance of getting esophageal cancer
increases with age
• Occur when reflux of the stomach acid into the
lower esophagus – damage the line of the
esophagus
• Causes the gland cells to replace the squamous
cells that normally lining the the esophagus
• The longer someone with reflux, will develop
barrett’s esophagus
• This condition will develop to esophageal cancer
• The longer the person use tobacco, the higher the cancer
risk
• Drinking alcohol increases risk of getting squamous cell
carcinoma more than adenocarcinoma.
American Cancer Society (2020)

Dysphagia
• Trouble in
swallowing.
• Gets worst as
opening of
esophagus gets
smaller
Weight loss
• Happen due to
swallowing
difficulties
• Become
decrease their
appetite
Bleeding
• Bleeding into
the esophagus
• Lead to blood
loss
Chest pain
• Discomfort at
mid of the chest
• Usually happen
when swallowing
as food or liquied
reach the tumor
area.
CLINICAL
PRESENTATION:
Muhammad Masab, et al (2020), American Cancer Society (2020)

CLIENT DATA
GENDER • Female
RACE • Malay
AGE • 63 year old
D.O.B • NIL
ADDRESS • Pasir Puteh, Kelantan
OCCUPATION • Housewife
SOCIAL
HISTORY
• Live together with husband and one child
TREATMENT
COARSE
• Under surgical team
MRS M
Date of Admission:
3/11/2020
Reason of Admission:
Due to chemo port insertion
MEDICAL DIAGNOSIS: ESOPHAGEAL CARCINOMA

Patient has started
feeding regime since 3
weeks before admitted
in ward
Patient is diagnosed
with Oesophageal
Cancer since May 2020
CASE REVIEW
In ward, patient is
planning for chemo port
insertion to start
chemotherapy

3 NOVEMBER 2020.
1st visit
10.30AM

NUTRITION
ASSESSMENT
MRS M
Weight and height stated
in clinical chart medical
folder
: ANTHROPOMETRY DATA
DATE
PARAMETER
3/11/2020 INTERPRETATION
WT (KG) 65
Patient’s BMI was normal based on WHO
Guidelines.
HT (CM) 165
BMI (KG/M2) 23.9
Previous weight is 77kg (as stated in medical folder).
Claimed to have weight loss of 12kg since May 2020.
(percentage of weight loss: 16%, significant weight loss)

NUTRITION
ASSESSMENT
: BIOCHEMICAL DATA
DATE
PARAMETER 3/11/2020 NORMAL VALUE
WBC 10.73 3.4-10
RBC 3.74 3.5-5.2
HB 8.8 11.6-15.1
Na 134 135-145
Potassium 4.1 3.5-5.0
Urea 5.5 1.7-8.3
Creatinine 61 70-130
Uric acid 216 150-350
• High level of WBC maybe d/t
inflammation
• Low level of Hb maybe d/t
poor energy intake
• Low level of Na maybe d/t
poor oral intake
• Low level of Creatinine maybe
d/t cancer and poor oral intake

NUTRITION
ASSESSMENT
: CLINICAL DATA
CLINICAL DATA
• no vomiting and diarrhea
• well-tolerated to feeding regime while at home
• c/o having constipation since consuming feeding regime last 3 weeks
• No medication/supplement intake
• LOA
• Able to speak with muffled voice

Allergy to seafood
Patient is on Ryle’s Tube Feeding (almost 3 weeks),
tolerate to diet regime w/o vomiting
Less frequent b/o (twice per week)
NUTRITION
ASSESSMENT
: DIETARY ASSESSMENT
Patient unable to sip water orally at all due to dysphagia

Dietary intake
6 sc Ensure Gold + H2O  300ml, 4hourly (5 times per day)
(1.08kcal/ml)
Enteral Nutrition Intake:
Bolus tube feeding, assist by the caregiver for the
preparation of the enteral product.
EER: ~1350kcal/day
EPI: ~63g/day

Middle socioeconomic status
• live with husband who is pension from government
officer.
Taken care by husband and daughter alternately
• Feeding was prepared by daughter everyday
ENVIRONMENTAL
FUNCTIONAL
• Ambulate in ward with assistance

