Theoretical discussion of disease condition
Gastric ulcers are generally caused by a variety of environmental factors, most of which are contributed
by “hostile” factors such as NSAID use, alcohol abuse, and tobacco use, among many others. Smoking
as well as age can increase a person’s risk of developing a perforated gastric ulcer. These factors
increase the risk because they affect the gastric secretion in the gastric mucosa. Recurrence of a
perforation is high in populations over 60 years of age. Additionally, mortality rate due to perforated
gastric ulcers is also increased in these populations. [3]
Alcohol abuse is also strongly correlated with recurrent gastric bleeds from a perforated gastric ulcer.
According to a study, alcohol abuse was identified in “19.7 % of patients with non-variceal upper
gastrointestinal bleeding.” Recurrent bleeds were as high as 16.7% in alcohol abusers versus 9.1% in
those that did not abuse alcohol. Patients with non-variceal upper gastrointestinal bleeding that also
abuse alcohol are at a higher risk of re-bleeding and their risk of mortality is increased. Most patients are
followed by a primary care doctor or gastroenterologist and placed on a long-term proton pump inhibitor to
prevent further peptic ulcers and gastric bleeds. [4] It is also strongly recommended that patients limit
NSAID use, alcohol, and smoking during treatment of Peptic Ulcer Disease.
Usual treatment of Peptic Ulcer Disease and perforated peptic ulcers.
If a patient is found to have gastro-intestinal bleeding or discomfort, either a stool sample is tested or an
exploratory endoscopy is performed. The endoscopy is a more invasive method where samples or
biopsies of the ulceration may be taken to determine the cause is H.pylori. Once the bacteria is found to
be the culprit of the ulcer, antibiotics are administered to eradicate H.pylori from the patient’s digestive
tract. If the ulcer is bleeding, cauterizing and closing the perforation safely is the most immediate concern.
While there are several causes of peptic ulcer disease, oftentimes a person’s risk factors can easily be
decreased by making several lifestyle changes early on in life. Quitting smoking or reducing NSAID and
alcohol consumption are some of the most profound ways to prevent an H.pylori infection. Smoking in
particular has been found to adversely affect the gastric mucosal protective mechanisms, thus
predisposing a person to peptic ulcer disease. Several clinical studies have observed that smokers are
move likely to develop ulcers which subsequently are more difficult to heal if smoking cessation does not
occur.
Other than reducing alcohol consumption, NSAID use or smoking cessation, some patients may be
placed on a proton pump inhibitor or antibiotics. A proton pump inhibitor may be given to a patient to
prevent additional ulcers as well as to prevent an existing ulcer from bleeding again. It works by reducing
the amount of stomach acid produced while the ulcer heals. [5]
Diagnosing whether or not a patient has a peptic ulcer can be determined through various different
diagnostic tools. Some research suggests that gastric ulcers can be found by using a CT scan. Other
diagnoses are found via exploratory endoscopy. The perforation is usually repaired laparoscopically by
cauterizing the crater. Duodenorrhaphy or gastrorrhaphy, suturing of either a duodenal ulcer or gastric
ulcer, has long since replaced the need for gastric resection which used to be a common treatment in
reparation of a perforated peptic ulcer. [6] Due to the seriousness of this illness it is important that the
diagnosis is definitively made and repaired in a timely manner.
Patient’s symptoms upon admission leading to present diagnosis
Some symptoms associated with peptic ulcer disease, or a perforated gastric ulcer can include, but are
not limited to bloody or dark tarry stools, fatigue, vomiting, and weight loss. All of these classic symptoms
were presented in the patient at the time of his visit. FK was admitted with severe malaise and fatigue
with fainting spells at his home. He was found confused and was previously referred to Fort Hamilton
Hospital from the patient’s ENT at UC West Chester. The patient was severely underweight and was
experiencing some slight abdominal discomfort. Most of his perforated ulcer symptoms were hidden by
the fact that he was not eating well due to his mandibular fracture (and possible jaw mass) as well the
mass on the base of his tongue. Additionally, the patient’s history of alcohol abuse also covered up some
of the symptoms he was experiencing such as the weight loss and loss of appetite.
