Jamison, John Bryan O.

HNF 41 A-2L

April 28, 2015

Maam Ilagan

EXERCISE 7: Medical Nutrition Therapy for Peptic Ulcer Disease,

And Disease of the Liver and Biliary Tract
I.

INTRODUCTION

One of the most common problems in health care is GI disorders. There are over 50 million visits
to ambulatory care facilities for signs and symptoms related to the digestive system, and over 10 million
surgical procedures involving the GI tract are done annually. Food habits have a large role in the
development of these GI disorders. This can determine the onset, prevention and treatment. Overall, the
type of diet during treatment can alleviate patients well-being and quality of life by improving the
patients condition, decreasing the pain, suffering, worry, healthcare visits and the costs associated with
GI disease. (Escott-Stump, S & LK Mahan, 2004)
The gastrointestinal tract is a structure in the body involving food with its nutrients absorbed,
wastes collected and eliminated, vitamins synthesized, and enzymes produced. One can see that the GIT
is like the powerhouse of the body, which provides us energy to thrive thus, a lot of chemical processes
happen in this system (Porth, 2010). Obstructions in the GI tract will cause great harm to the person and
requires not only medical intervention but also nutritional intervention for the prevention, treatment and
maintenance after the treatment.
II.

OBJECTIVES
At the end of the exercise, I was able to:
1. Analyze the data if different case patients with specified GIT-related illnesses
requiring dietary management;
2. To plan and prepare diets modified in energy, fat and protein; and
3. To evaluate the modified diets with due consideration to the principles of dietary
management.

III.

SUMMARY OF INSTRUCTIONS AND METHODOLOGY

Three different cases relating to GI tract disorders were analyzed. These are Diseases related
to the gallbladder specifically cholecystolithiasis, related to liver diseases specifically cirrhosis, and
related to the stomach specifically peptic ulcer. The Nutrition Care Process are performed to the
different case patients. The given information were summarized and interpreted for the statements
in Nutrition assessment. This assessment was then analyzed and made nutrition diagnosis based from
the given assessment. The best nutrition intervention was then made specifically for each diagnosis
and the planned monitoring and evaluation was summarized for effects seen in every intervention.
This was documented and summarized in attachment 1.1, 2.1 and 3.1 for cholecystolithiasis, liver
disease, and peptic ulcer, respectively. Specific dietary plan was then summarized and attached to
1.2, 2.2, and 3.2, respectively. Each dietary recommendations had rationale explaining why that kind
of diet is recommended.

Attachment 1.1 ADIME Chart of a Case Patient having Cholecytoslithiasis

ASSESSMENT
Patient hx: 50 year old
female with weight 77 kgs
and height 52; The
computed BMI is 31.05,
thus the nutritional status
of the patient is obese
(WHO);
Medical hx: admitting
diagnosis was
cholecystolithiasis as
evidenced by irregular
density at the right upper
quadrant showed in x-ray
and stones, thickened
gallbladder wall within
dilatation as revealed
ultrasonography; suffered
from severe epigastric
pain; has on and off pain
radiating from upper right
quadrant and to the back
for almost a year. Blood
tests shown increased
WBC, increased indirect
bilirubin, and increased
cholesterol levels;
Calculated BMI of 31.04;
Nutrition hx: Preference
for salty and fried food,
chocolates and chicharon;
assessed with low fluid
intake.

DIAGNOSIS

Obesity R/T
preference of salty
and fried foods and
chocolates AEB BMI
of 31.24
Excessive fat intake
R/T preference of
fried foods like
chicharon as AEB
increased cholesterol
levels in blood test
results
Excessive sodium
intake R/T salty food
preferences AEB
formation of
gallsontes

INTERVENTION

Patient will attend

nutrition counseling
about the disease
cholecystolithiasis
(pathophysiology),
recommended food
choices specific for
that disease for
treatment and
recurrence
Patient will attend
nutrition counseling
about weight
management.
Recommending
alleviating physical
activity and avoid
certain food.
Before operation,
follow the
recommended diet
that is low sodium,
low fat and calorie
restricted diet. Also
high protein is
recommended (See
Attachment 1.2 for a
recommended sample
one day diet)
After operation,
follow the
recommended diet
that is Clear liquid to
Full Liquid to Low fat,
Low fiber and
avoidance of gas
forming foods to Diet
as tolerated.

