Liz Lancione

ARAMARK Dietetic Internship

March 9, 2014
Case patient was admitted 1/24/2014 for
scheduled subtotal gastrectomy with G and Jtube
placements. Postop course was prolonged by
slow return of bowel function. Treatment
included gradual advancement of Jtube feeds
with Gtube initially to suction, then to gravity,
alternating with being clamped. As the patient
began tolerating tube feeds, she began PO.
Patient was discharged when she was
hemodynamicaly stable, afebrile, and tolerating
soft diet with cycled tube feeds.
Etiology
Can occur with no clear cause
Relationship between a diet high in smoked, salted
and pickled foods and stomach cancer
Family history of gastric cancer

Epidemiology:
Male
Elderly
Cigarette smokers
Obese
Pathology:
Adenocarcinoma: Begins in glandular cells (cells
that line the inside of the stomach secrete mucus).
Accounts for majority of all stomach cancers.
Lymphoma: Cancer in immune cells of the stomach.
Lymphoma in the stomach is rare.
Carcinoid cancer: Cancer of the hormone-
producing cells in the stomach. This type is rare.
Gastrointestinal stromal tumor (GIST): Begins in
specific nervous system cells found in your
stomach. GIST is rare.
Clinical Signs/Symptoms:
May be asymptomatic
Fatigue
Feeling bloated after eating
Early satiety
GERD
Diarrhea
Nausea
Stomach pain
Persistent vomiting
Unintentional weight loss


Comorbidities:
Cardiovascular
Pulmonary (COPD)
Other GI issues
Other cancer
Obesity
Diabetes
Anemia
Short-term effects of supplementary feeding
with enteral nutrition via jejunostomy
catheter on post-gastrectomy gastric cancer
patients
METHODS: Study compared two groups of post-
gastrectomy patients, one was not tube fed and the
other was fed through a jtube after surgery.
RESULTS: Compared with the assessments of the
patients preoperatively, the jtube fed group lost
significantly less weight than the tubeless group.
The number of patients with a nutritional risk score
greater than three increased in the tube-free group
and decreased in the jtube fed group!
Quan et al. Short-term effects of supplementary feeding with enteral nutrition via jejunostomy
catheter on post-gastrectomy gastric cancer patients. Chinese Medical Journal. 2011: 124(20):
3297-3301

The Comparison between Early Enteral
Nutrition and Total Parenteral Nutrition after
Total Gastrectomy in Patients with Gastric
Cancer: The Randomized Prospective Study
METHODS: Gastric cancer patients were assigned to
an enterally fed group and a parenterally fed group
postoperatively. Nutritional parameters, liver
function, LOS and abdominal symptoms were
compared.
Chung, JB; Kim, CB; Kim, HU. The Comparison between Early Enteral Nutrition and Total Parenteral Nutrition after Total Gastrectomy in Patients
with Gastric Cancer: The Randomized Prospective Study. Korean K Gastroenterol Vol 59 No. 6, 407-413

The Comparison between Early Enteral
Nutrition and Total Parenteral Nutrition after
Total Gastrectomy in Patients with Gastric
Cancer: The Randomized Prospective Study
RESULTS: No significant differences were found
between the groups regarding liver function or
nutritional parameters, but vomiting and abdominal
distention were more common in the EN group, but
increased AST, ALT, and total bilirubin were more
common in the TPN group. Length of hospital stay
was shorter in the EN group but not statistically
significant.
Effect of early oral feeding after gastric
cancer surgery: A result of randomized
clinical trial
METHODS: Patients in the early feeding group
began a clear liquid diet 2 days post-gastrectomy,
and began a soft diet on the 3
rd
day until they were
discharged. The other group began a liquid diet on
the 4
th
postop day. The study was to measure which
group had a longer hospital stay.
Hur et al, Effect of early oral feeding after gastric cancer surgery: A result of randomized clinical trial. Surgery, Korea 2010: 10. 003. 561-568

Effect of early oral feeding after gastric
cancer surgery: A result of randomized
clinical trial
RESULTS: Duration of hospitalization and time until
flatus were significantly shorter in the early feeding
group. Quality of life scores were also improved in
the early orally fed group.
84 year old female
Diagnosis:
Gastric Outlet Obstruction
Procedures:
Exploratory laparotomy, subtotal gastrectomy,
gastrostomy tube placement, jejunostomy tube
placement
Hospital Problems:
Gastrinoma, gastric perforation, carcinoid tumor of
small intestine and others not GI related

Past Medical History
Diverticulosis of Colon
Acute duodenal ulcer with hemorrhage
Calculus of gallbladder without cholecystitis
Hyperlipidemia
Jejunal ulcer
Carcinoid tumor
Extensive non-GI related

