MINI CASE STUDY: RECTAL CA AND IUP

JONATHAN TELLIER, DIETETIC INTERN

BACKGROUND EVALUATION ASSESSMENT

OUR PATIENT
AN a 29-Year old female, admitted (3/13/19), with Dx of ABW: 127 lbs. (57.7 kg) DAY 01
Ht: 62 in. (157.48 cm)
Rectal CA 20 week IUP, s/p low anterior resection (LAR) with BMI: 23.32 (Normal) IBW: 110 lbs.
Total mescorectal excision (TME). Weight Hx: Operative report 112 lbs. (3/13), admit wt. 127 lbs. (3/14), bed wt. 136
lbs. (3/15).
FOOD NUTRITION HX Diet: CLLQ (3/14), FULQ (3/15),
Reports being on a special diet for colitis prior to Sx procedure. PO intake: Per nurse <25% (3/14-3/15)
GI: N/V Per Pt.
PMHX
Estimated needs: Based on Admit wt.
GERD, H.Pylori, Colon Cancer, Rectal Bleeding, Chlamydia, Anemia,
Calorie: 2,040 kcal/day (30 kcal/kg + 300 kcal for pregnancy)
Ovarian Cyst, Alcohol Abuse, Tobacco Use, Substance Abuse. Protein: 112 gram/day (1.5 g/kg + 25 for pregnancy)
HOSPITAL COURSE Fluid: 2,325ml/day (30 ml/kg + 600 ml for additional loss from colostomy)
3/4/19: Biopsy confirmed Colonic Adenocarcinoma
3/13/19: Partial colectomy end colostomy transferred to PACU
3/15/19: FULQ 3 bouts of emesis from ensure, Nausea
3/17-18/19: NPO Post op Ileus (3/17)
3/19-20/19: CLLQ, started TPN (3/19 @ 17:00)
3/21/19: TPN DC at 09:20, Soft diet-Regular. Some hard stool
passed. OB consult for viability. Pt. Discharged on Regular diet.
PROCEDURES RELATED TO ADMISSION DIAGNOSIS
3/13/19: Low anterior resection, w/ total mesorectal excision
resection of paraaortic and paracaval nodes.
3/19/19: PICC placement SVC w/ Chest Xray- Expanded Lungs
PATHOPHYSIOLOGY OF RECTAL CANCER
Colonic Adenocarcinoma- the most common type of colon cancer
starts in goblet cells that form glands producing mucus for
lubrication of colon and rectum. Cancer of the colon most
commonly begins with adenomatous polyps, which are
noncancerous (benign) clumps of cells. Polyps are caused by
mutations in certain genes causing continual division of cells.
Hereditary conditions that cause colon polyps to form include Lynch
syndrome, Familial adenomatous polyposis, Gardner’s syndrome,
MYH-associated polyposis, Peutz-Jeghers syndrome, and Serrated
polyposis syndrome.
Signs and symptoms- include rectal bleeding, change in stool color
and change in bowel habits, pain, and iron deficiency anemia. DIAGNOSIS
PATHOPHYSIOLOGY OF TOTAL COLECTOMY W/ COLOSTOMY
(3/15) Altered GI Function R/T Colon carcinoma AEB colostomy, vomiting,
Total colectomy- is a surgical procedure to remove the large and no colostomy output.
intestine from the distal ileum to the rectum. LAR is a surgery (3/19) Inadequate oral intake R/T limited food acceptance AEB vomiting
done to treat cancer of the rectum. Part of the rectum is removed and nausea and intake less than 10% x 10 recordings.
and the remaining part of the rectum is reconnected to the colon. (3/21) Excessive parenteral nutrition infusion R/T increased total volume
This is called an anastomosis. TME strictly applies in the TPN w/ dextrose @ 15% still AEB carbohydrate consistently more than
performance of a LAR for tumors of the middle and lower rectum. recommended intake.
Colostomy- (ileostomy) is needed for a short time after LAR. A INTERVENTION
colostomy keeps waste from passing through the colon and Recommendation: (3/15-3/19) Cont. FULQ diet with ensure TID and advance
rectum allowing the anastomosis to heal. A part of the small as tolerated to Low residue bland diet.
intestine is brought out through an opening made in the Discussed current FULQ diet and delivered handout for colostomy nutrition.
abdomen called a stoma. A waterproof pouch (colostomy bag) is (3/19) TPN- @ 85 ml/hr D15% 110gAA 60Lipid to meet pt. nutrition needs.
used to collect waste from the body. (3/21) TPN- @ 95 ml/hr D13% 110gAA 60gLipid to meet pt. nutrition needs.
Nutrition therapy- Focus on decreasing risk of obstruction, (2047 kcal) Continue soft diet and monitor PO intake.
maintain fluid and electrolyte balance, reduce excessive fecal MONITOR AND EVALUATION
output and/or change consistency of output, and minimize gas. Monitor: (3/15) PO intake, Wt., Diet Tolerance
PREGNANCY Goal: PO >75%, Stable Wt., Advance to solid foods.
Normal weight gain for pregnancy is 25-35 lbs. if the patient is of
Monitor: (3/19) Labs, wt., Blood glucose, GI Function, PO intake
normal BMI. For the second and third term women need an extra Goal: PO >75%, Stable Wt., Advance to solid foods.
300-450 kcal/day to support fetal needs. Protein needs are Monitor: (3/21) Labs, wt., Blood glucose, GI Function, PO intake, PN-related
estimated to be between 75-100 grams, an additional 25 grams is complications
considered for lactation. This was applied to AN due to increased Goal: Stable wt., Stable labs, Continue with TPN until PO intake average is > 75% for
needs from surgery and previous weight loss during pregnancy. a minimum 3 days, BM or colostomy output.
Both total red blood cell mass and plasma volume increase, but NUTRITION RISK: SEVERE
plasma volume increases to a greater extent resulting in
hemodilution and anemia during pregnancy. Anemia during
second trimester is defined by an Hgb <10.5 g/dL and an Hct <32%..
Serum total protein and albumin decrease by 30% during
pregnancy. The RDA of micro nutrients increase, specifically
vitamin A, and D, folate, niacin, riboflavin, thiamin, pyridoxine,
cobalamin, vitamin C, iron, selenium, and zinc.
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