MONITORING AND EVALUATION

Monitoring:
The patient will have follow ups for
different sessions organized by the
dietitian. Session 1: Introduction of
MNT and the disease and a few
recommendations for the
management of the disease. Food
diary is kept. Follow the diet plan.
(after a week)Session 2: food diary
is checked. Review of what is
learned then. Introduce the allowed
and restricted food in the diet.
Introduce weight management.
(after the treatment) Session 3:
food diary is checked. Review of
what is learned then. The treatment
for cholecystolithiasis is now
assumed to be done. Prevention of
recurrence of stone is implemented.
Thus, weight management will now
be focused. Physical activity will
increase. And the reducing diet will
be heightened Session 4: food diary
is checked. Monitoring of the
weight management.
Evaluation:
Recommended to continue the
prescribed diet. Comparison to a
standard data to figure out the
abnormalities in the process. If the
goal is not met/ the problem is not
solved, change the intervention.

Attachment 2.1 ADIME Chart of a Case Patient Having Liver Disease

ASSESSMENT
DIAGNOSIS
INTERVENTION
Patient hx: A 36 year old male
construction worker with a
weight of 72 kgs and height of
54; Calculated BMI is 27.25 ;
thus, the nutritional status of
the patient is overweight;
Medical hx: brought to the
hospital with physical signs
and symptoms specifically
being weak, listless, with skin
and sclera being yellowish in
color. Complained with
abdominal fullness and
abdominal girth was
increasing each day of
confinement. The laboratory
results reported high in direct
bilirubin and SGOT. He was
diagnosed with Laennecs
Cirrhosis. The initial dietitian
increased his dietary
requirement except for fat and
sodium.
Nutrition hx: Habitual drinking
of alcohol after work and
during weekends influenced
by the neighborhood.

Excessive alcohol
intake R/T work rituals
and neighborhood
influence AEB dietary
habits
Overweight R/T
increased intake of
alcohol Intervention
AEB dietary habits
Increased bilirubin R/T
Excessive alcohol
intake AEB jaundice

Nutrition counseling
about the liver disease
- cirrhosis
(pathophysiology) and
its management as
well as the allowed
and restricted food in
this disease.
Nutrition counseling
about weight
management. In this,
alcohol management
is included. PERSUADE
the patient to
progressively quit
alcohol.
Follow the
recommended diet
plan with specific
protein requirement
and low sodium diet.
(see attachment 2.2)

MONITORING AND
EVALUATION
Monitoring:
The patient will have follow ups
for different sessions organized
for the dietitian. Session 1:
Introduction of cirrhosis and its
management. Food diary is
given. Monitor weight for
sodium intake. Follow the diet
plan.
Session 2: Review of what is
learned. Food diary is checked.
Introduce the allowed and not
allowed foods in the diet for
more variations in the diet plan.
Monitor the weight for sodium
intake. Follow the diet plan.
Session 3: In this session, it is
assumed that the patient is
already treated. Food diary is
checked. Introduce preventive
measure for the recurrence of
the disease. Introduce weight
management, recommend a
calorie restricted diet.
Session 4: Food diary is
checked. Monitoring of the
weight management. Still have
follow ups every month for the
monitoring of the weight
management.
Evaluation: Compare with a
standard data to figure out
evaluation in the process and
further improve. If the goal is
not met/ the problem is not
solved, change the intervention.

