ABDOMINAL PAIN WITH EATING

Transcription

1 ABDOMINAL PAIN WITH EATING Major Case Study Rachel Haynes Mar-Apr 2016

2 INTRODUCTION Patient initials: CA Admission date: 3/20/16 Date discharged: 4/20/16 Reason for admission: Nausea, vomiting, and abdominal pain Age: 78 Sex: Female Race: White

3 PAST MEDICAL HISTORY Peripheral artery disease, tobacco use, and hyperlipidemia CA was previously admitted to the hospital during the week prior with metabolic acidosis, AKI, and abdominal pain of unclear etiology. Nausea and vomiting was assumed to be from an antibiotic she was on, but was told to return to the ED if abdominal pain continued.

4 MEDICAL TREATMENT Upon this admission, mesenteric ischemia was begun to be suspected as she had a history of peripheral vascular disease. She was placed on bowel rest with IV fluids and CA also had a history of gallstones, and cholecystitis was also suspected as the cause of pain. However, CA continued to have renal failure, which contraindicated dye studies that would be used to diagnose ischemic colitis.

5 MEDICAL TREATMENT A lot of time was spent waiting for return of renal function so that an arteriogram could be done to diagnose mesenteric ischemia. Bilateral stents were eventually placed in the kidney that helped to reduce creatinine.

6 MESENTERIC ISCHEMIA Ischemia refers to the loss of blood flow to tissues, resulting in lack of oxygen supply. Ex: ischemic stroke, ischemic heart disease, mesenteric ischemia Mesenteric ischemia is a medical condition in which injury of the small intestine occurs due to not enough blood supply. It is a cut-off of blood supply from the mesenteric artery. Generally characterized by post-prandial pain.

7

8 TREATMENT Treatment options may include any of the following: Removal of the occluded artery and reconnecting remaining. Removal of the specific portion of the bowel. Medicines to dissolve clots

9 MEDICAL TESTING CA had several different tests done to locate the cause of abdominal pain including: HIDA scan- gallbladder Esophogastroduodenoscopy- for gastric pain EGD- look inside with light Ateriogram- test for mesenteric ischemia and celiac s

10

11 RESULTS HIDA- no obstruction to the gallbladder Esophogastroduodenoscopy- no gastric cause EGD- only mild candida esophagitis Arteriogram- no GI compromise

12 NUTRITION INVOLVEMENT Once all major causes of abdominal pain were ruled out, it was important to focus on CA s nutritional status. CA received TPN on and off during her stay. CA had an NG tube placed for a couple of days. CA was prescribed a full liquid diet. CA was prescribed six small meals. CA was prescribed an appetite stimulant. CA was encouraged to start by eating a small percentage of her meals.

13 ANTHROPOMETRIC DATA Age: 78 Female Ht: 63 inches Wt: 53.1 kg (admit weight) IBW: 52.3 kg (102%) BMI: 20.4

14 Lab Admission (Day 1) Ref-range Sodium (mmol) Potassium (mmol) 3.5 L Chloride (meq/l) 110 H TCO2 (meq/l) 20 L Glucose (mg/dl) 111 H BUN (mg/dl) Creatinine (mg/dl) 2.1 H T Bili (mg/dl) T Protein (g/dl) 5.4 L Alk Phos (IU/L) AST/ SGOT (u/l) 56 H ALT/ SGPT (u/l) egfr 22 L >/= 60 Calcium (mg/dl) 8 L Albumin (g/l) 3.4 L H/H (g/dl)/ (%) 11 / 32.6 L /

15 ABNORMAL LABS 3/23 3/25 3/28 4/1 4/5 4/7 4/11 4/14 4/18 Na 147 H K+ 3.4 L Gluc 113 H 136 H 129 H 117 H 119 H 252 H 137 H Alb 2.5 L 2.5 L 2.6 L 2.2 L 2.6 L 2.5 L 2.5 L 2.6 L BUN Crea 3.6 H 3.5 H 2.4 H PAB 6 L 5 L 3 L 10 L CRP 9 H

