This document provides details about a 40-year-old female patient who presented with malnutrition due to chronic alcoholic pancreatitis, liver cirrhosis, and a history of gastric bypass surgery performed 10 years prior. She was admitted to the hospital for placement of a PICC line and initiation of total parenteral nutrition (TPN) due to failure to thrive. Her hospital course and treatment are described, including monitoring of her nutritional status and prescription of TPN to meet her nutrient needs. The case highlights the importance of thorough nutritional assessment and management of patients with complex medical histories and nutritional complications following bariatric surgery.

1. Medical and Nutrition
Therapy for Malnutrition
and Malabsorption Status
Post Gastric Bypass
Surgery
Lauren Wathen, Dietetic Intern
University of Maryland,
College Park

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. 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. Biliopancreatic Diversion with
Duodenal Switch
Mayo Clinic Video

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

23. 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/>.