Attachment 3.1 ADIME Chart of a Case patient having Peptic Ulcer

ASSESMENT
DIAGNOSIS
INTERVENTION
Patient hx: A 50 year old male
Increased gastric
Nutrition Counseling
overall operations manager with
acidity R/T skipping
about peptic ulcer, its
height 55 and weight 57 kg.
meals and excessive
management, as well
Computed BMI is 20.9 thus the
coffee intake AEB
as the foods allowed
nutritional status is Normal.
peptic ulcer
and restricted.
Medical hx: 3 months prior to
Increase gastric
Nutrition Counseling
admission, experiences dull
acidity R/T frequent
about healthy
gnawing pain in the upper
alcohol intake AEB
lifestyle and healthy
abdomen. A month prior to
peptic ulcer
food choices for the
admission, the pain become more Increased gastric
prevention of
persistent and with complains of
recurrence of
acidity R/T Use of
indigestion. Took Maalox as an
disease.
cigarette AEB peptic
aid. On the day of admission,
ulcer
Follow the
vomiting blood was occurring and
recommended diet
thus rushed in the hospital.
of bland diet and
Diagnosed with gastric ulcer at the
balanced diet. As well
lower curvature showed by gastric
as high protein. (See
x-ray. Treated with blood
attachment 3.2)
transfusions, IV fluids, and
electrolytes, including Vit C.
Nauseated but no vomit. Stools
was then tarry. End of the second
week in the hospital, he was
allowed to go home.
Nutrition hx: frequently misses
meals. Habitual coffee drinker; If
ever takes meals, those meals are
usually on the go or on odd hours;
habitual smoker and vodka
drinker.
Recommendations of the
clinician: Advised to slow down,
quit smoking and go slow in
alcohol beverages, eat regularly
and watch his diet, and have
adequate rest BEFORE going to
work.

MONITORING AND EVALUATION

Monitoring:
Have follow ups organized into
sessions by the dietitians. Session
1: Introduction of the diseases and
its management. Food diary is
given. Follow the prescribed diet.
Session 2: Review of what is
learned, food diary is checked. List
the foods that are allowed and not
allowed. Give further
recommendations on how to
prevent on the recurrence of the
disease
Session 3: Review of what is
learned. Food diary is checked.
Lecture about healthy food choices
and healthy lifestyle and the
benefits of this.
Evaluation:
Compare with a standard data to
figure out evaluation in the process
and further improve. If the goal is
not met/ the problem is not solved,
change the intervention

IV.

COMPUTATION OF PLANNED MEALS/ MENU

Case 1: Cholecystolithiasis

Profile
Female
Weight 77 kg
Height 5 feet 2 inches = 62 inches = 157.48 cm
Computation of the BMI
=kg/m2
=77 kg/(1.57482)
=31.05
Classification (WHO): Obese Class I
Computation of the DBW (Tannhaussers)
= 157.48 100 = 57.48 5.748
= 51.73 kg
Computation of the TER (Krause)
= ABW x PA
= 77 x 27.5
= 2117.5 Kcal
Rationale: ABW instead of DBW is used since the
person might be too shocked with reduced
energy requirement. The PA used is bed rest
since he is confined in the hospital.
= 2117.5 kcal 500 kcal
= 1617.5 1600 Kcal
Rationale: A reducing diet is recommended to
obese patient even before going to surgery. Just
make sure that there is enough carbohydrate for
glycogen stores (Ruiz, Claudio & de Castro, 2004)
Distribution of the TER into CPF
Before Surgery
General recommendations:
Low calorie diet for obese patients
(recommended even before surgery)
Adequate carbohydrate for glycogen
stores and for sparing of proteins
High protein for rapid wound healing,
resistance to infection, nitrogen
reserves, prevent edema from occurring
at site of the wound, protect liver
against toxic effects of anesthesia and to

promote regeneration of hemoglobin

(Ruiz, Claudio & de Castro, 2004)
Low Fat for the prevention of the pain
Other specific recommendation is in the
one day diet plan
Determination of PRO requirement (NPC
method):
1.65 g/kg ABW (addition of 50% normal
protein allowances/day) is used for NPC
method
1.65 x 77
= 127.05 g 125 g PRO
Determination of CHO and FAT requirement
= 127.05 g PRO x 4 = 508.2 Kcal PRO
= 1600 508.2 = 1091.8 Kcal remaining for
CHO and FAT
= .85 (1091.8)/4 = 232 g 230 g CHO
= .15 (1091.8)/9 = 18.19 g 20 g FAT
Rationale: 85 15 is used for CHO and FAT,
respectively because the recommended diet
is low in fat. With this, only 10% fat is in the
total calories.

