Medical and Nutrition

Therapy for Malnutrition

and Malabsorption Status

Post Gastric Bypass

Surgery

Lauren Wathen, Dietetic Intern

University of Maryland,

College Park

Objectives

• Overview of malnutrition status post biliopancreatic

diversion with duodenal switch gastric bypass

surgery

• Review medical and nutritional complications

associated with chronic alcoholic pancreatitis and

liver cirrhosis

• Understand the medical and nutrition treatment of a

patient with all of these medical issues

Gastric Bypass Procedures

• More than 1/3 of the U.S. adult

population is obese

• Surgery has become increasingly

common

– 1998: 7.0 per 100,000 patients

– 2002: 38.6 per 100,000 patients

31.6% increase in 4 years

Biliopancreatic Diversion with

Duodenal Switch

Mayo Clinic Video

Patient Report - SS

• 40 yo Caucasian female

• Ht: 162.6 cm

• Wt: 48 kg

• BMI: 18

• IBW: 54.5 kg

• % IBW: 88%

• Lives at home alone

• Former smoker

• History of EHOH abuse and

heavy dependence on

narcotics for chronic pain

• Past Medical History

– Gastric bypass performed

ten years ago

– Chronic alcoholic

pancreatitis

– Liver cirrhosis

– GERD

– Anemia

– Anxiety disorder

– Deep vein thrombosis

(DVT)

– Chronic abdominal pain

– MRSA

Hospital Course

• SS presented to the ED requiring PICC line

placement for Total Parenteral Nutrition (TPN)

secondary to malnutrition and long-standing failure to

thrive from liver cirrhosis.

• Emaciated with temporal and clavicle wasting

• Had flat affect and generalized weakness

• Generalized abdominal tenderness and increased

bowel sounds

• Afebrile with a normal pulse and blood pressure of

98/60. Alert and oriented x3

Hospital Course

• Day 1- 3/25/14: Patient admitted from Emergency Room for

malnutrition, intractable abdominal pain, nausea with vomiting.

Admission lab results showed hyponatremia and hypomagnesemia

which may be related to poor intake and nausea with vomiting

admission as serum potassium level was normal. Gastroenterology

recommended PICC line placement and consultation with nutrition

for initiation of TPN after line placement. Diet – No order placed.

• Day 2 – 3/26/14: PICC line placement. Diet – Regular; minimal

intake.

• Day 3 – 3/27/14 – Patient seen by nutrition for initial assessment.

TPN dosed by pharmacist and initiated. Diet – Regular; minimal

intake.

Hospital Course

• Day 4 – 3/28/14: Patient underwent ultrasound guided paracentesis due

to ascites. The physician removed 6.8 L of ascetic fluid from peritoneal

cavity. Diet – NPO for procedure then Regular; minimal intake.

• Day 5, 6 – 3/29/14-3/30/14: Patient continues on TPN. Patient continues

to experience chronic abdominal pain that is being treated with IV

narcotics. No other complaints currently. Diet – Regular; minimal intake.

• Day 7 – 3/31/14: Patient discharged home to continue with home TPN

and home health services arranged by case management. Patient’s

urine grew MRSA which was deemed to be colonization not infection as

per infectious disease consult; they recommended Bactrim-DS x 1 week

which was prescribed. SS has remained hemodynamically stable and

afebrile. Follow up with primary care provider planned within 3-5 days

and follow up with her usual gastroenterologist as instructed.

Nutrition Assessment – Diet History

• SS reported poor appetite with limited intake and difficulty

breathing prior to admission (PTA) due to symptomatic ascites

• Reported some nausea with vomiting

• Reported consuming 1-2 three oz. pre-digested whey protein

shots per day based on tolerance. Was taking Vita4Life

Bariatric MVI and Calcium (4 capsules/day). Reported not

taking extra B12.

