Vy Doan

CSUSB ISPP Dietetic Intern

May 19, 2017
1. Identify nutritional implications (nutritional deficiencies)
for patients with total gastrectomy
2. Identify key components in a total gastrectomy diet
3. Understand how elemental formula & trophic feeds save
gut integrity
 The lymphatic system is an extensively branched
network of walled vessels that lead to lymph
nodes (glands).
Transports a watery clear fluid called lymph
directly towards the heart (R subclavian vein)
distributes immune cells and other factors throughout
the body.
interacts with the blood circulatory system to drain
fluid from cells and tissues.
 From our interstitial fluid (plasma that
leaks out of the blood vessels and carries
nutrients and WBC)
Lymph collects in the tiny spaces
between tissue cells
Made up of
Proteins and fats called Chyle, from
intestines
White blood cells known as lymphocytes
Antibodies (taggers of antigens)

As lymph moves through the lymphatic

system...
Filtered by lymph nodes
help to remove microorganisms (e.g.,
viruses, bacteria, etc.) and other foreign
bodies from the bloodstream.
 Comes from the lymphoid stem cell
T CELLS
Form in bone marrow and mature in thymus (behind breast bone)
Helper-T cells : determine response to an antigen
Cytotoxic cells : can kill the pathogenic cell

B CELLS
Originate and mature in bone marrow
Plasma cells: production of protein antibodies
Memory B cells: block infection and fight symptoms, rapid response of antibody production
Antibody found in gamma globulin portion of serum
IgG, IgA, IgM, IgD, IgE (*Remember: probiotics have been shown to produce IgA)
 GALT, BALT, & MALT compromise about 50% of lymphoid tissue
Some contain B & T cells, macrophages, and dendritic cells
GALT (Gut-associated lymphoid tissues) includes
Peyers patches large aggregates of lymphoid tissue in SI
Lymphoid aggregates in appendix and LI
Lymphoid tissue that accumulates with age in the stomach
Small aggregates in the esophagus

BALT (Bronchus associated lymphoid tissue)

Respiratory epithelium

MALT (Mucosa-associated lymphoid tissue)

Tonsils and adenoids (glands located on roof of the mouth)
 Uncommon; accounts for less than 15% of gastric malignancies and 2% of all
lymphoma types
Survival rate is less than 25% in the United States
Non-Hodgkins lymphoma (NHL) -lymphomas that arise from abnormal B-
lymphocytes (B-cell lymphoma)
Either mucosa-associated lymphoid tissue (MALT) gastric lymphoma or diffuse large
B-cell lymphoma (DLBCL) of the stomach.
Etiology: MALT gastric lymphoma is often associated with infection with the
Helicobacter pylori bacterium
Infection common; only a very small number of individuals with this bacterium develop
MALT gastric lymphoma.
 may be no noticeable physical findings upon diagnosis
Abdominal pain or cramping (common)
Early satiety
abdominal tenderness
nausea, vomiting
unintended weight loss
a general feeling of poor health (malaise), and indigestion.
Gastric bleeding may occur in some individuals and can be the first noticeable symptom of
primary gastric lymphoma.
A mass large enough to be able to be felt when applying pressure to the stomach may also be
present in some advanced cases.
Less frequently, weakness, fatigue, night sweats, jaundice (yellowing of the skin and the
whites of the eyes), fever, and dysphagia (difficulty swallowing) may occur.
 Main Goal: Prevent Malnutrition
Clear liquid diet following chemotherapy may be recommended
Small frequent meals
Low-fat foods
Soft foods
Nutrition supplements (high calorie, high protein)
Room temperature meals
Avoid eating favorite foods when N/V occurring
 Admitted 4/23
65 y.o M
Dx: Lymphoma w/ gastric perforation s/p exp lap, gastrectomy, jejunotomy
C/o: 2 weeks of epigastric pain + 3 episodes of emesis
PMHx: recent lymphoma (2013), receives tx every 3 weeks
Social Hx: Married w/ 3 daughters, lives at home, wife is primary care taker
Financial Status: Retired, not much, but we get by
Independent with adl's, with cane
Spanish-speaking primarily
Catholic
 Last treatment: CT abd: thickening
Remission of of the stomach & duodenum &
cancer in possible infection +gastritis

2017
Dx with abdomen.
2013

2015
lymphoma of Biopsy: 4/23- Admitted SBMC for c/o 2
neck leading to +Lymphoma weeks of epigastric pain + 3
esophagus involving episodes of coffee-ground like
obstruction stomach & emesis (no blood)
-Procedures: pancreas. Gets
trach + TF chemo tx at
City of Hope

