GASTRIC CANCERBy Heidi Thomason, RD Intern

POSSIBLE GASTROINTESTINAL BLEED

Mr. Anderson91 year old patient admitted with

intermittent epigastric pain for previous 6 months

Weight loss of 40 lbs. CT showed thickening of gastric

wall Stool positive for occult blood Pre-op labs revealed anemia (8.5

Hgb), requiring blood transfusion

Anthropometrics: Wt: 133#/60.6kg (10/30/13 – bed scale) Ht: 65” (stated by pt.) IBW: 136#/62kg %IBW: 98% UBW: 173#/79kg, 77% UBW 23% loss in body wt. in 6 mos. = Severe wt. loss

Lab results 10/30/2013: Alb: 2.7 – Critically Low H/H: 8.1/24.9 – Critically Low BUN/Cr: 28/1.26 - High Na/K: 140/4.1 - Normal Cl: 108 – High

PHYSICAL ANTHROPOMETRICS & BIOCHEMICAL RESULTS

MEDICAL HX. OF MR. ANDERSON Medical History:

Atrial fibrillation Hypertension Hypogonadism Hypothyroidism Benign prostatic

hyperplasia Hx. Of pericarditis

Surgical History: Pacemaker Appendectomy Craniotomy Various ortho. surgeries

Current Medications Sotalol (Beta-blocker)

40mg 2x/d Niferex (Fe) 150mg

2x/d MVI 1/d Testosterone 100mg/d

Social Hx: Nonsmoker No drug or EtOH use Lives independently 2 sons who are MDs

FOOD - MEDICATION INTERACTIONS Sotalol (beta-blocker) decreases food

absorption by 20%, must be taken separately from Mg, Ca, and Al.Can cause wt. changesCan cause N/V/D, abdominal pain,

flatulence In DM pts, can cause a prolonged

hypoglycemia response Niferex (Ferrous salts – elemental iron)

Can cause stomach upset, N/V/D, occult fecal blood, anorexia

High doses may decrease Zinc absorption

NORMAL INTAKE & NEEDS Usual intake:

Unable to assess usual intake or preferences due to delerium and altered mental status until RD consult was done four days after admission.

Needs:Using IBW of 136 lbs./62kg

Calories: 62kg x 25-30kcals = 1550-1860kcals/day

Protein: 62kg x 1.2-1.5g (GIB, anemia, low Alb) = 75-93g protein/day

Fluids: 62kg x 25+ml (cardiac pt.) = 1550ml H2O/day

FIGURING OUT THE PROBLEM

2 units RPBC transfusion done, PET scan scheduled

Esophagogastroduodenoscopy (EGD) & CT done Showed an ulcerated mass lesion on the

anterior wall of the gastric antrum Biopsy revealed adenocarcinoma of the distal

stomach Hemi-gastrectomy scheduled

Adenocarcinoma cells

PRE-OP NUTRITION DIAGNOSIS 10/30 Unintended wt. loss (NC-3.2) related to

GIB AEB reported loss of 40 lbs./23% loss of body weight.

Altered nutrition-related laboratory values related to gastrointestinal bleeding, anemia AEB low albumin and low H/H.

PROGRESS NOTE Hemi-gasrectomy done; S/P resection of

adenocarcinoma of the distal stomach Postop delerium Tachycardic – uncontrolled atrial fibrillation Renal function improved (BUN: 6 – Low) WBC high (13.4) H/H improved but still low (34.3/11.4)

G-tube placed when partial gastrectomy done

RESECTION OF THE DISTAL STOMACH NPO status initially for 3 days – in the

ICUNo BM for 4 days, hypo BS, flatus absent

Tube feed ordered, RD consult orderedTF of Fibersource HN @ 20ml/hr initiated to

provide: 576kcal, 26g protein, 389ml free H2O per MD order

ADAT to goal rate of 60ml/hr to provide: 1728kcals, 78g protein, 1166ml free H2O

RD CONSULT

RD consult provided: No known food allergiesNo food intolerancesNo difficulty chewing or swallowingNo food preferencesRegular diet followed at homeUsual appetite is goodSkin integrity: abdominal wound, shoulder

contusion, no edema

NEW DIAGNOSIS POSTOP 11/3 Altered GI function related to gastric

cancer AEB NPO since 11/1/13, no BM since 10/31, and TF ordered.

Altered nutrition-related laboratory values related to gastric adenocarcinoma, GIB AEB low Alb, low H/H.Future Topics to Discuss

Postop gastrectomy diet

NUTRITION REASSESSMENT 11/4 TF stopped and TPN ordered.

TPN of Clinamix E 5/15 with standard daily lipids ordered @ goal rate of 80ml/hr to provide: 1776kcals, 80g protein

Recommend: Monitor closely for signs of refeeding syndrome due to

severe wt. loss Labs daily per TPN order Daily wts. per TPN order Clear liquid to regular diet when medically possible

Goals: Meet nutritional needs, no GI distress, PO>75%, adv. diet, gradual wt. gain, wound healing, bowel regularity, incr. Alb/Prealb., BG <160mg/dL on TPN.

M/E: Will monitor I&O’s, labs, PO intake, tx. plan, skin.

