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Jillian O’NeilKNH 41302/11/14

Case Study 1 – Peptic Ulcer Disease

1. List all the food items that may contribute to GG’s condition and explain why.

Foods:

a. “Fast foods with a high fat content” – These products often contain simple carbohydrates

in addition to the unhealthy fats. Foods containing a significant amount of fat cause an

inflammation among the stomach lining and increase gastritis symptoms. According the

Ratini, dietitians would encourage GG’s diet to include complex carbohydrates with

healthy fats; in addition, the meals would include a proper combination of healthy fats and

proteins with carbohydrates – a concept most fast food restaurants do not provide to

clients. Lastly, overall portions are not controlled at fast food chains for the client’s

moderation of meals – Ratini also encouraged small meals to ensure proper digestion.

b. “Did not stop to eat anything” – a lack of food can cause an imbalance in the client’s

digestive tract. In addition, it is encouraged to eat small meals 5-6 times per day. Skipping

meals will increase the severity and discomfort to clients.

c. “Frozen dinners or fried foods” – these products often contain high amounts of sodium,

fat, cholesterol and simple carbohydrates. In correlation with the food items from “a” and

“b,” this type of meals would increase severity of the condition as well as increase

discomfort for the patient. Foods containing a significant amount of fat – such as fried

foods – may cause an inflammation among the stomach lining and increase gastritis

symptoms. Ratini encourages a lower sodium diet plan coinciding with a healthy fat diet.

In addition, excess sodium could irritate the stomach lining which would ultimately

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increase the gastritis symptoms. Lastly, most of these items would not contain the

adequate fiber GG needs to have a healthy digestive system – such as fruits or vegetables.

d. “Chocolate bars during the day” –It is recommended for clients to avoid simple sugars and

simple carbohydrates as well as sweetened food items. Chocolate bars contain a

significant amount of sugar, simple carbohydrates in addition to caffeine. Consuming

caffeine is also encouraged for patients to avoid because may cause an inability to sleep

well. Lastly, caffeine may cause an increased amount of stomach acid product and thus

damaging the stomach lining overtime and increasing her stomach pain symptoms.

e. “Milk” – dairy products should be limited and taken one hour after a meal. Excess dairy,

or any “nutrient-rich drink” cause trigger symptoms because of the rich emulsions present.

Therefore, it is usually encouraged for clients to consume lactose-free products.

Drinks:

a. “Strong, black coffee throughout the day and into the night” – Decaffeinated beverages are

encouraged because they can cause or irritate symptoms of the condition. It may cause

increased amount of stomach acid product and thus damaging the stomach lining overtime

and increasing her stomach pain symptoms. In addition, drinking liquids throughout the

day isn’t encouraged. Ratini suggests to not eat solids and liquids at the same time; do not

drink during the sixty minutes around a meal – thirty minutes before until thirty minutes

afterwards. Lastly, caffeine intake later in the day and at nighttime can have a great affect

on her inability to sleep well.

b. “Rum and coke at bedtime” – Large amounts of alcohol often irritates the gastritis

symptoms. Not only will the caffeine, from the coke, have a great affect on her inability to

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sleep well; but also, the caffeine will increase stomach acid and thus increase stomach pain

(a symptom of gastritis).

(Ratini, Dumping Syndrome Diet, Parrish, Johnson)

2. List any additional oral intake that may have contribute to GG’s condition and explain

why.

a. “Smoking” - the chemicals from a single cigarette can damage the stomach lining and

increase gastritis symptoms from the tobacco irritations.

b. “Aspirin” – Aspirin reduces prostaglandin, which provides protection to the stomach.

Continuous aspirin use can cause stomach-lining irritation and increase gastritis symptoms

c. “TUMS” – Although antacids can positively influence the body, misuse of antacids can

induce gastritis. Antacids can reduce stomach acid levels and allow vulnerability for

infections which can ultimately cause further gastritis concerns.

