Gastric Cancer By Heidi Thomason, RD Intern
Possible Gastrointestinal bleed • Mr. Anderson • 91 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
Physical Anthropometrics & Biochemical Results • 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
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. changes • Can 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 ICU • No BM for 4 days, hypo BS, flatus absent • Tube feed ordered, RD consult ordered • TF 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 allergies • No food intolerances • No difficulty chewing or swallowing • No food preferences • Regular diet followed at home • Usual appetite is good • Skin 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 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 11/11 • 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 • Accuchecks11/9-11/11: 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 sets • Helicobacter pylori infection • Anemia • Functional 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.