MINI CASE STUDY

NUTRITIONAL MANAGEMENT OF RECTAL CANCER AND SURGICAL INTERVENTIONS

OBJECTIVE INFORMATION
 Patient: 68 year old male
 Admitted on 2/17/20 with abdominal pain and constipation x 7days.
 X-ray revealed stool in colon and diagnosed with bowel obstruction due to invading tumor (2/17/20).
 Patient was recently diagnosed with locally advanced (T3) rectal cancer PTA (2/7)
 Tumor location: 10 cm from anal verge
 Tumor size:: 3.3 cm
 Anthropometrics:
 Height: 5’8” (172.7 cm)
 Weight: 134 lbs (60.9 kg)
 BMI: 20.4 kg/m2 (normal)
 Medical Hx:
 CAD, rectal cancer, HTN , hyperlipidemia, CHF, and depressive disorder
 Social Hx: Chronic smoker (0.5 ppd) and alcohol drinker
WEIGHT HISTORY
 Weight history:
 5/26/19: 130 lbs.
 6/5/19: 136 lbs.
 7/15/19: 135 lbs.
 8/14/19: 131 lbs
 9/16/19: 131 lbs.
 2/18/20: 134 lbs.
 Weight change: + 3lbs.
 Time period: 6 months
 Weight loss: 2%
 Significant: No. Needs to be at least 10% in 6 months to be significant.
BIOCHEMICAL DATA, MEDICAL DATA, PROCEDURES

 Pertinent labs: AST 57 (H)

 AST: Could be due to alcoholism that lead to liver damage.

 Pertinent Meds: Zofran, Zoloft, Norco

 Zofran: Prevents nausea/vomiting

 Zoloft: Treats depression (loss of appetite)

 Norco: Treats pain

 Pertinent Procedures: Laparoscopic descending colon end colostomy mucous fistula (2/17/20)
 Colostomy: Surgical operation where a piece of colon is diverted to an artificial opening in the abdominal wall to bypass damaged
part of colon or rectum.

 Mucous fistula: Abdominal stoma to discharge mucous or gases from non-functioning portion of colon or rectum.

 Current Diet Order: Full liquids (due to recent surgery)

 Will slowly transition to solids

 Recommended to have a low fiber diet for 4-6 weeks (rest GI after surgery)

 Low spice and fat foods (can cause diarrhea and reflux)

 Increase protein for healing

NUTRITION RISKS OF COLOSTOMY

 The large intestine consists of the cecum, colon, rectum, and anal canal.
 Procedures:
 Descending/Sigmoid colostomy: A portion of the LI is removed or bypassed.
 Nutrients are well absorbed as most of GI tract remains intact.

 Transverse colostomy: A large portion of LI is removed or bypassed.

 Patients might experience decreased absorption of fluids and electrolytes.

 Ascending colostomy: Most of the colon is removed or bypassed.

 Decreased ability to absorb fluid and electrolytes.
 Dehydration can occur with excessive sweating, diarrhea, and or vomiting.

 Ileostomy:
 Entire colon, rectum, and anus are removed or bypassed. SI is brought through the abdominal wall.
 Decreased ability to absorb nutrients, fluid, and electrolytes

 Higher risk for dehydration.

 Might affect ability to absorb B12 (absorbed in ileum). Supplements might be needed.
RECTAL CANCER BACKGROUND

 Rectal cancer: Abnormal cell growth in rectum.

 Rectum is the last 12 centimeters of LI.
 Pt’s tumor was found 10 cm from anal verge (3.3 cm)

 Signs: Rectal bleeding, bloating, abdominal pain, constipation, change in

appetite
 Stages:
 Stage 0: Cancer has not grown beyond on the inner layer (mucosa) of the
rectum.
 Stage 1: Cancer has grown through the mucosa into the submucosa.
 Stage 2: Cancer has grown into the muscularis propia.
 Stage 3: Cancer has grown into the outmost layers of the rectum and has
spread to nearby organs or lymph nodes.
 Stage 4: Cancer has spread to distant organs (liver, lungs).
 RECTAL CANCER BACKGROUND

 Treatment:
 Chemotherapy
 Radiation therapy
 Surgery
 Biotherapies
 Rectum does not have the same protective outer layer (serosa) as the colon. Therefore, easier for a tumor to break
through and spread locally.
 Rectal cancer is10x more likely to come back than colon cancer after treatment started.
 20% risk of local recurrence, versus 2% with colon cancer
RECTAL CANCER RISKS AND DIAGNOSTIC METHODS
 Uncontrollable risk factors:
 50 years old or older

 Genetics

 Hx of IBS (such as crohn’s colitis and ulcerative colitis increases risk)

 Controllable risk factors:

 Diet high in red, process, or charred meats

 Lack of exercise

 Obesity, particularly extra fat around the waist

 Smoking (studies show that smokers are 30-40% more likely die of colorectal cancer)

 Drinking too much alcohol

 Diagnostic methods:
 Physical exam and history

 Digital rectal exam (DRE)

 Colonoscopy: A procedure to look inside the rectum for polyps (small bulging of tissue), abnormal areas or cancer.

 Biopsy: Removal of cells that can be viewed under microscope

 Immunohistochemistry: A laboratory test that uses antibodies to check for certain antigen (markers)

 Carcinoembryonic antigen (CEA) assay: test that measures the level of CEA in blood. CEA is released into bloodstream from both canceler and normal cells. When found higher than normal
amounts can be a sign of cancer.
SUBJECTIVE DATA

 Pt reported poor appetite for the last few weeks.