CT done in ER:
Responded well Large amount of free air
with Chemo; and ascites, thickening of
Tube removed 4 the stomach,
months later dilated gastric bowel,
decompressed duodenum,
and he had some small
bowel edema
as well.
 Exploratory laparotomy
Total gastrectomy
Roux-en-Y esophagojejunostomy with feeding jejunostomy
jejunotomy (removed: stomach and distal esophagus, segment jejunum)
Post-op: Esophagus + Jejunum anastomosis
 Other functions:
Digestion of food
Releases gastric juice: mucus +
HCL acid + digestive enzymes
Lab 4/27 4/28 4/30 Normal Ranges
Sodium 136 136 135 135-145 mEq/L
Potassium 3.8 3.9 4.2 3.5-5.0 mEq/L
Glucose 106 103 122 70-105 mg/dL
BUN 12 11 6 9-24 mg/dL
Creatinine 0.68 0.64 0.73 0.6-1.0 mg/dL
Lab 4/23 4/26 Normal Range
Lactic Acid 5.8 1.4 0.4-2.2
Lipase (4/24) <4 15-69 units/L
Lab 4/23 4/24 4/25 4/27 Normal Ranges

Hgb 13.1 12.9 11.0 10.1 12.5-16.3

Hct 40.1 38.7 33.2 29.1 36.7-47.1
MCV 90.2 89.8 89.3 87.2 80-96
MCH 29.6 29.9 29.7 30.1 27.5-33.2
WBC 20.2 4.1 11.5 8.8 3.6-10.2
 Iron Deficiency B12 or Folate Anemia of Chronic
(Microcytic) (Macrocytic) Diseases (normocytic)

RBC May be normal Decreased Decreased

Hemoglobin Low Low Low
Hematocrit Low Low Low
MCV Low High Normal
MCH Low High Normal
MCHC Low Slightly decreased Normal
or normal
TIBC High Low Low
Medication Usage Potential DNI
Lovenox Anticoagulant/low molecular wt Monitor CBC, platelet count, fecal occult
heparin blood
Insulin Antidiabetic, hypoglycemic wt, glucose
Diflucan Antifungal AST, ALT, Alk phos, billi
Levofloxacin Antibiotic Taste loss, N/V, dyspepsia, abdominal pain,
(Levaquin) diarrhea, constipation, flatulence
Meropenum Antibiotic Glossitis, N/V, diarrhea, constipation

Metronidazole Antibiotic Dry mouth, metallic taste, N/V, epigastric

distress, diarrhea, constipation

Pantoprazole Antigerd, proton pump inhibitor May abs of folate and Vit B12
 4/23: CT abd + pelvis w/ IV contrast
c/o abd pain
Moderate pneumoperitoneum, free fluid, mild ventral pneumoperitoneum suspicious for
perforated viscus
Stomach with moderate wall thickening and distention
Diffuse small bowel wall thickening
No bowel obstruction

4/23: XR chest
Free intraperitoneal gas is present.

4/28: XR UGI wo KUB

s/p Esophagojejunostomy/total gastrectomy
Esophagojejunal anastomosis, no obstruction or extravastation
 Surgeon: Dr. John Kearney
Indication: perforated viscus, Hx of gastric lymphoma
Findings:
Large gastric lymphoma with perforation from the incisura
along the lesser curvature all the way up to the esophagus at
the junction (~8cm in length).
Tumor eroded posteriorly into body of the pancreas.
Anastomosis made from anvil of stomach
Feeding jejunostomy tube in place (previous)
 Height: 170.18 cm (67 in)
Weight: 68.4 kg (150#)
weight history: couldnt remember
BMI: 24
UBW: Reports same; no weight significant weight changes
IBW: 69.5 kg (153#)
%IBW: 98%
 Clinical Issues: POD#2 of total gastrectomy w/ SBR (small bowel resection)-w/ PEJ
feeding tube; Tolerating trophic feeds at this visit w/ elemental EN formula
pending M/S floor
GOAL: tolerate EN at goal : ? advance to oral diet vs continued EN (PEJ)

PES: Inadequate enteral nutrition infusion r/t 24 hr volume infusion (initial Rx) AEB
meets <50% est. needs x 2 days.
Intervention: Monitor EN tolerance and advancement by Sx
Goal: Enteral nutrition to meet 75-100% of estimated nutritional needs, Other: vs PO
diet
 Estimated Kcal Need : 2000
Estimated Kcal Need Based On : 1426(1.1)(1.3)
Estimated Protein Need : 90gm
Estimated Protein Need Based On : 1.3gm/kg(68kg)
Estimated Fluid Need : 2000ml
Estimated Fluid Need Based On : 30ml/kg(68kg)
 Enteral/Parenteral Nutrition
Nutrition Support : Day 1 Vital AF 1.2 at 10ml/hr via PEJ