DRX 1600 Kcal C230g P125g F20g

Table 1.1 Distribution of CPF into exchanges
Food Group
Vegetables
Fruit
Milk (Very Low
Fat)
Sugar
Rice
Meat (Lean Meat)
Meat (Medium
Fat)
TOTAL

Ex
3
3
1
4
7
11

CHO
(g)
9
30

PRO
(g)
3

12
20
161

1
232

FAT
(g)

KCAL
48
120

14
88

11

80
80
700
451

86

121

17

1565

Table 1.2 Distribution of exchanges into meals

Vegetables
Fruit
Milk (Very
Low Fat)
Sugar
Rice
Meat (Lean
Meat)
Meat
(Medium
Fat)
TOTAL %
per meal

1
1

1
1

1
1
1

1
29.71

2.56

33.23

2.56

31.95

After Surgery
General Recommendations:
A progressive diet is recommended with again
high protein, low calorie and adequate
carbohydrate with the same reason above.
1. NPO
2. Clear liquid
3. Full Liquid
4. Low fat, Low fiber and avoidance of gas
forming foods (this will help the body adjust
to its non-gallbladder state).
5. Diet as tolerated.

CASE 2: Liver Disease

Distribution of TER into CPF (NPC)

Profile
Male
Weight: 72 kg
Height: 54 64 inches 162.56 cm
= 157.48 cm

Determination of PRO Requirement

1.5 g/kg ABW will be used as factor for
PRO requirement
1.5 x 72 = 108 g PRO 110 g PRO

Computation of the BMI

=kg/m2
=72 kg/(1.62562)
=27.25
Classification (WHO): Pre Obese

Determination of CHO and FAT

108 g PRO x 4 = 432 Kcal PRO
1980 -432 = 1548 Kcal from CHO and FAT
0.70(1548)/4 =270 g CHO
0.30(1548)/9 = 50 g FAT

Computation of the DBW (Tannhaussers)

= 162.56 100 = 62.56 6.256
= 56.30 kg 56 kg

DRX: 2000 Kcal C270 g P110g F50 g

Table 2.1Distribution of CPF into exchanges

Computation of the TER (Krause)

= ABW x PA
= 72 x 27.5
= 1980 2000 Kcal
Rationale: ABW instead of DBW is used since the
person might be too shocked with reduced
energy requirement. The PA used is bed rest
since he is confined in the hospital.

Food Group
Vegetables
Fruit
Milk (Whole)
Sugar
Rice
Meat (Lean Meat)
Meat (Medium
Fat)
Meat (High Fat)
Fat

Rationale: I will not recommend a reducing diet

even though he is pre obese since it may slow
down the healing process.

Ex
3
3
1
2
9
9

CHO (g)
9
30
12
10
207

1
0
5
268

TOTAL

Table 2.2 Distribution of Exchanges into meals

Vegetables
Fruit

1
1

Milk (Whole)

1
1

1
1

0.5

0.5

Milk (Low Fat)

Milk (Very Low Fat)
Sugar
Rice
Meat (Lean Meat)
Meat (Medium Fat)

3
2
1

3
4

3
3

1
29.06

2
31.15

2
29.06

Meat (High Fat)

Fat
TOTAL % per meal

5.36

5.36

PRO
(g)
3

FAT
(g)

10

18
72

KCAL
48
120
170
40
900
369

8
0

6
0
25

86
0
225

109

50

1958

Case 3: Peptic Ulcer

Profile
Male
Weight 57 kg
Height 5 feet 5 inches = 65 inches = 165.1 cm

Table 3.1 Distribution of CPF into exchanges

Food Group
Vegetables
Fruit
Milk (Whole)
Milk (Low Fat)
Milk (Very Low Fat)
Sugar
Rice
Meat (Lean Meat)
Meat (Medium Fat)
Meat (High Fat)
Fat

Computation of the BMI

=kg/m2
=57 kg/(1.6512)
=20.91
Classification (WHO): Normal

Ex
3
3
1

3
8
7
1

CHO
(g)
9
30
12
0
0
15
184

PRO
(g)
3

FAT
(g)

8
0
0

10
0

16
56
8
0

4
250

TOTAL

91

7
6
0
20

KCAL
48
120
170
0
0
60
800
287
86
0
180

43

1751

Computation of the DBW (Tannhaussers)

= 165.1 100 = 65.1 6.51
= 58.59 kg 59kg
Table 3.2 Distribution of exchanges into meals

Computation of the TER (Krause)