Past Surgical History
Ligate fallopian tube
Removal of gallbladder
Upper GI endoscopies, biopsies (multiple)
Colonoscopies (multiple) & polypectomy
Esophagogastroduodenoscopy
Exploratory of abdomen
Repair perforated duodenum
Freeing bowel adhesion, enterolysis
Upper GI endoscopy with balloon dilation
Upper GI endoscopy with stent placement
Gastroscopy

Social History
Nonsmoker
Widowed
Less than 2 drinks/day
Lives alone
Two daughters very active in patient care
Patient on Home TPN for over 6 weeks PTA
due to gastric outlet obstruction
Weight lost due to inability to tolerate food
due to gastric outlet obstruction
No food allergies
No problems swallowing


Upper dentures
Clavicular wasting mild to moderate
Able to sit up in chair for long periods of time
History of knee surgeries and chronic knee
pain



Height
55
Weight
155 lbs (70 kg)
BMI
25.83 kg/m2
Usual Body Weight
172 lbs in June 2013
Changes in Weight
About 20 lb weight loss in 6 months (10%, severe)
Component Result Ideal Range Explanation
Glucose 113 mg/dl 60-99 mg/dl Blood glucose is
commonly high after
surgery
Magnesium 1.6 mg/dl 1.7-2.8 mg/dl Poor PO intake
Hemoglobin 11.7 gm/dl 12.0-15.0 gm/dl Commonly low after
surgery due to blood
loss
Calcium 8.0 mg/dl 8.5-10.3 mg/dl Poor PO intake
Initial Assessment
Estimated Energy Needs per Day
25-30 kcal/kg body weight is 1750-2100 kcal.

Estimated Protein Needs per Day
1.2-1.5 g/kg body weight is 84-105 grams.

Estimated Fluid Needs per Day
30 ml/kg body weight is 2100 milliliters.
Severely compromised secondary to
GI Surgery
New tube feeding
Weight loss
NPO status
TPN dependent prior to admission

Not malnourished
Problem:
Altered GI Function (NC-1.4)
Etiology:
related to gastric outlet obstruction caused by gastric
cancer
Signs/Symptoms:
As evidenced by status post exploratory laparotomy,
subtotal gastrectomy, gastrostomy tube placement,
jejunostomy tube placement, and need for enteral feeds
to meet estimated nutritional needs.

Patient seen 3 days post admit to floor NPO with NG
Medical Procedures:
Trickle tube feeds began 1/27
Initiated clear liquid diet 2/01
Surgical Procedures:
Exploratory laparotomy
Subtotal gastrectomy
Gastrostomy tube placement
Jejunostomy tube placement
Domain:
Food and/or Nutrient Delivery (ND)
Nutrition Intervention Term:
Enteral Nutrition (ND-2.1)
Nutrition-Related Intervention:
Initiate and tolerate tube feeds
Meet goal rate to provide at least 75% of estimated
needs
Initiate PO diet per primary service
Initiate and tolerate tube feeding
Meet at least 75% of estimated nutrition needs
Attain/maintain minimum estimated
nutritional needs
Monitor Biochemical Tests and Procedures:
Intake/Output
Residuals
Electrolytes
Blood chemistry
Abdominal exams
Initiate and tolerate PO diet

3 days post initial assessment
PES Statement:
Altered GI Function (NC-1.4) related to gastric
outlet obstruction caused by gastric cancer as
evidenced by status post exploratory laparotomy,
subtotal gastrectomy, gastrostomy tube placement,
jejunostomy tube placement, and need for enteral
feeds to meet estimated nutritional needs.
Nutrition Intervention Performed: Clear liquid
plus tube feeding
Goals set: advance as tolerated to general soft
diet, 6 small meals
Level of achievement/compliance: good
7 days post initial assessment
PES Statement
Altered GI Function (NC-1.4) related to gastric outlet
obstruction caused by gastric cancer as evidenced by
status post exploratory laparotomy, subtotal
gastrectomy, gastrostomy tube placement,
jejunostomy tube placement, and need for enteral
feeds to meet estimated nutritional needs.
Nutrition Intervention Performed: Full liquid plus
tube feeding
Goals set: Advance as tolerated to general soft
diet with 6 small meals per day
Level of achievement/compliance: good

Discharged 9 days post initial assessment
Follow up phone call 2/11
Pt complaining of upset stomach, resolved
eventually
Office visit 2/17
Recovery is going well
Office visit 2/25
Patient eating without difficulty
May start clamping Gtube continuously instead of
intermittently.
This patients case is a good example of the
success of Jtube feedings after a gastrectomy
in order to help meet nutritional needs. She is
currently doing well and no malignancies
were found at her follow-up visits.