• Denied ever having issues with dumping syndrome but did

state she has always had loose stools since the bypass

procedure

• Food preferences included cottage cheese, yogurt, pudding,

and peanut butter crackers

Laboratory Values

Lab 3/25 3/26 3/27 3/28

Na 132 L 136 133 L 135

K 4.2 3.5 4.0 4.1

Cl 95 109 H 108 H 107

Creatinine 0.71 L 0.61 L 0.57 L 0.53 L

BUN 11 7 5 L 6 L

Glucose 97 78 75 90

Ca 10.1 8.1 8.0 7.9 L

Mg 1.4 L 1.4 L 1.8 1.7

Phos 3.8 2.9 2.1 L 2.4

Albumin 3.6 2.5 L 2.4 L 2.2 L

AST 31 24 24 32

ALT 23 18 19 21

Lactate 2.3

Hemoglobin 10.2 L 9.2 L 9.1 L 9.2 L

Hematocrit 31.0 L 28.1 L 27.8 L 28.0 L

In-Patient MedicationsMedication Dosage Dates Received

Benadryl 12.5 mg IV 3/25

Magnesium sulfate 1-2 g in 50-100 mL IV 3/26, 3/28, 3/29

Oxycodone 5-10 mg 3/25-3/31

Potassium chloride 10 mEq in 100 mL IV 3/26, 3/29

Rocephin 1 g 3/25-3/31

Colace 100 mg PRN 3/26-3/31

Lovenox 50 mg BID 3/26-3/31

Drisdol 50, 000 units weekly 3/26-3/31

Lasix 40 mg BID 3/28-3/31

Lactulose solution 10 g q 6 hours PRN 3/26-3/31

Morphine sulfate 2 mg q 4 hours PRN 3/26-3/31

Medication Dosage Dates Received

Ocuvite 1 tablet daily 3/26-3/31

Zofran 4 mg q 6 hours PRN 3/26-3/31

Pancrelipase 5000 units TID with meals 3/26-3/31

Protonix 40 mg 3/25-3/31

Phenergan 12.5 mg IV 3/25-3/31

Inderal 10 mg 3/26-3/31

Xifaxan 550 mg 3/26-3/31

Mylicon 80 mg 3/26-3/31

Aldactone 50-100 mg 3/25-3/31

TPN 20-40 mL/hr 3/27-3/31

Vancomycin 750 mg 3/26-3/27

Vitamin B12 500 mcg tablet 3/26-3/31

TPN Orders

Date 3/27/14 3/28/14 3/29/14 3/30/14

Protein (grams) 38.4 (0.8 g/kg) 67.2 (1.4 g/kg) 81.6 (1.7 g/kg) 81.6 (1.7 g/kg)

Calories 416.5 kcal 792.21 kcal 1, 048.18 kcal 1, 048.18 kcal

Lipids (grams) N/A N/A N/A N/A

Dextrose (70%) 80 g/L 160 g/L 220 g/L 220 g/L

Volume 960 mL (40

mL/hr)

960 mL (40

mL/hr)

960 mL (40

mL/hr)

960 mL (40

mL/hr)

% Calorie Needs 29% 55% 73% 73%

% Protein Needs 40% 70% 85% 85%

Nutrition Diagnosis

• Inadequate oral intake (NI-2.1) related to cirrhosis

with ascites, chronic pancreatitis, h/o gastric bypass,

and poor PO intake PTA as evidenced by patient

complaints of anorexia, nausea with vomiting, and

consult for TPN for malnutrition.

Nutrition Prescription

Source Kcal

Requirements

Protein

Requirements

Fluid

Requirements

Facility Standards 1440-1920 kcal/day

(30-40 kcal/kg/day)

57-96 gm/day

(1.2-2 gm/kg/day)

1440-1920 mL/day

(30-40 mL/kg/day)

EAL N/A N/A N/A

Nutrition Care

Manual

1362.3 kcal/day

(BEE (Mifflin-St.

Jeor) x 20%)

38.4-57.6 gm/day

(0.8-1.2 g/kg/day)

Average healthy

adult – 30-35

ml/kg/day*

Height Weight BMI IBW % IBW

162.6 cm.

(64 in.)

48 kg

(106 lbs.)

18 54.5 kg

120 lbs.