(Health Central, Namiot, Ehrlich)

3. List the non-oral stimulants (physical or psychological stress) that could contribute to

GG’s condition and what she could do to change them.

a. “Single Mom” – Although being a recently single mother can pose great stress on GG

and her condition, she can cope with the difficulties by reaching out to her close family

members and friends. Asking for help for simple tasks – including picking her son up

and babysitting for no cost, or helping with groceries – will make GG’s life significantly

“easier” and give her time to manage her condition.

b. “Divorce” – After an eight-year marriage, losing her husband will pose trauma and

stress on GG’s body. Not only is she now lacking financial support, she has to start from

scratch with her finances due to her lack of job skills and education. Separation is

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mentally and physically draining on GG. Although nothing can technically be done in

regards to improving the divorce, GG can focus on the idea her marriage brought her a

son. Doing activities with her son can bring a positive attitude into her life.

c. “Part-Time Job + Accounting Degree” – These two additions to GG’s life can cause her

to be overwhelmed and stress. Previously, she didn’t have job skills or an education;

thus, adding these two factors to her other stress factors can increase her body tension

and induce gastritis symptoms. To deal with this stress, she can focus on time

management – she can have designated time for class and work. In addition, she can set

time slots for the library to dedicate for homework and studying without the distractions

at home. Then once she goes home, she can focus on relaxing and spending quality time

with her son.

d. “Maintain good grades for loan” – This additional stress can be maintained by keeping

up with her studies and not letting herself fall behind. Attending office hours, every

class, and studying hard can help her maintain good grades.

e. “Son Diagnosed with ADHD” – GG has multiple factors influencing her stress level.

She can manage this stressor by organizing her son’s time when she is and isn’t with

him. Keeping him busy and occupied can help him maintain a balanced lifestyle, which

would ultimately aid in decreasing the stress within her life.

f. “Symptoms of Her Condition” – Managing her condition is key to decreasing the

induced stress. By listening to the doctor, she can have a positive life, even with her

condition. She can manage her stress as well as eliminate her intake of alcohol, caffeine,

ASA, cigarettes and high fat foods.

(Information obtained from Case Study #14 Packet)

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4. List the symptoms of GG’s gastritis

GG’s gastritis symptoms include: stomach burning, severe pain in the right lower quadrant 30

minutes after eating, stomach pain, extreme indigestion, severe gastric pain.

(Information obtained from Case Study #14 Packet, Johnson)

5. Was a bland diet necessary? Explain and list the principles of the diet plan that you

think GG should follow.

According to personal conducted research, a bland diet isn’t necessary. Although it is important

to improve dietary choices, total elimination to “start from scratch” is not necessary in this

situation. A helpful diet plan for GG would include 6-8 small meals throughout the day,

increasing digestion duration by increasing protein, consuming a low carbohydrate diet, reducing

beverages consumed during mealtime (decreasing change of aggravating the condition), and to

reduce or eliminate foods containing excess sugar, chocolate, and peppermint. In addition, GG

can reduce the intake and consume small amounts of milk products as well as resting post-meals

to allow proper food digestion. The Canadian Cancer Society promotes the elimination of

consuming food or liquids after 7:00pm to aid in digestion before the average bedtime. Lastly,

gradually increasing fiber in her diet can help slow the absorption of sugars and can help form

stool by binding to the water. In regards to her diet history, total elimination of high fat foods,

processed foods, caffeine, coffee, chocolate, aspirin, alcohol and smoking can greatly improve

her life. Instead, she can consume foods containing low fat and sodium as well as healthy fats,

proper distribution of macronutrients and a high fiber diet. By eliminating most of her foods

from her original diet, she will automatically replace them with healthy options – providing her

with the nutrients necessary for an improved gastritis lifestyle.