Current Enteral Kcal : 288

Current Enteral gm Protein : 18
Current Free Water : 194 mL
Additional Free Water Ordered : 0 mL
Current Total Water via Feeding Tube : 194
 Helps manage inflammation and promotes GI tolerance
Hydrolyzed peptide-based protein system
MCT/fish oil structured lipid, a well-tolerated and absorbed next-generation fat to
promote absorption of fatty acids
1.2 g of Nutraflora scFOS/8 fl oz (5.1 g/L)
scFOS- prebiotic fibers that stimulate the growth of beneficial bacteria in the colon
EPA + DHA from fish oil to help modulate inflammation and support immune function
Elevated antioxidants vitamin C and vitamin E to help reduce free radical damage
Meets or exceeds 100% of RDI for protein and 24 essential vitamins and minerals
 Trickle or trophic (10-15 mL/hr)
Usually done along side parental nutrition to further meet needs
Increased permeability to bacteria from atrophic intestinal cells d/t lack of enteral
stimulation
Goal: minimize villous atrophy & prevent bacterial translocation
**Bacterial translocation: the passage of viable bacteria from the gastrointestinal
(GI) tract to extraintestinal sites, such as the mesenteric lymph node complex
(MLN), liver, spleen, kidney, and bloodstream
Colectomy + gastrectomy have high rates of bacterial translocation
 Clinical Issues: Pt. reports not feeling hungry at all and feels better, no tolerance
issues at this time. No signs of wasting. Resolving sepsis, lactic acidosis, possible
start PO diet per Sx.

PES: Inadequate enteral infusion r/t TF infusion rate aeb meets <76% est needs x 4
days
Intervention: Monitor EN tolerance and advancement by sx
Goal: Enteral nutrition to meet 75-100% of estimated nutritional needs, Other: vs PO
diet
**Current Nutrition Intake : Meeting <76% of estimated nutrient needs via TF.
However TF current rate is promoting gut integrity.
 Enteral/Parenteral Nutrition
Nutrition Support : Day 4 Vital AF 1.2 at 30ml/hr via PEJ

Current Enteral Kcal : 864

Current Enteral gm Protein : 54
Current Free Water : 584 mL
Additional Free Water Ordered : 0 mL
Current Total Water via Feeding Tube : 584 mL
 Clinical Issues: Patient s/p total gastrectomy, Diet has been advanced to
Regular/Soft Diet.

PES #1: Increased nutrient needs r/t gastrectomy aeb po diet + tube feeding
Intervention: Modify distribution, type, or amount of food and nutrients, Enteral
Nutrition, Monitor/evaluate: Food & nutrient intake
Goal: Meet at least 80% of nutritional needs
PES #2: Altered GI fxn r/t Sx aeb s/p gastrectomy, s/p jejunostomy
Intervention: Modify distribution, type, or amount of food and nutrients, Enteral
Nutrition
Goal: Other: enteral feedings + po diet
Date Diet Rx Intake Meets % Needs
4/24 Vital AF 1.2 @ 10 mL/hr 10 mL/hr 14% kcal, 20% protein
4/25- 5/2 Vital AF 1.2 @ 30 mL/hr 30 mL/hr 45% kcal, 66% protein
4/28 Clear liquid diet + Vital AF 1.2 @ 30 mL/hr 10% 45% kcal, 66% protein
4/29 Full liquid diet + Vital AF 1.2 @ 30 mL/hr 93% 113% kcal, 107%
protein
4/30 Regular, Soft + Vital AF 1.2 @ 30 mL/hr 100% 153%
5/1 NDD III (Chopped Diet)+ Vital AF 1.2 @ 30 85% 138%
mL/hr
5/2 NDD III (Chopped Diet) + Vital AF 1.2 @ 30 55% 104%
mL/hr
 LOS: 8 days
D/C Dx: Pneumoperitoneum,
lymphoma, leukocytosis,
elevated lactic acid, Peritonitis
Condition: stable
New prescriptions: Discontinued meds:
Pantoprozole (GERD) Metronidazole
Tamsulosin (enlarged prostate) Omeprazole
Pyridoxine (vitamin B6) Acyclovir
Meds to continue: Ciproflaxin
Acetaminophen (pain)
 Discharge Diet: Chopped
Discharge education: Education handout: Diet following bariatric
surgery (Spanish)
Weight at discharge: 68.4 kg (150#)
Activity as tolerated, has personal cane
Follow-up instructions:
City of Hope w/in 5-7 days
Dr. Kearney of Sx within 1-2 weeks
 Length of interview: ~40 minutes
Appointment to see Dr. Kearney on Thursday, May 18th @ 4:00PM
Staple + tube removal?
Progress updates