Following the exploratory endoscopy, FK was found to have a severe gastric bleed. Cultures were taken
of the patient’s stool as well as inside the stomach lining, showing that he did have an H.pylori infection.
The etiology of peptic ulcer disease shows overwhelming evidence blaming smoking as highly correlating
with the disease, as explained throughout this case study. In smokers under the age of 75, H.pylori
infection was found to account for about 77% of all gastric perforations. Excessive NSAID use also
accounted for nearly one third of gastric perforations from H.pylori infections. [6]
There are some indications that radiation treatment or exposure to radiation treatment can predispose a
patient to be more susceptible to gastric ulcers. This is usually due to the disruption of fast growing cells
such as the gastric lining and gastric mucosal secretions. FK had approximately 42 radiation treatments in
the past due to tongue cancer. The treatment would have been focused on his neck and upper GI area.
Unfortunately there are not enough studies to show if radiation has lasting effects to possibly indicate it in
being part of the etiology of peptic ulcer disease.
Treatment: Medical (mention any diagnosis tests and state the results obtained.)
Surgical procedures and findings and results
During FK’s first admission, an exploratory colonoscopy as well as an exploratory endoscopy were
performed. During the colonoscopy, the physician found that the patient’s colon was filled with pus from
an infection. Blood was also found in the patient’s stool, indicating that there was an upper GI bleed.
Once the endoscopy was performed, No esophageal varices were found which often occur in those with
liver disease and those with a history of alcohol abuse. Prior to the endoscopy, esophageal varices were
thought to be a possible cause of the bleed. However, the physician did find a bleeding perforation in the
patient’s stomach which was immediately repaired through cauterization. To prevent recurrent bleeding,
FK was placed on a proton pump inhibitor. Proton pump inhibitors work by reducing the acid in the
stomach, therefore allowing a clot to form and stabilize where the perforation was. Proton pump inhibitors
are often used to prevent recurrent bleeds when used in corroboration with antibiotics. Though, this
treatment is most effective if a patient is not taking NSAIDs. In fact, it is strongly recommended that
patients completely discontinue the use of NSAIDs during Peptic Ulcer treatment. However, the only true
way to prevent a recurrent bleed is to completely eradicate H.pylori. [8]
FK was observed after his initial gastric repair and unfortunately, his stool continued to look black and
tarry, indicating that his bleed was still ongoing. An additional repair was made via cauterization and his
proton pump inhibitor dose was increased. Unfortunately, there is not enough research that shows
whether a high dose orally or intravenously is more effective than a lower dose orally or intravenously. [9]
Shortly after FK’s second repair he was admitted to an extended care facility where they could watch his
improvement closely.
Two days after FK was admitted to the extended care facility, he was admitted again with a bleeding ulcer.
The physician indicated that the patient had failed proton pump inhibitors and required additional surgery.
A vagotomy and antrectomy were considered, but due to the patient’s surgical risk being increased due to
his cirrhosis and high blood pressure these procedures were declined. A vagotomy is a surgical operation
where one or more portions of the vans nerve are cut, decreasing a patient’s gastric secretions. This can
be performed in conjunction with an antrectomy, or removal of the distal third of the stomach. These
procedures, particularly a vagotomy can be used in the management of severe peptic ulcer disease,
however with they predate pharmacological use of proton pump inhibitors. A vagotomy sometimes is
indicated if a patient is resistant to proton pump inhibitors such as in FK’s case.[10]
The surgical team decided that his ulcer was to be repaired once again by placing hemoclips on both
sides of his ulcer to stop the bleeding. Though during surgery, the ulcer was found to be reduced in size
and was apparently healing, a vessel was still exposed and required attention. FK was observed for
improvement over another week-long admission after his third surgery. A follow up endoscopy was
scheduled as an outpatient procedure after his discharge to ensure that his gastric perforation was
healing properly. The results of the patient’s follow up endoscopy have yet to be recorded in his chart.