= DBW x PA
= 59 x 30
= 1770 1750 Kcal
Rationale: DBW instead of ABW is used since the
person is not overweight. He needs the increase
of energy for the healing process. The PA used is
sedentary since he is no longer in the hospital
but still is advised to have adequate rest before
going to work.
Distribution of the TER (NPC)
Determination of PRO
1.5 g/kg DBW is used since high protein
is still recommended to hasten the healing
process.
1.5 x 59 kg = 88.5 g 90 g PRO
Determination of CHO and FAT
88.5 g PRO x 4 = 354 Kcal PRO
1770 354 = 1416 Kcal for CHO and FAT
0.70 (1416)/4 = 247.8 g 250 g CHO
0.30 (1416)/9 = 47.2 g 45 g FAT

DRX: 1750 Kcal C250 g P90g F45g

Vegetables
Fruit
Milk
(Whole)

1
0.5

0.5

1
0.5

0.5

1
1

2
1

1
18.90

1
20.73

1
22.33

1
17.30

Fat
TOTAL %
per meal

1
0.5

0.5

Sugar
Rice
Meat
(Lean
Meat)
Meat
(Medium
Fat)

20.73

Attachment 1.2 A One Day Meal Plan for the Case Patient having Cholecystolithiasis

DRX 1600 Kcal C230g P125g F20g

Recommendations:

Sodium Restricted (>2000 mg)

Low Fat
High Protein
Calorie Restricted

Pre-operative diet:
Dish/ food

Final Amount

Exchange

FOOD GROUP

Boiled Carrots

45 g

Veg A

Fruit

Rice

Meat lean

meat med

Pastillas

sugar

Boiled cow pea

Santol
Rice
Grilled pork
tenderloin

1
1
3

Veg B
Fruit
Rice

meat

hard candy

Sugar

boiled green peas

Strawberry shake:
Strawberry
Milk
Rice
broiled chicken leg

veg

fruit

1
2
4

very low fat

rice
lean meat

Banana
Boiled Rice

160 g

Grille Breast
Chicken
Boiled egg

After Surgery
General Recommendations:
A progressive diet is recommended with again
high protein, low calorie and adequate
carbohydrate with the same reason above.
1. NPO
2. Clear liquid

3. Full Liquid
4. Low fat, Low fiber and avoidance of gas
forming foods (this will help the body adjust to
its non- gallbladder state).
5. Diet as tolerated.

Attachment 2.2 A One Day Meal Plan for the Case Patient having liver disease

DRX: 2000 Kcal C270 g P110g F50 g

Recommendations:

Moderate protein
Use of BCAA
Use of MCT as fats with essential fatty acid
Vitamin C, K, zinc, and magnesium rich foods
Sodium restriction

Dish/ food

Ingredients

Final
Amount

Exchange

FOOD GROUP

Veg B

Banana
Rice

1
1
1
3

meat lean
fat
fruit
Rice

Boiled Chicken leg

Meat lean

Boiled Carrots
Fried Egg

egg
oil

Pastillas with milk powder

Pastillas
Milk

1
0.5

Sugar
Milk whole

Boiled green peas

Apple
Rice
Fried Tenderloin

green peas
apple
Rice
tenderloin
oil

1
1
3
4
2

veg
fruit
Rice
lean meat
fat

Yema

Milk
Sugar

0.5
1

Milk
Sugar

Buttered corn

corn

veg

oil

fat

lean meat

1
3
1

fat
Rice
Fruit

sauteed chicken breast

Rice
Orange

*oil = coconut oil

chicken
breast
oil
Rice
Orange

Attachment 3.2 A One Day Meal Plan for the Case Patient having Peptic Ulcer

DRX: 1750 Kcal C250 g P90g F45g

Recommendations:

Bland diet to stop irritation

High protein diet to facilitate wound healing
Balanced diet to provide good nutrition
Small frequent feedings

Exchange

FOOD
GROUP

boiled carrots

Veg

strawberry
Rice
Boiled chicken
boiled egg

1/2
2
1
1

Fruit
Rice
Lean meat
med meat

bread
chicken
mayo
banana
milk
sugar

1
1
1
1
1/2
1

rice
meat lean
fat
fruit
milk whole
sugar

Tenderloin
Oil

1
1/2
2
2
1

veg
fruit
rice
Lean meat
Fat

1/2

fruit

1/2

milk

Chicken leg
oil

2
1
1

Rice
meat
fat

Buttered Corn

corn
butter

1
1

veg
oil

Pineapple tidbits with sugar

pineapple

1/2

fruit

sugar

2
1
2

sugar
rice
lean meat

Dish/ food

Chicken Sandwich

Banana shake

Boiled Green peas

Orange
Rice
Grilled Tenderloin

Papaya with milk powder

Rice
Fried chicken leg

pan amerikano
boiled chicken

Ingredients

Papaya
Powdered
milk

Final
Amount

V.