COMPARATIVE
STANDARD
HARRIS BENEDICT EQN
EER= 655.1 + 9.56(65) +
1.85(165) – 4.68(63)
= 1286.9 X 1.1 X 1.3
= 1840.3 kcal/day
MIFFLIN METHOD
REE = 10(65) +
6.25(165)-5(63) -161
= 1205.25
TEE = 1205.25 X AF X
SF
= For AF (1.1 for
bed rest)
= For SF (1.3 for
mild illness
ambulatory)
= 1723kcal/day
PROTEIN REQUIREMENT
= 1.2g/Kg/day x 65kg
= 78Kg/day
FLUID REQUIREMENT
= (30-40) ml/kg BW
x 65
=1950-2600ml/day
= For AF (1.1 for bed rest)
= For SF (1.3 for mild illness
ambulatory)
Estimated Energy Requirement (EER)=
1800 – 1700 kcal/day
Compare to EI:
~1350kcal/day
Estimated Protein Requirement (EER)=
78kg/day
Compare to EPI:
~ 63g/day

Inadequate enteral nutrition infusion
Inadequate enteral nutrition infusion related to infusion volume not reached the
recommended calorie as evidenced by dietary recall (1350kcal) shown inadequate nutrition
volume compared to measured requirement (1760kcal/day)
NUTRITION DIAGNOSIS
P
E
S
Patient unable to complete the recommended volume of the enteral product
Dietary assessment shown less than estimated energy intake

To achieve minimum energy requirement (1700kcal/day)
NUTRITION
INTERVENTION
SHORT TERM
To maintain bodyweight at normal BMI
LONG TERM
To provide adequate protein intake
To improve quality of life (QoL)

Implementation
Step 1: 6.5 sc Ensure Gold + H2O  300ml
Step 2: 7 sc Ensure Gold + H2O  350ml, 4hourly (5 times per day)
(0.9kcal/ml)
EI: 1575kcal/day (90% of EER)
PI: 61.3g/day
Enteral Nutrition Intake
• Planned with the same enteral product
• Increase calorie by step up feeding if tolerated
• Aspirate 4hourly
• Bed elevation at 30 - 40° during and after 30-60minutes feeding
• Flushing before and after providing the enteral product 20-30cc

Monitor and review on WBC, HB, Na and Cr
MONITORING &
EVALUATION
BIOCHEMICAL
CLINICAL
Monitor and review on b/o and i/o chart
Monitor patient toleration to step up feeding

3 NOVEMBER 2020.
1st Follow Up
9.30AM

NUTRITION
ASSESSMENT
No latest anthropometry
ANTHROPOMETRY DATA:
CLINICAL DATA:
No latest biochemical data available
BIOCHEMICAL DATA:
• Conscious and afebrile
• Vomiting one time with step 2 of diet regime
• Medication: T. pcm 1g TDS
• b/o: 2/52

Patient cannot tolerate to step up feeding prepared
by nurse
Complain of become vomiting if took step 2
Patient request to continue her previous intake (80% ER)
NUTRITION
ASSESSMENT
Patient unable to sip water orally at all due to dysphagia

Inadequate enteral nutrition infusion
Inadequate enteral nutrition infusion related to infusion volume not reached the
recommended calorie as evidenced by dietary recall (1350kcal) shown inadequate nutrition
volume compared to measured requirement (1760kcal/day)
NUTRITION DIAGNOSIS
P
E
S
Patient unable to complete the recommended volume of the enteral product
Dietary assessment shown less than estimated energy intake
Problem does not resolve

NUTRITION
INTERVENTION
(0.9kcal/ml)
• Continue feeding with step 1 feeding as tolerated
• Increase once the patient able to proceed with
other step (after 1-2 times full-feeding)
(1.08kcal/ml)

3 NOVEMBER 2020.
2nd Follow Up
9.00AM

NUTRITION
ASSESSMENT
No latest anthropometry
ANTHROPOMETRY DATA:
CLINICAL DATA:
No latest biochemical data available
BIOCHEMICAL DATA:
• C/O vomiting 2 times (with little amount of blood)
• Planned for chemotherapy 10/11/2020
• BP: 102/67 mmHg
• b/o: 2/52
• Medication: IV Tramal 50mg, IV Pantoprazole 40mg

Patient cannot tolerate to step up feeding
Complain of become vomiting if took step 2
5 sc Ensure Gold + H2O  200ml (11am, 4pm,8pm, 12am)
NUTRITION
ASSESSMENT
Patient still inadequate energy and protein intake