16 Medications used Colace (Docusate Sodium) KCl (Klor-con M20) Tums (Calcium Carbonate) Xanax (Alprazolam) Protonix (Pantoprazole) Heparin Seroquel (Quetiapine) Iron Sucrose Zofran (Ondanestron) Morphine Milk of Magnesia (Magnesium Hydroxide) Mouth Kote Megace Indications for use/ DNI Stool softener; high fiber and fluid diet to prevent constipation. Used to treat hypokalemia; do not take with salt substitutes. Antacid, mineral supplement, phosphate binder. Take separately from large amounts of fiber, oxalate, or phytate foods; Take Fe, Zn, Mg, or F separately by 1-2 hrs. Used to treat anxiety and panic disorder; limit caffeine; caution with grapefruit. Used for GERD; also used as stress ulcer prophylaxis; may decrease absorption of Fe and Vit B12. Blood thinner; used to decrease the blood s ability to clot. Antipsychotic; caution with grapefruit; may increase appetite and weight gain. Supplemented to treat low Iron levels; Vit C may increase absorption; take carbonate antacids separately. For use as an antiemetic or antinauseant Used for pain relief; analgesic, narcotic, opioid; can cause constipation, dry mouth, and weight loss. Laxative, antacid; take with high fiber/ fluid to prevent constipation; Take Fe or Folate supplement separately by at least 2 hrs. Oral moisturizer to ease discomfort of xerostomia. Appetite stimulant, antineoplastic; increases appetite and increases weight.

17 NUTRITION THERAPY 3/23 The initial dietitian assessment was trigged by a low Albumin of 2.4. It was discovered that the patient had had a poor PO intake for the past few weeks due to pain with eating. Due to the unclear cause of abdominal pain, the MD did not want any nutritional supplements ordered. Nutrient needs: kcals (25-30 kcals/kg) g protein ( g/kg) 1593 mls fluid (30 mls/kg) PES statement: Inadeuqate PO intake related to abdominal pain with eating as evidenced by NPO x3 days.

18 NUTRITION THERAPY 3/25 Follow-up nutrition visit. Per MD notes, TPN had been ordered for the patient due to prolonged poor PO intake and possible mesenteric ischemia. TPN recommendations (for pharmacy): Pt specific formula kcals g protein >100 g CHO PES statement: Inadequate energy intake related to possible mesenteric ischemia as evidenced by 0% PO intake and need for PN.

19 NUTRITION THERAPY 3/28 The patient continued to receive TPN, meeting 100% of her nutrient needs until renal function returned for arteriogram to R/O mesenteric ischemia. 42 ml/hr provided: 1410 kcals 1210 NPC 50 g protein 1000 ml/day 250 g CHO/day 36 g fat/day

20 NUTRITION THERAPY 4/1 AND 4/5 CA continued to receive TPN meeting 100% of nutrient needs as she waited to have an anteriogram. CA continued to have 0% PO intake.

21 NUTRITION THERAPY 4/7 After mesenteric ischemia was ruled out, it was decided that it was safe for CA to receive EN, post-pylorically. The following recommendations were made, but recommendations were not made before the MD instead decided to giver her a PO diet. Osmolite 1.2@ 55ml/hr+ 20 ml/hr H2O flush 1584 kcals 73 g protein 1086 mls free water (1566 mls with flushes) CA developed severe AMS and respiratory issues and was instead attempted to be given a PO diet consisting of six small meals and finger-foods, as preferred.

22 NUTRITION THERAPY 4/11 The day previous CA received enteral nutrition through an NG tube providing Osmolite 55 ml/hr. However, the patient had high residuals and aspirated before making it to goal. She was again given a full liquid diet.

23 NUTRITION THERAPY 4/14 Pt began a calorie count, per MD orders. Pt was also started on Megace as an appetite stimulant. If calorie count did not meet needs, Osmolite 55 ml/hr was again recommended through PEG.

24 RESULTS OF CALORIE COUNT Day 1: 803 kcals 32 g protein Meeting 60% of kcals needs Meeting 60% of protein needs Day 2: 350 kcals 13 g protein Meeting 26% of kcal needs Meeting 25% of protein needs Day 3: 0% intake. Most nutrition was provided by nutritional supplements.

25 NUTRITION THERAPY 4/18 The patient reported feeling like she had more of appetite but did not want food placed in front of her. The family was considering a GJ tube to meet needs. The nurse practitioner worked work CA to focus on eating small meals, diving her meals into small portions and have Ensure between meals.

26 DISCHARGE CA had a psych eval ordered and then was discharged on 4/20 to a long-term care facility where she would further be aided in her nutrition progress.

27 QUESTIONS?