 Estimated he ate 25% of his meals at home for a few weeks (no dietary recall provided)
 Does not take nutrition supplements at home.
 Weight loss: 3 lbs. in 6 months (not significant).
 Nutrition physical focused exam:
 Fat loss: Unremarkable: Slightly bulged fat in pads in orbital region. Fat tissue obvious between folds of skin in upper arm.
 Muscle loss: Mild-Moderate- Slight depression and scooping in temple region. Can see/feel muscles in clavicle region.
Interosseous muscle bulges.
 Skin: Braden score 18. Drain/device on right/left side of abdomen (colostomy).
 Nutrition Status Classification: NS3 (Rectal cancer, < 75% for > 7 days)
NUTRITION PRESCRIPTION

 Energy needs: dosing wt 60.9 kg, 30-35 kcals/kg = 1827-2132 kcals/day

 Increased needs due to recent surgery and cancer diagnosis

 Protein needs: dosing wt 60.9 kg, 1.4-1.6 g/kg = 85-97 grams of pro/day
 Increased needs due to recent surgery and cancer diagnosis.

 Fluid needs: dosing wt 60.9 kg, 30 mL/kg = 1827 mL/day

NUTRITION DIAGNOSIS, INTERVENTION & MONITORING

 Nutrition diagnosis: Inadequate protein energy intake related to decreased ability to

consume sufficient protein energy and meet increased nutrient needs (rectal cancer)
due to lack of appetite as evidenced by estimated protein energy intake from diet
less than estimated needs.
 Intervention: Full liquid diet. Ensure Enlive 1x/day per Pt’s request
 Monitoring/Evaluation: Pt to meet >50% of EER and estimated protein needs by 2/21
 CHECK ON PT (2/19)

 Checked on Pt’s diet and nutrition supplement

 New MD note indicated that previous biopsy (2/7) from invading tumor did not show malignancy but did
show high-grade dysplasia (presence of cells of an abnormal type within a tissue).
 Pt underwent a sigmoidoscopy flexible with rectal mass removal with hot snare procedure for another biopsy
(2/19/20).
 A test that checks the inner lining of rectum via tiny camera. Biopsy was taken by looping a thin wire
around mass and using heat to remove it.
 Pt was NPO for surgery and has not tried the nutrition supplement yet. Will continue to monitor for
supplement tolerance.
RESCREEN 2/20: SUBJECTIVE
 Subjective Information
 Pt continues to have poor appetite and claims that food “taste is off.”
 Ate 25% of his breakfast. ~ 237 calories, 6 g. protein.
 Pt did like the ensure (1x/day) but declined altering nutrition regimen.
 Provided education on how to enhance taste of food and increase appetite from handout in NCM.
 Improve Taste
 Use plastic utensils if metallic taste present.
 Season foods with tart flavors such as citrus fruits.
 Flavor foods with onion, garlic, barbecue sauce, and other seasonings.
 Add sugar to improve the flavor of salty foods.
 Add salt to decrease the sweetness of sugary foods
 Serve foods cold or at room temperature.
 Increase appetite
 Eat small meals or snacks ever 1-2 hours
 Keep high-calorie, high-protein snacks on hand.
RESCREEN 2/20: OBJECTIVE

 Objective Information
 Weight: 60.9 kg (no change)
 Labs: AST 57 (H)- no improvement.
 Medications: Zoloft (loss of appetite).
 Diet order: Full liquid diet.
 Biopsy results are still pending. Once diagnosis confirmed, Pt will undergo treatment plan of chemo/RT as an
outpatient.
 Per MD, expected to be discharged in 2-3 days.
RESCREEN 2/20: INTERVENTION & DISCHARGE

 Nutrition diagnosis: Inadequate protein energy intake related to decreased ability to consume sufficient amount of
protein energy and increased needs (rectal cancer) due to lack of appetite as evidenced by estimated protein
energy intake from diet less than estimated needs (No Improvement Shown).
 Goals: Pt to meet >50% of EER an estimated protein needs by 2/25.
 (Previous goal of consuming >50% was not met)
 Intervention: Full liquid diet. Ensure Enlive 1x/day. Provided nutrition handout on tips on how to improve altered
taste and poor appetite.
 Discharge: Advance diet when medically tolerable. Nutrition supplement 1-2x/day.
 Nutrition Status Classification: NS3 (Rectal cancer, < 75% for > 7 days)
REFERENCES

 Colon-Rectal Cancer (n.d.). American Cancer Society. Retrieved February 21, 2020 from https://www.cancer.org/cancer/colon-
rectal-cancer/detection-diagnosis-staging/staged.html.
 Eating With an Ostomy (n.d). United Ostomy Association of America. Retrieved February 22, 2020 from
https://www.ostomy.org/wp-content/uploads/2019/10. pdf.
 Nutrition Care Manual (n.d.). The Academy of Nutrition & Dietetics. Retrieved February 21, 2020 from
https://www.nutritioncaremanual.org/auth.cfm. Accessed February 21, 20220.
 Rectal Cancer Treatment (n.d.). National Cancer Institute. Retrieved February 23, 2020 from
https://www.cancer.gov/types/colorectal/patient/rectal-treatment-pdq?fbc
 Risk Factors for Rectal Cancer (n.d.). Memorial Sloan Kettering Cancer Center. Retrieved February 23, 2020 from
https://www.mskcc.org/cancer-care/types/rectal/prevention-risk-factors?fbclid=IwAR0HqJb8oLd.
 Zalewski, S. (2019). How colon and rectal cancer differ. Michigan Medicine. Retrieved February 22, 2020 from
https://health.uofmhealth.org/cancer-care/how-colon-and-rectal-cancer-differ.