NUTRITION REASSESSMENT 11/7 TPN running @ goal (Clinamix E 5/15 @ 80

ml/hr) Wt: 59kg (standing scale 11/6), I&O’s

variable, 3+ edema. LBM 11/5, hypo BS, flatus absent

Skin: surg. wound improving, no further breakdown

Meds: Pain meds, Biaxin & Flagyl (abx.), Nitro, Protonix, Sotalol. PRN Zofran, MOM

Labs: 11/6 – Alb/Prealb:1.7/105L, BG:122H, BUN:22H, K:3.3L, CR/NA/CL/P/MG/WBC/TRIG: WNL

NUTRITION REASSESSMENT 11/7

Recommend: Monitor closely for signs of refeeding syndrome

due to severe wt. loss Labs daily per TPN order Daily wts. per TPN order Clear liquid to regular diet when medically

possibleGoals: Meet nutritional needs, no GI

distress, PO>75%, adv. diet, gradual wt. gain, wound healing, bowel regularity, incr. Alb/Prealb., BG <160mg/dL on TPN.

M/E: Will monitor I&O’s, labs, PO intake, tx. plan, skin.

NUTRITION REASSESSMENT 11/11 Full liquid diet & supplement of Ensure

ordered in addition to TPN; PO Intake = 0-25%, Suppl. Intake = 25-50%. Labs: 11/11 – Alb:1.9L, BG:138H, BUN:31H,

Na:130L, H/H:27.5/9L Accuchecks 11/9-11/11: 111-152mg/dL

Diagnosis: Altered GI function related to gastric cancer

AEB TPN and full liquid diet ordered. Altered nutrition-related laboratory values

related to GIB, metabolic stress, TPN Rx AEB low Alb., low Prealb, low H/H, high BG at times

NUTRITION REASSESSMENT 11/11 Recommend:

Continue current diet orders, consider decreasing to 40ml/hr to increase PO intake; adv. diet as able.

Daily labs per TPN order Daily wts. per TPN order

Goals: Meet nutritional needs, no GI distress, PO>75%, adv. diet, gradual wt. gain, wound healing, bowel regularity, incr. Alb/Prealb., BG <160mg/dL on TPN.

M/E: Will monitor I&O’s, labs, PO intake, tx. plan, skin.

NUTRITION NOTE 11/16 Pt. transferred to Vibra LTAC

TPN continued and PO order setsHelicobacter pylori infectionAnemiaFunctional Decline

Nutritional Level: High

NUTRITION ASSESSMENT 11/17 Admitting Diagnosis: Gastric cancer Nutrition screen consult: TPN

PES: Altered nutrition-related laboratory values related to gastric cancer, anemia, GIB AEB low Alb, low H/H.

Intervention: TF not tolerated well since initiation, currently on

hold. Current TPN of Clinamix E 5/15 meets 100% of estimated needs (1776kcals, 80g protein). Alb/Prealb remains low and significant wt. loss since admission was d/w MD.

RD ASSESSMENT 11/17 Recommend:

Continue TPN order; adv. diet as medically possible when pt. can tolerate TF @ goal rate

Daily wts. and labs per TPN order Advance TF of Fibersource HN to goal rate of 60ml/hr as

medically possible Prealbumin labs q week on TF once TPN DC’d SLP to follow for possible diet advancement If PO diet possible, recommend regular diet (texture per

SLP) Diet Education: N/A due to confusion. Will monitor for

education needs PRN. Expected outcome/goals:

Support nutrition needs, utilize GI as able, incr. Alb/Prealb to wnl, post-op wound healing, no significant wt. loss/gradual wt. gain

REASSESSMENTS & FINAL RESULTS Pt. continued to have N/V and never

tolerated PO diet well. He stayed at Vibra for two weeks and multiple attempts to use a TF formula were never met.

On 11/30, he went to SRMC to get a PEG tube placement, but did not do well S/P. He failed a swallow eval. done on 12/4 and was never able to tolerate a TF. He eventually was changed to comfort care and DNR code status. His TPN was DC’d on 12/10 and he expired on 12/19.

MAINTAINING NUTRITIN IN POST GASTRIC CANCER PATIENTS According to journal articles, critically ill

patients are hypermetabolic and maintaining nutrition is difficult and necessary for their survival1&2. Mr. Anderson’s complications with his h.

pylori infection made it nearly impossible to feed him. If an PEJ tube had been placed earlier, he may have tolerated a TF better.

The number of successful patients fed post-pyloric TF’s after a gastric resection are high.

REFERENCES Boulton-Jones J.R., Lewis J., Jobling J.C., Teahon K.

(2004). Experience of post-pyloric feeding in seriously ill patients in clinical practice. Clinical Nutrition. 23, pp.35-41.

Nelms M, et al, (2011). 'HIV and AIDS'. In: (ed), Nutrition Therapy and Pathophysiology. 2nd ed. : Wadsworth Cengage Learning. pp.735-770

Pagana K., Pagana T. (2010). Mosby’s Manual of Diagnostic and Laboratory Tests.4th ed.: Elsevier Inc.

Zhu X., Wu Y., Qiu Y., Jiang C., Ding Y. (2013). Effect of early enteral combined with parenteral nutrition in patients undergoing pancreaticoduodenectomy. World Journal of Gastroenterology. 19(35), pp.5889-5896.