GUIDE QUESTIONS

Case 1: Cholecystolithiasis
1. Describe a gallbladder by its anatomy and functions.
The gallbladder is a pear shaped, hollow structure located on the undersurface of the liver
by the right side of the abdomen. The main function of this organ is to concentrate, store and
excrete bile. The gallbladder serves as the reservoir for bile that is not immediately used for
digestion. (Ruiz, Claudio & de Castro, 2004)
2. What is bile? Bilirubin?
Bile is used for the emulsification of fats. The constituents of bile are cholesterol, bilirubin,
and bile salts. Bile also contains immunoglobulins for the support of the integrity of intestinal
mucosa. Bile is removed from the liver via bile canaliculi that drain into intrahepatic bile ducts.
Bilirubin is the main bile pigment. This is derived from the release of hemoglobin from RBC
destruction. It is then transported to liver, where it is used to make bile. (Escott-Stump, S & LK
Mahan, 2004)
3. Why does Lornas pain persist after eating a fatty meal? What is cholecystolithiasis? What
factors could have promoted the development of a gallbladder disease?
Cholecystolithiasis is the formation of gallstones with infection in the gallbladder. The
pain is more evident during a fatty meal because the gallbladder tends to excrete bile to facilitate
in the emulsification of fats but since the gallbladder is impaired due to gallstones, the lining of
the gall bladder is trucked by the stones causing the pain. Risk factors that could contribute for
the development of the stones are female gender, pregnancy, older age, family history, truncal
body fat distribution, diabetes mellitus, inflammatory bowel diseases, and drugs. (Escott-Stump,
S & LK Mahan, 2004)
4. What kind of diet would work best for Lorna? Why? What is your recommended prescription
for Lorna? Give an explanation for your recommendation/s?
Low fat, low salt diet works best for Lorna. This is to prevent the pain to occur. The
occurrence of pain may be induced during a fatty meal because the gallbladder tends to excrete
bile for the emulsification of fat, but since there is an impaired gallbladder due to the formation
of stones with infection, pain will persist every time there is a fatty meal. A low calorie diet should
also be given for the reduction of weight. (Escott-Stump, S & LK Mahan, 2004)
5. Should there be a corresponding change in the type of fat given to her? Why?
The type of fat given should not be fat coming from animal sources since it stimulates
more the secretion of bile but instead shifting the source to fat coming from plant sources.
(Escott-Stump, S & LK Mahan, 2004)
6. After cholecystectomy, what will be your recommended diet?

General Diet: Cholecystectomy is the surgical removal of the gallbladder. To adjust the body for the
change, the recommended diet is low fat, low fiber with the avoidance of gas forming foods. Spicy foods
can also cause some gastro intestinal symptoms thus should be avoided. Low fat food is recommended
because the body is still adjusting to the change since the gallbladder is no longer there and the liver
directly leaked the small amount of bile into the small intestine, thus low fat diet will facilitate the change.
Low fiber diet with the avoidance of gas forming food may cause discomfort thus be careful to introduce
the food slowly over time. (Escott-Stump, S & LK Mahan, 2004)
Specific Diet: Clear liquid to Full Liquid to Low fat, Low fiber and avoidance of gas forming foods to
Diet as tolerated. (Escott-Stump, S & LK Mahan, 2004))
Case 2: Liver Disease

1. What are the functions of the liver?

The functions of the liver include a multitude of function. This includes metabolism,
detoxification and regeneration. Metabolism includes metabolizing carbohydrate, protein and fat.
Detoxification includes detoxifying alcohol, drugs, waste, and other foreign substances and
regeneration of the organ itself when it is damaged. The liver also maintains the body in functioning
and keeping it to be healthy. (Ruiz, Claudio & de Castro, 2004)
2. What is jaundice? What are the types, if any? How does it occur?
Jaundice exists in impaired liver. It is a syndrome that is directly related to hyperbilirubinemia.
This results in the yellowing of the skin, mucous membrane and sclera. There are two types of
jaundice, prehepatic, hepatic and posthepatic. Prehepatic or hemolytic jaundice results from massive
destruction of RBC. Hepatic or toxic jaundice results from immature liver that cannot convert fat
soluble bilirubin to water soluble form. Post-hepatic or obstructive jaundice results when the flow of
bile into the duodenum is blocked. (Ruiz, Claudio & de Castro, 2004)