88%

Nutrition Intervention

• 1. General Healthful Diet (ND-1.1): Recommend continuing current diet

with pancrelipase. Pt refused nutritional supplements. Will communicate pt

food preferences and add snacks (cottage cheese, yogurt, peanut butter

crackers).

• 2. Parenteral Nutrition/IV Fluids (2.2): Provide 1080-1440 kcals and 43-72

gm protein to meet 75% of estimated needs.

• 3. Collaboration with other providers (RC-1.4): Recommend appetite

stimulant. Recommend increasing pancrelipase (2 caps pancrelipase 12,000

units with meals) and providing it with meals (current order is to be given 1

hour before meals).

• 4. Referral to other providers (RC-1.5): Patient to follow-up with primary

physician or GI specialist as instructed to monitor home IV infusion of TPN.

Nutrition Monitoring and Evaluation

Indicator Criteria

Total Energy Intake (FH-1.1.1.1) Oral intake >50% of estimated

energy and protein needs.

Parenteral Nutrition Intake (FH-

1.3.2.1)

TPN solution to provide >75% of

estimated energy and protein needs.

Weight (AD-1.1.2) Weight gain of 0.5-1 lb/week

Nutrition-related

complementary/alterative

medicine use (FH-3.2.1)

Patient to continue using daily oral

vitamin and mineral supplements

due to risk of

malabsorption/maldigestion s/p

gastric bypass.

Case Discussion

• It is evident that the patient understood some aspects of long-

term nutritional care necessary since SS reported taking

appropriate protein supplements and vitamins PTA.

• A detailed diet history would have been very valuable to

evaluate just what the patient was consuming and what may be

contributing to the malnutrition.

• Important to take into account the increased needs as well as

being mindful of the possibility of refeeding syndrome with TPN

since the patient was malnourished.

• The origin of the cirrhosis could be a long-term complication of

the BPD surgery, secondary to chronic alcohol abuse and/or a

combination of these.

Case Discussion

• Chronic abdominal pain also may be secondary to cirrhosis

with ascites, pain associated with chronic pancreatitis, and/or

generalized low pain tolerance.

• Analgesic drugs continue to be a primary means to control

chronic abdominal pain related to chronic pancreatitis.

• The nausea with vomiting could be worsened by excessive

opioid use that the patient required for pain control.

If Only I Had Asked…

• How much weight was lost in total since the

surgery?

• What was the patient actually eating at home?

• How long had the alcohol abuse been

occurring and what was the extend of it?

Implication of Findings to Dietetics

• Dietitians must be able to recognize and distinguish

between normal and abnormal nutritional status

following bariatric procedures to ensure patients are

successful at weight loss while optimizing proper

nutritional status.

• This case highlights the importance of completing a

thorough nutritional assessment to identify all

contributing factors related to the patient’s condition.

References

• "Bariatric Surgery." 2014. Nutrition Care Manual. Document. 16 May 2014.

• Clinic, Mayo. Video: Biliopancreatic diversion with duodenal switch. 2014.

http://www.mayoclinic.org/tests-procedures/bariatric-

surgery/multimedia/biliopancreatic-diversion/vid-20084649. 16 May 2014.

• Ertelt, Troy W., et al. "Alcohol abuse and dependence before and after bariatric

surgery: A review of the literature and report of a new data set." Surgery for

Obesity and Related Diseases (2008): 647-560. Document.

• Flamm, Steven. "Rifaximin treatment for reduction of risk of overt hepatic

encephalopathy recurrence." Therapeutic Advances in Gastroenterology

(2011): 199-206.

• Gachago, Cathia and Peter V Draganov. "Pain management in chronic

pancreatitis." World Journal of Gastroenterology (2008): 3137-3148.

• MedLinePlus. 14 May 2014. 19 May 14.

<http://www.nlm.nih.gov/medlineplus/ency/imagepages/19500.htm>.

• Story of Obesity Surgery - Biliopancreatic Diversion and Duodenal Switch.

2014. 16 May 2014. <http://asmbs.org/story-of-obesity-surgery-biliopancreatic-

diversion-and-duodenal-switch/>.