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Chapter 17: Esophageal

Cancer with Enteral


Nutrition
Case Study
Dana Shafer
Page 121

Esophageal Cancer
7th leading cause of death
On the rise
Nutritional Challenges:
Oral intake due to obstructions (tumors)
Dysphagia
Malnutrition
Weight loss, cancer cachexia

Higher than pt with other cancer

Stages

Patient
Age: 56 years old male
History:
GERD
Barretts esophagus
Drinks 3-4 martinis on weekends
Smoking
30 packs/yr
2.5 packs/month (50 cigs/month or about 2 cigs/day)

Nutritional-Focused Physical
Findings
Appears weak and uncomfortable
Coughing
Sore throat
Nausea
Early satiety
Progressive difficulty swallowing
Odynophagia (painful swallowing)
First, solid foods
Now liquids

Food/Nutrition-Related
History
Current Diet:
Scrambled eggs, oatmeal, apple juice, canned
peaches, soup
Small amounts of food

Medications
Intravenous fluids
Ondanestron
Used to prevent nausea and vomiting

Hydromorphone
Opioid pain med

Lansoprazole
Stomach and intestinal ulcers
PPI (proton-pump inhibitor)

Chemotherapy
5-fluorouracil
Cisplatin

Diet: Full liquid diet as tolerated

Anthropometrics
Height:
58, 68

Weight:
165 lbs, 75 kg

BMI: 25.1
Overweight (25-29.9)
Usual weight:
185 lbs (4 months ago)

IBW:
154 lbs +/- 10% (139-169 lbs)

Biochemical Data
Parameters

Results

Normal Ranges

Sodium

140 mEq

135-147 mEq/L

Potassium

4.3 mEq/L

3.5-5.0 mEq/L

Chloride

100 mEq/L

98-106 mEq/L

CO2

25 mEq/L

21-30 mEq/L

BUN

15 mg/dL

8-23 mg/dL

Creatinine

0.9 mg/dL

0.7-1.5 mg/dL

Glucose

89 mg/dL

70-110 mg/dL

Phosphorous

3.2 mg/dL

3.0-4.5 mg/dL

Albumin

2.9 mg/dL (L)

3.5-5.5 mg/dL

Prealbumin

8 mg/dL (L)

16-40 mg/dL

Hemoglobin

13.8 mg/dL (L)

14-18 g/dL

Hematocrit

37% (L)

38-54%

Tests
Modified barium swallow
Results:
Functional oropharyngeal swallow
Moderate-to-severe esophageal dysphagia
Delayed movement of liquids in upper esophagus
Reflux in pharynx

Biopsy
Results:
Adenocarcinoma of the distal esophagus
Gastroesophageal junction

Micrograph of an esophageal adenocarcinoma (dark blue upperleft of image) and normal squamous epithelium (upper-right of image).
H&E stain (wikipedia).

Treatment
Esophagectomy
J-tube placement
Radiation
Chemotherapy
5-fluorouracil
Cisplatin

Question 1
What risk factors does this client have for

esophageal cancer?
Smoking
Drinking
GERD
Barretts esophagus
Sex (male)
Age: between 45-70

Question 2
What is his:
IBW:

154 lbs +/- 10% (139-169 lbs)

BMI: 25.1
Overweight (25-29.9)
Usual weight:

185 lbs (4 months ago)

%IBW

Current weight: 165 lbs


165/154 = 107 %

%UBW

165/185 = 89%
Lost 11% in 4 months

Question 2 (cont.)
Comment on his recent weight change and

nutritional status

Lost 11% of total body weight in 4 months


Severe weight loss
Malnourished

Calculate his energy, protein, and fluid needs.


High kcal, high protein, consistency modified diet
Kcal: 30-35 kcals/kg (2250-2625 kcals)
Pro: 1.5-2.5 g/kg (113-188 g PRO)
Fluids: varies, based on output/status

If 30 mL/kg = 2250 kcals

Question 3
List the nutritional-related side effects of

chemotherapeutic agents that he will be receiving.


Nausea, Vomiting, Constipation, Diarrhea
Loss of appetite
Mucositis (inflamed lining of digestive tract)
Dec RBC (anemia), dec WBC
Odynophagia (painful swallowing), dysphagia
Cancer cachexia

What are the possible nutritional related side effects of

radiation treatment?
Fatigue, mucositis, fistulas, dysgeusia, xerostomia, dysphagia,

odynophagia, severe esophagitis, esophageal obstructions,


bowel problems (diarrhea, chronic malabsorption, strictures)

Question 4
Do you think he will be able to take sufficient

nutrition by mouth during his chemo and


radiation? Why/why not?
No, painful swallowing
Side effects: chewing/swallowing difficulties,

smell change, taste change (dysgeusia),


xerostomia (dry mouth)
Dumping syndrome

Question 5
What specific dietary interventions could be

used to attempt oral nutrition support before


the esophagectomy and surgical j-tube are
performed?
Soft diet, high protein, kcal dense
Supplements (ensure, boost)
Small, frequent meals

Question 6
Assuming gastric access can be obtained preoperatively,

suggest an enteral feeding regimen that would provide


sufficient kcals, protein, and fluid for him using an
intermittent feeding schedule given over 30-45 minutes 4-6
times daily.
Formula: 1.5 kcals/mL, high protein
Starting volume: low rate through pump, half
strength 25 cc/hr
How you would advance the feeding: advance feeding
over several days
Goal volume for formula and flushes would be:
Flushes: 30 cc every 4 hours
Goal volume: full strength formula, 3-8 times per
day, with increase of 60-120 cc every 8-12 hours
as tolerated

Question 10
Write a note that summarizes your assessment in ADIME format.
A: Assessment
56 y/o male
Labs: Albumin 2.9, prealbumin 8, Hemoglobin 13.8, Hematocrit 37%
BMI: 25.1
Wt: 165#, Ht: 68
D: Diagnosis
Involunatry weight loss (NC-3.2) related to nausea, vomiting, difficulty
swallowing as evidence by weight loss of 20# in 4 months
I: Intervention
Nutritional-Related Modification Therapy (C-1) using goal setting
methods to maintain weight and increase albumin levels
M: Monitor and E: Evaluate
Follow up in 7 days
Monitor weight changes and re-evaluate diet recommendations if
needed
Assess compliance with goals
Monitor lab values and request another script in 7 days

References
1. Emery, Elizabeth Zorzanello. Clinical Case

Studies for the Nutrition Care Process.


Chapter 17: Esophageal cancer and enteral
nutrition. 121-125.
2. WebMD. Esophageal Cancer.
http://www.webmd.com/digestive-disorders/
esophageal-cancer
. Accessed 4/8/14.
3. Richards, Marcia. Neoplastic Disease power
point slides. 2014.
4. ASPEN. Journal of Parenteral and Enteral
Nutrition.