3. Explain and correlate the biochemical results with the disease.

According to biochemical lab results of the patient, he has increased direct bilirubin and SGOT.
With increased bilirubin in the general circulation, the bilirubin gets attached to the elastic tissues
since it has an affinity for them, thus, the manifestation of the yellowing of the skin and the sclera.
SGOT, is not called AST or alanine amino transferase. It is used in detecting liver damage since this
enzyme is located in the cytosol and mitochondria of hepatocyte though it can also in cardiac and
skeletal muscle, brain, pancreas, kidney and leukocytes. (Escott-Stump, S & LK Mahan, 2004)

4. What is Laennecs Cirrhosis? What happens when the liver gets deranged with alcohol?
Laennecs Cirrhosis is also known as alcoholic cirrhosis that is the third stage of alcohol
hepatitis. This type of cirrhosis is induced by alcohol. It has the same symptoms as Alcohol hepatitis.
When the liver gets deranged with alcohol, several nutritional problems may occur. This impairs the
hepatic amino acid uptake and synthesis into proteins, reduces protein synthesis, and secretions from

the liver, and increases catabolism in the gut. Fat deposition is in the hepatocytes is occurring due to
lack of reduction of equivalents such as NADPH and impaired oxidation of triglycerides. . (EscottStump, S & LK Mahan, 2004)

5. What is your dietary recommendation? Give an explanation for your recommendation.

A daily intake of 35-50 Kcal/kgDBW is recommended for the maintenance of the person n
positive nitrogen balance. I also recommend a moderately high protein intake should be given (1
1.5 g protein/kgDBW) for the formation of cholic or cholalic and other bile acids. A high protein should
not be given for the prevention of ammonia build up. Branched chain amino acid (BCAA) such as
valine, leucine and isoleucine should be used for the enhancement of protein synthesis in the liver
cells, assistance in restoration of liver function, and prevention of chronic encephalopathy. Sources of
BCAA include red meat and dairy product as well as plant proteins from pasta, vegetable, rice, fruits,
and lima beans. Glutamine is not recommended for liver disease. An increase of dietary carbohydrate
is good to reach the energy requirement since it is well tolerated in the liver disease. It is also aids in
recovery probably due to protein sparing action. Moderate amounts of fats should be recommended
and the use of MCT should be implemented. In this, there is reduction in steatorrhea and thus treating
the malabsorption of fats. Essential fatty acids should be included in the diet. B-complex vitamins and
iron should be adequate because patients tend to develop poor physical conditions from limited food
intake. Vitamin C, K, zinc, and magnesium rich foods should be recommended. Fluid intake should
increase for fluid retention. Sodium restricted diet is also recommended for the prevention of ascites.
(Ruiz, Claudio & de Castro, 2004)
6. Draft a meal pattern and make a one day sample menu. Why sodium is level monitored? How
could you control his sodium intake?
Sodium intake level is monitored for the prevention of ascites which is describe as fluid
accumulation in the peritoneal cavity. Sodium intake can be controlled by the prevention of sodium
in the diet. Such foods high in sodium include canned vegetables, noodles, breads, salted processed
meats etc. Also, the monitoring of the weight of the patient is valuable in seeing the level of sodium
in the body. Rapid body weight gain means that water is retained thus, sodium in the body is high.
(Ruiz, Claudio & de Castro, 2004)
7. Is there a need to modify his protein intake? The type? What possible complications could
develop if his condition does not improve? What will be your recommended prescription? Draft
a meal pattern and make a one day sample menu.
If the conditions did not improve, encephalopathy also known as hepatic coma might develop.
This is a serious complication of advanced liver disease. In a normal liver, it has the capability to
remove the ammonia from the blood and excrete it in our body as urine. But in a diseased liver, this
process cannot take place and thus the body takes serious damage form this effect. Increased
ammonia in the blood will have complications related to nervous system since ammonia is a direct
cerebral toxin. I recommend a moderately high protein intake should be given (1 1.5 g
protein/kgDBW) for the formation of cholic or cholalic and other bile acids. A high protein should not
be given for the prevention of ammonia build up. Branched chain amino acid (BCAA) such as valine,
leucine and isoleucine should be used for the enhancement of protein synthesis in the liver cells,
assistance in restoration of liver function, and prevention of chronic encephalopathy. Sources of BCAA

