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Clinical Case Report: Nutritional Management of Colon Cancer

Clinical Case Report: Nutritional Management of Colon Cancer. Andrea Stumpo ARAMARK Dietetic Internship Underwood Memorial Hospital January 4, 2013. Disease Description. Colon Cancer Etiology > 60 years of age Diet high in red meat Epidemiology 4 th most common form of cancer

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Clinical Case Report: Nutritional Management of Colon Cancer

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  1. Clinical Case Report: Nutritional Management of Colon Cancer Andrea Stumpo ARAMARK Dietetic Internship Underwood Memorial Hospital January 4, 2013

  2. Disease Description • Colon Cancer • Etiology • > 60 years of age • Diet high in red meat • Epidemiology • 4th most common form of cancer • Pathology • Non-cancerous polyps that become cancer • Clinical Signs and Symptoms • Abdominal pain, bloody stool, weight loss, change in bowel habits

  3. Disease Description • Diverticular Disease • Epidemiology • 60% > 70 years of age • Diverticulitis is rare • Pathology • Diverticula formation • Inflamed= Diverticulitis • Clinical Signs and Symptoms • Lower abdominal pain, fever, leukocytosis

  4. Disease Description • Small Bowel Obstruction • Etiology • Mechanical blockage vs. “something in the way” • Pathology • Obstruction of GI tract • Clinical Sign and Symptoms • Abdominal swelling, fullness, gas, breath odor, constipation, diarrhea, inability to pass gas, and vomiting

  5. Disease Description • Left colectomy • Procedure details • Removing one side and attaching it to the other • Reasons for Procedure • Necrotic tissue, inflammatory bowel disease, obstructions, lower gastrointestinal complications • Jejunal Ileostomy • Procedure details • Fecal matter diverted to a bag outside the body • Reason for procedure • Inflammatory bowel disease, colon or rectal cancers, familial polyposis, birth defects of the intestines, or damage to intestines via accident

  6. Evidence-Based Nutrition Recommendations • Article 1 • Author: Bozzetti, Gianotti, Braga, et al • Statistical Analysis: Pearson’s chi-square test • 1410 subjects • Evaluation of effectiveness of TPN, EN, IEEN, and SIF Bozzetti, Gianotti, Braga, et al. Postoperative complications in gastrointestinal cancer patients: The joint role of the nutritional status and the nutritional support. Clinical  Nutrition: An International Journal Devoted to Clinical Nutrition and Metabolism.  2007;Volume 26, Issue 6: 698-709.

  7. Article 1 (continued) • Findings: • Nutritional support decreased the morbidity vs. standard IV fluids in postoperative patients being treated for gastrointestinal cancers • Increase in the effects of PN, EN and IEEN in these postoperative pts • Overall Mortality of 2.1% was increased in malnourished pts Bozzetti, Gianotti, Braga, et al. Postoperative complications in gastrointestinal cancer patients: The joint role of the nutritional status and the nutritional support. Clinical  Nutrition: An International Journal Devoted to Clinical Nutrition and Metabolism.  2007;Volume 26, Issue 6: 698-709.

  8. Evidence-Based Nutrition Recommendations • Article 2 • Author: Gamze Akbulut • Review of current literature • Examination of nutrition support in patients with cancer Akbulut, Gamze. New perspective for nutritional support of cancer patients: Enteral/parenteral nutrition. Experimental and Therapeutic Medicine. 2011; 2(4): 675-684.

  9. Article 2 (continued) • Findings: • Three goals of TPN therapy • Stabilize the nutritional risk of patients or reduce the progressive weight loss of these patients • Improve patients’ quality of life • Increase the effectiveness reduce the side effects of anticancer therapies • Decreases catabolism that results from cancer Akbulut, Gamze. New perspective for nutritional support of cancer patients: Enteral/parenteral nutrition. Experimental and Therapeutic Medicine. 2011; 2(4): 675-684.

  10. A.S.P.E.N Evidence-Based Guidelines • Guideline B2 • “If there is evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation” • Evidence (Grade C) • Study suggests that PN therapy in malnourished patients is associated with overall fewer complications Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; Volume 33, No.3: 277-316.