Medical Nutrition Therapy:
FK lives alone and normally purchases and prepares for himself with some assistance from family
members. He often uses a crockpot for cooking soft foods and though he has been told by several
physicians to follow a low sodium diet, he does not follow one at home. FK eats all of his meals at home
and only eats about 2 meals a day. FK has trouble chewing and swallowing due to his broken jaw and
mass on his tongue, so the texture of his food is important. He denied choking on any particular texture of
food but claimed that it was easier to chew and swallow when food was soft and had extra gravy or
sauce.
FK’s diet in the hospital ranged from Soft Dysphagia to Heart Healthy. Tube feed was discussed with the
Gastroenterologist and Nurse Practitioner but was not recommended due to the patient’s recurrent gastric
bleeding. It was also recommended that a Speech Therapist do a swallowing evaluation with the patient,
however the patient was uncooperative during each attempt made. Speech Therapy was unable to
perform any substantial swallow evaluation so he was placed on a Soft Dysphagia diet per his reported
home diet. Sodium restriction was not an important concern during his visit due to a noted loss of muscle
mass and subcutaneous fat.
During the patient’s visit Boost Plus was also sent as supplements during each meal to increase his
calorie intake. FK did not drink any boost at home but drank several Boosts during his admission at the
hospital. In fact, according to nursing staff at Fort Hamilton, the Boost Plus drinks were almost the only
item on his tray that he consistently consumed. Though FK did not consume much, other than the Boost
Plus, he did end up gaining some weight by the end of his second visit.
According to ASPEN guidelines a nutrition screen is to be performed within 24 hours of a patient’s
admission to an acute care setting. FK was referred to nutrition care for assessment with unplanned
weight loss, poor oral intake, and difficulty chewing and swallowing. During the patient’s assessment, it
was noted that he lost approximately 15.5% of his body weight in about one month’s time. His intake was
also severely decreased to less than 50% of his usual intake for about a month or more since he started
having pain in his jaw. This two issues immediately indicated that a physical malnutrition screening was
necessary. [11]
Upon, his physical assessment, FK was found to have severe malnutrition with significant loss of muscle
mass and subcutaneous fat. Due to his protein-calorie malnutrition, his needs were significantly higher
than the average person. As mentioned previously, tube feed was discussed with patient’s
gastroenterologist but was declined due to FK’s recurring gastric bleeds. Therefore, Boost Plus
supplements were given three times a day to increase protein and calories.
According to his 24 hour recall at home, FK is severely lacking in calories and protein as well as several
vitamins and mineral. The patient also drinks more than the recommended amount of alcohol per day
which may also contribute to malabsorption of key vitamins and minerals. According to several studies, a
primary issue with patients that abuse alcohol is megaloblastic anemia. This particular type of anemia is
associated with a deficiency in folate. [12] FK is currently on a vitamin regimen that includes folate.
However, according to the patient’s labs he is still found to be anemic. This could be due to his GI blood
loss as well as his possible alcohol induced folate deficiency. FK would benefit from supplementation of
both folate and iron.
Some nutrition interventions for FK included promoting protein intake, promoting oral intake, and nutrition
supplementation with Boost Plus. The patient seemed receptive to increasing his protein and oral intake
and was willing to drink Boost Plus. However, during each subsequent visit he became increasingly
irritable and unwilling to cooperate. During his second visit, FK refused a physical malnutrition screen and
his body language suggested that he was disinterested in any information or assistance given.
FK was discharged to an extended care facility who would subsequently take care of all of his nutritional
needs. Physical Therapy and Speech Therapy found that the patient was unable to take care of himself
and required assistance. The patient’s daughter assisted him when she was able to at home, however
during his admission she did agree that it was best for FK to be admitted to a facility that would give him
“around the clock” care. The patient would be followed by physicians and dietitians at the facility for
improvement. He also had a scheduled follow-up endoscopy planned for a week or so after his discharge.