include red meat and dairy product as well as plant proteins from pasta, vegetable, rice, fruits, and
lima beans. (See attachment 2.2 for the one day sample menu). (Ruiz, Claudio & de Castro, 2004)

Case 3: Peptic Ulcer

1. What information is provided by gastric analysis? What factors could have led to the
development of peptic ulcer? Explain the temporary relief of snacks on gastric pain. Is milk
advised to be given to cure the gastric pain? To prevent the recurrence of ulcer, what
prophylactic measures must he take?
Gastric analysis measures the pH and acid output of stomach contents. The amounts of the
pH and acid output can indicate gastric ulcerations. The factors that could have led to the
development of peptic ulcer are smoking, poor nutrition, stress, alcohol abuse and heredity. The
temporary relief of snacks increases comfort, stimulates the gastric blood flow, decreases the chance
for acid reflux but unfortunately may still increase net acid output. Thus, the frequency of meals is
still controversial. Milk is a traditional cure then, with the belief that it may coat the intestinal mucosa,
but unfortunately, there are not scientific basis about it. Since it is high in protein content, it may
temporarily buffer gastric secretions but also stimulate secretions of gastrin, acid and pepsin. Also,
the neutralization of the milk will effect in the hypersecretion of gastric acid. Thus milk is no longer
advised to be given as treatment. In the prevention of the recurrence of ulcer, smoking should be
inhibited; refusal to use NSAID, use antibiotics, sucralfate, antacids; use acid secretion suppression.
(Escott-Stump, S & LK Mahan, 2004)

2. What diet is most appropriate for Mr. Perfecto? What is your prescription? Give an explanation
for your recommendations?
General recommendations:
Bland diet which is decreased consumption of alcohol, spices, particularly red and black
peppers. When the stomach is inflamed, coffee and caffeine should also be decreased. Intake of
omega 3 and 6 fatty acids which will have a protective effect in the lining and decrease intake of coffee
and caffeine is recommended. Balanced diet will provide adequate nutrition and help the body defend
against H. Pylori bacteria. (Ruiz, Claudio & de Castro, 2004)
Specific Recommendations:
When the ulcer is bleeding, no food is allowed thus, in this case parenteral nutrition is
employed. Then, transitional diet is employed after the organ has been allowed to rest. After the
condition improves, full liquid diet is imposed, then to regular diet with the elimination of irritants.
Thus the final diet should be diet as tolerated by the patient. (Ruiz, Claudio & de Castro, 2004)
3. Helicobacter pylori is found to be the major causative agent of peptic ulcer, what is the
relevance of diet therapy in the dietary management of ulcers?
H. Pylori is the one responsible for the weakening of the protective mucous coating of the
stomach and thus allows the acid to get through the sensitive lining beneath. Thus, the relevance of
diet therapy is to eradicate this bacterium to prevent recurrence of ulcer with corresponding

nutritional management that recommends a still adequate energy intake with a diet that is tolerated
by the patient. The relevance of diet therapy is to figure out the right foods specific for that patient
since different patient has different intolerances. (Ruiz, Claudio & de Castro, 2004)

References:
EscottStump, S & LK Mahan (2004) Krauses Food, Nutrition and Diet Therapy. 11th ed. Singapore: PTE
LTD.
Jamorabo-Ruiz, A.,Claudio,V. & de Castro, E. (2004) Medical Nutrition Therapy For Filipinos. 5th ed. Manila,
Philippines: Merriam & Webster Bookstore, Inc.
Nutritionist-Dietitians Association of the Philippines (2008) Diet Manual 5th ed. Phil: NDAP
Porth, C.M (2010) Essentials of Pathophysiology: Concepts of Altered Health States. 3rd ed. USA:
Lippincrott Williams & Wilkins