  11. Case Presentation • Current visit • Weakness and difficulty with po intake • N/V • PICC placement • Trial with clear liquid diet • Initiation of Procalamine and TPN therapy

  12. Nutrition Care Process: Assessment • Client history: • Stage IV adenocarcinoma of the colon with recurrent and extensive carcinomatosis • Left hemicolectomy • End colostomy • Jejunal ileostomy • Oral thrush • Anxiety • Hypothyroidism • Perforated Bowel • Degenerative joint disease • Obesity

  13. Nutrition Care Process: Assessment • Food/Nutrition Related History • Extreme N/V • No supplementation • Food supply access available • Limited physical activity • Decrease in quality of life

  14. Nutrition Care Process: Assessment • Nutrition-Focused Physical Findings • Dehydration-Acute kidney injury • No physical signs of muscle wasting or sunken fat pads • History of obesity • Oral thrush • Weakened immune system

  15. Nutrition Care Process: Assessment • Anthropometric Measurements • Weight: 64 kg • Height: 5’4” • BMI: 24.22- within normal range

  16. Nutrition Care Process: Assessment • Biochemical Data, Medical Tests, and Procedures • Elevated BUN, creatinine, and phosphorous • GFR: 10.69 • Elevated blood glucose and CO2 levels • Low chloride and sodium levels

  17. Nutrition Care Process: Assessment • Nutrient needs • Kcal needs: 30-35 kcal/kg- 64 x (30-35 kcal/kg)= 1920-2240 kcal • Protein needs: 0.8 gm/kg- 64 x 0.8= 51.2 grams of protein • Fluid needs: 30-35 ml/kg- 64 x (30-35 ml/kg)= 1920-2240 ml

  18. ARAMARK Nutrition Status Classification • Assessed nutrition level • Severely compromised • Criteria • No appetite (< 50% for > 2 weeks)- 4 points • Pt currently on TPN therapy- 4 points • >10% weight loss in 6 months (81 lb. loss from 6/11/12-12/13/12)- 4 points • Diagnosis of GI obstruction- 4 points • Diagnosis of colon cancer- 3 points • Total: 15 points

  19. Diagnosis-Related Group (DRG) • Other Severe Protein-Energy Malnutrition • Clinical Evidence includes: • Inadequate intake > 3 days • < 90% of UBW

  20. Nutrition Care Process: Diagnosis • NI-2.1: Inadequate oral intake related to persistent nausea and vomiting and inability to keep anything down as evidenced by patient consuming less than 25% of kcal needs and 81 pound weight loss in ~ 6 months.

  21. Nutrition Care Process: Intervention • Medical Intervention: • PICC placement • Nutrition Intervention • Parenteral Nutrition/IV fluids • ND-2.2.1: PN therapy: Procalamine-TPN prescription • ND-2.2.3: IV fluids • Trial with clear liquid diet

  22. Nutrition Care Process: Monitoring and Evaluating • Goal: Patient will improve her nutritional status and gain strength through PN therapy and IV fluids to prevent further weight loss • FH-1.3.2: Parenteral Nutrition Intake (Formula and IV fluids) • Initial recommendations: 1290 ml 30% Dextrose,510 ml 10% Amino Acid, and 200 ml 20% Lipids • Follow-up recommendations: 1105 ml 30% Dextrose, 770 ml 10% Amino Acid, 300 ml 20% Lipids

  23. Conclusion • Pt with multiple comorbidities • Solely on TPN therapy after failure with clear liquids trial • Pt d/c on TPN therapy • With improvement in nutritional status and stabilization of weight status, pt may be eligible for chemotherapy treatment for colon cancer

  24. References • Akbulut, Gamze. New perspective for nutritional support of cancer patients:  Enteral/parenteral nutrition. Experimental and Therapeutic Medicine. 2011; 2(4): 675-684. • American Dietetic Association. Pocket Guide for International Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Chicago, IL; 2011. • Boyle and Langman. Epidemiology. British Medical Journal. 2000; 321(7264): 805-808.   • Bozzetti, Gianotti, Braga, et al. Postoperative complications in gastrointestinal cancer  patients: The joint role of the nutritional status and the nutritional support. Clinical  Nutrition: An International Journal Devoted to Clinical Nutrition and Metabolism. 2007;Volume 26, Issue 6: 698-709.   • Colectomy. Mayo Clinic. Accessed January 4, 2013.  http://www.mayoclinic.com/health/medical/IM00232 • Colon Cancer. A.S.A.M. Medical Encyclopedia. PubMed Health. Updated November 17, 2012. Accessed January 4, 2013. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001308/

  25. References (continued) • Colon Cancer. Mayo Clinic. Accessed January 4, 2013. http://www.mayoclinic.com/health/colon-cancer/DS00035/DSECTION=causes • Estimation of Energy Expenditure for Adult Patients. University of Virginia Health System. 2008. Accessed January 4, 2013. http://www.healthsystem.virginia.edu/pub/dietitian/nutrition_manual/energy-expenditures-uva-modifications • Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition. 2009; Volume 33, No.3: 277-316. • Ileostomy. MedlinePlus. Accessed January 4, 2012. http://www.nlm.nih.gov/medlineplus/ency/article/007378.htm • Intestinal obstruction. MedlinePlus. Accessed January 4, 2013. http://www.nlm.nih.gov/medlineplus/ency/article/000260.htm • Sheth, Longo and Floch. Diverticular Disease and Diverticulitis. American Journal of Gastroenterology. 2008; 103:1550-1556.

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