(Canadian Cancer Society, WebMD, University of Pittsburg Medical Center)

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6. What is the mechanism of action of the following medications GG is receiving:

Carafate, AlternaGel, and Pepcid?

a. Carafate – Sucralfate is used as a prevention method and as a treatment option for

intestinal ulcers. This drug is responsible for forming a “coating” over the ulcer in

prevention of an additional injury to the area; thus resulting in a quicker recovery.

While Ogbru stated that the mechanism of action for Carafate isn’t “entirely

understood,” researchers have thought it is important for: the sucralfate to bind to ulcer

surfaces to attach a protein, and protect the surface of the ulcer from acid or pepsin.

This medication stops pepsin when stomach acid is present and thus salts from the liver

are bound to the sucralfate as prevention of the lining of the stomach to have damage

from bile acids. Lastly, this medication is found to increase prostaglandin production (a

protector of the stomach lining).

b. AlternaGel – Aluminum hydroxide is often prescribed when a patient has excess

stomach acid. It is used to rapidly lower the stomach acid levels in a patient with

already existing conditions. As an antiacid, this medication’s mechanism of action is to

react with stomach acids and neutralize the levels by increasing the pH. In the intestine,

it is responsible for forming aluminum phosphate by binding with the phosphate ions.

c. Pepcid – Famotidine is responsible for blocking stomach acid production. This

histamine blocker inhibits the histamine actions in the cell and ultimately reduces acid

production.

(Ogbru, WebMD, Drugs, MedicineNet)

7. List the nutrient-drug interactions that are associated with these medications.

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a. Carafate – Although there are a list of medications that should not be taken with

sucralfate, GG’s list of medications do not conflict. In general, other medications

should be taken two hours before the sucralfate. This medication also needs to be

taken on an empty stomach and one hour before the designated meal. In addition

to the listed interactions, sucralfate may also have interactions with dietary

supplements. First, blood calcium levels may increase when taking

supplementation in addition to this drug; the recommendation is to avoid calcium

supplementation. Lastly, sucralfate may interact with the mineral, Phosphorous,

by significantly decreasing the blood levels. Extreme cases may lead to bone pain

– which is the reason for a constant monitoring of calcium and phosphorous

levels.

b. AlternaGel – In addition to multiple drug interactions, Aluminum hydroxide can

alter a patient’s phosphorous levels. The Aluminum and magnesium will form a

“complex” with phosphorous in the body and reduce it’s levels – thus, causing a

decrease in calcium levels. Therefore, it is a concern for GG if she is at an

increased risk for osteoporosis. In addition, it is not recommended to consume this

medication during a meal because it will inactivate thiamine.

c. Pepcid – This drug can interact with Vitamin B12 by reducing its ability to attach to

protein and be properly absorbed. Therefore, most would prescribe B12

supplementation. In addition, Vitamin C and Vitamin E may also be prescribed in

supplementation form because reducing stomach acid levels may allow bacteria to

survive in one’s stomach.

(WebMD, Ogbru, Health Central)

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8. What are GG’s IBW and percent IBW (Appendix A, Tables 7 and 8)?

Height: 5’2” Current weight: 98 pounds

Ideal Body Weight: 100 + 5(2) = 110 pounds

Percent IBW: 98/110 = .8909 * 100 = 89%

(Nelms 48)

9. Estimate her daily energy needs using the Harris-Benedict equation and appropriate

stress factor (Appendix A, Table 17).

Since GG has lost weight, we would use this equation using her ideal body weight of 110 pounds

because weight gain is necessary.

W: 110 pounds / 2.2 = 50 kg H: 5’2” = 62” = 62*2.54 = 157.5 cm A=27

REE = 655.1 + 9.6W + 1.9 H – 4.7 A

REE = 655.1 + 9.6(50) + 1.9(157.5) – 4.7(27) = 1307.45 kcalories

Stress Factor: 1.2 - this value takes into consideration her hospital visit &weight loss. Although

she is below her ideal body weight, using her IBW in the original equation already provides her

with excess calories – thus, the lower stress factor value.