NUTRITION
INTERVENTION
Step 1: 5 sc Ensure Gold + H2O  200ml 4hourly (5-6 times per day)
EI: 1125kcal/day
PI: 43.75g/day
• Continue feeding with previous feeding as tolerated
• KIV to increase feeding until tolerated
EI: 1575kcal/day
PI: 61.3g/day
• Planning to add Hexbio as patient complain of less bowel
movement once she start tube feeding
1
2
3 • Educate on flushing in each feeding before and after by 50cc

MONITORING &
EVALUATION
CLINICAL
Monitor and review on b/o and i/o chart
Monitor patient toleration to step up feeding

Treatment in
esophageal cancer
Strong evidence that recommend
multimodal treatment with
radiation / targeted therapy /
endoscopy / chemotherapy /
chemoradiotherapy(CRT)
followed by surgery called
esophagectomy
• Avoiding the risk factors:
smoking, consumption of alcohol and
reduce the risk to have Barret’s
esophagus
• Campaign introduced by
government ‘Tak Nak Merokok’ to
reduce smoking
Only possible option even higher
level of morbidity
National Cancer Institute , Siti Azrin et al (2016)
Traditionally: Acupunture  help
dysphagia but contradict to
pharmacokinetics ingredients
used during chemotherapy

MANAGEMENT OF
RTF
• Vomiting
• Abdominal distension
• Diarrhea
• High nasogastric
output
• High gastric residual
volume
Assess feeding toleration
• Routinely flushed 20-30ml of water
• Feeding occur every 4-6 hours
• Check on gastric aspirate before
and after
Maintaining Tube feeding patency
• Check on gastric aspirate 4-6 hourly
• Confirmed that tip of tube is is properly
positioned
• Elevate the head of the bed
• Reduce analgesic or sedation meds.
.
Minimizing Risk of Aspiration
MNT Nutrition Support in Critically Ill Adults

MANAGING COMPLICATIONS in RTF
To manage vomiting:
• Reduce sedating medication
• Switch to a low fat formula
• Reduce rate of delivery
• Reduce prokinetic drugs (metoclopramide)
MNT Critically ill Adults, Bodoky, et al, (2009)
To manage constipation:
• Increase fluid intake with 50cc for flushing before and
after feeding.
• Treat with laxatives
• Used fibre-enriched formula
To manage overfeeding:
• Must be cautios on energy contribution from non-
nutritive sources such as IV dextrose solution
• Must be monitored daily

CONCLUSION
• The cancer of esophageal poses major burden in economic towards family,
individuals and country.
• Most of the patients will have difficulties to manage their daily life as their
inabilities limit their routines
• Government should emphasize healthcare development and service to provide with
effectiveness for this type of cancer.
• Management of RTF must be taught correctly to the caregiver regarding frequency
and the amount for every feeding
• Increase calorie intake is not the main goal if patient shows no toleration

REFERENCES
National Cancer Institute (n.d). Esophageal Cancer Trearment. Retrieved from
https://www.cancer.gov/types/esophageal/hp/esophageal-treatment-pdq
Bodoky, G., & Kent-Smith, L. (2009). Basics in clinical nutrition: Complications of enteral nutrition. e-SPEN, the
European e-Journal of Clinical Nutrition and Metabolism, 4(5), e209-e211.
American Cancer Society (2015). What is cancer. Retrieved from https://www.cancer.org/cancer/cancer-basics/what-is-
cancer.html
Muhammad Masab, et al (2020). Esophageal Cancer Clinical Presentation. Retrieved from
https://emedicine.medscape.com/article/277930-clinical#b1
Siti-Azrin, Ab Hamid, Wan Adnan Wan-Nor-Asyikeen, and Bachok Norsa'adah. "Review of the Burden of Esophageal
Cancer in Malaysia." Asian Pacific Journal of Cancer Prevention 17, no. 8 (2016): 3705-3709.
Pichardo, G. (2020). Esophageal Cancer. Retrieved from https://www.webmd.com/cancer/esophageal-cancer#1

NUTRITION CARE IN PATIENT ESOPHAGEAL CARCINOMA WITH RYLE'S TUBE FEEDING

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