Appointment to see Dr. Harretta, oncologist at City of Hope on

May 26th
Last chemo tx done 4/19, none up till this point
Possible new Chemo tx, Lymphoma of pancreas check up (small tumor
upon discharge)
 Post-gastrectomy diet
Wife is primary care-taker
Given book/handouts on post-gastrectomy diet upon discharge. Educated by RN.
Feeds him small meals every 2-3 hours; complaints of early satiety
Tube still in place, HH RN instructs to flush tube every 4 hours
Daily meals consists of: oatmeal in AM, chopped vegetables, chicken noodle soup,
milk (no lactose intolerance development)
Supplemental nutrition drink: Ensure powder w/ low fat milk (8 oz- TID)
Pt. dislikes pre-packaged bottle since it is too sweet

Supplements
Vitamin B6 100 mg x 1 daily
Instructed pt. to ask Dr. Kearney about Vit B12 and possible iron supplementation
as well.
 Recommendations & Education
Eat iron rich foods
Beef, sardines, oatmeal, beans, tofu
Recommend Vit C to help with absorption
Oranges, grapefruit, cantaloupe, tomatoes
Small, frequent meals
Eat slowly
Limit foods high in fat/sugar (dumping syndrome precaution)
Extra calories, protein, and nutrients
Monitor weight, prevent weight decline
 eating smaller meals throughout the day
avoiding high fiber foods
eating foods rich in calcium, iron, and vitamins C and D
taking vitamin supplements
Requires regular blood draws to check for deficiencies
 acid reflux stomach acid leaking into esophagus,
which causes scarring, narrowing, or
diarrhea
constriction (stricture)
gastric dumping syndrome
a blockage of the small bowel
an infection of the incision wound
vitamin deficiency (i.e. vit B12)
internal bleeding
Decreased calcium and iron absorption
leaking from the stomach at the d/t reduction in secretion of HCL acid
operation site weight loss
nausea
vomiting
 Before CA
dx
205 Neck Dx of gastric
lymphoma + lymphoma s/p
esophagus gastrectomy
obstruction 155
132
115 120
Weight from
s/p trach + 4
HH RN last
months of TF
Friday

2013 2014 2015 2016 2017

Weight (lbs.)
The Good News
Trophic feeds of elemental advanced
formula greatly affected future PO
intake positively
Pt. advanced very quickly, consistently
met needs without being NPO >3 days
Now stomach cancer free!
However....
Possible Bad News?
Future chemo/radiation therapy
that could affect PO intake
? Pancreatic tumor to further affect
digestion
Lipases, amylase, proteases may
affect breakdown of
macronutrients even further on top
of no stomach to help digestion
May require oral digestive enzymes
THANK YOU!

Any Questions?
 Xu, W., Zhou, C., Zhang, G., Wang, H., Wang, L., & Guo, J. (n.d.). Repeating gastric biopsy for accuracy of gastric
lymphoma diagnosis. Retrieved May 17, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/20679784
Admin, N. (n.d.). About Stomach Cancer Stomach Cancer Hereditary Diffuse Gastric Cancer Statistics Risk & Prevention
Signs & Symptoms Treatments & Clinical Trials Life Without a Stomach Resources. Retrieved May 17, 2017, from
https://www.nostomachforcancer.org/about/life-without-a-stomach/special-concerns/nutrient-deficiencies
Zaneta M. Pronsky, MS, RD, LDN, FADA. Dean Elbe, BSC (Pharm), BCPP, Pharm D, Keith Ayoob Ed D, RD, FADA. Food
Medication Interactions. 18th edition. 2015
Abbott Industries Nutrition Product Reference. 2015-2016

A., J., C., A., D., K., . . . M. (2017, April 19). Ensure Original Nutrition Powder. Retrieved May 17, 2017, from
https://ensure.com/nutrition-products/ensure-
powder?gclid=CjwKEAjw6e_IBRDvorfv2Ku79jMSJAAuiv9YdlZKm8NvKCWmxhPP2seJ2ddWtG0Dj-bh9PlmyRszRRoC503w_wcB
Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Lymphatic system. In: Ball JW, Dains JE, Flynn JA, Solomon BS,
Stewart RW, eds. Seidel's Guide to Physical Examination. 8th ed. Philadelphia, PA: Elsevier Mosby; 2015:chap 9.
Hall JE. The microcirculation and lymphatic system: capillary fluid exchange, interstitial fluid, and lymph flow. In: Hall
JE, ed. Guyton and Hall Textbook of Medical Physiology. 13th ed. Philadelphia, PA: Elsevier; 2016:chap 16.
Nelms, Sucher, Lacey, Roth. Nutrition Therapy & Pathophysiology 2nd Ed. 2011.