1307.45 * 1.2 = 1569 kcalories

(Nelms 60)

10. What might be the cause of the LUQ pain along with her usual pain (Hint: Consider the

enzymes that are elevated).

Multiple factors may be the cause of GG’s LUQ pain in addition to her usual pain. First, her liver

function blood work panel states an elevated Alkaline phosphatase level of 122U/L. An elevated

ALP level may indicate a problem with her liver, bile ducts, and bone. Her liver may be damaged

due to the excess alcohol, bile ducts damage due to improper body functions, and bone damage

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from a decrease in calcium from the AlternaGel medication. Secondly, her bilirubin total was

also elevated at 0.6 mg/dl. An increased TBIL may also indicate liver damage – if too much

bilirubin is produced or the liver is unable to remove bilirubin properly, blockage in the bile

ducts and liver disease may develop; ultimately causing stomach pain. Lastly, her elevated

Amylase level – of 350U/L – may indicate recent intake of alcohol, stomach ulcer, pancreatitis,

blockage to intestines, gallstones, or kidney failure – all of which may induce LUQ pain.

(Dugdale, Medline Plus, WebMD)

11. In the second set of lab values, glu, BUN, Cr, ser alb, Na, K, Cl, hgb, and hct all

dropped. This probably means that GG was: c. Dehydrated when the first labs were

drawn. I believe “C” is the correct answer because GG returned to her “old ways” of caffeine

and alcohol prior to returning to the hospital. Therefore, she would induce dehydration in her

system prior to the ER visit.

12. In the second set of lab values, serum amylase, AST, and ALT all dropped. This

probably means that: a. enzymes were elevated due to alcohol. I believe “A” is the correct

answer because her history indicated “another binge and drank too much” the evening before

the ER visit. If she has an increased alcohol intake prior to blood testing, her lab values

would be altered and elevated.

13. Refer to the two lab tables again, and not that two days after admission, GG’s Alk Phos

and CPK remained essentially unchanged. Why? a. These enzymes are not affected by

alcohol or hydration. Although it is not recommended to consume food or beverages 10

hours prior to blood testing for Alk Phos, GG had passed the 10 hours mark when she went

to the ER the next morning. Special pre-testing procedures are not required for CPK blood

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testing. Therefore, both of these enzymes were unchanged due to the fact that they aren’t

affected by alcohol or hydration levels.

(WebMD)

14. What diagnostic test(s) (not lab values) indicate(s) that GG has an ulcer?

GG’s condition indicates an ulcer through the following diagnostic tests:

a. Her stool was shows for occult blood.

b. An esophagogastroduodenoscopy displayed a positive result for “an ulcer on the dorsal

wall of the duodenum, just below the pyloric sphincter.

(Information obtained from Case Study #14 Packet, WebMD)

15. Briefly sketch the anatomical position where GG’s ulcer can be found

GG’s ulcer is found on the dorsal wall of the duodenum, just below the pyloric sphincter.

Photo 1 displays a “zoomed out” version of the intestines.

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Photo 2 displays the actual location of the ulcer in comparison to the duodenum and the

pyloric sphincter.

16. Define:

a. H2 antagonist: medical drugs that work to reduce stomach acid production; it is used to

ultimately reduce irritations and relieve symptoms

b. Proton pump inhibitor: medical drugs that are used for the reduction of stomach acid

secretion

(WebMD, Nelms 209)

17. What is the mechanism of action of the following medications GG is receiving: Nexium,

amoxicillin, and clarithromycin?

a. Nexium: Esomeprazole is a protein pump inhibitor. It is responsible for limiting

gastric acid secretion. It inhibits H+/K+ which will block the “final step” in acid

production and reduces the gastric acid levels.

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b. Amoxicillin: Amoxicillin is an antibacterial drug used for the treatment of

bacterial infections already present in the body. It binds to the penicillin proteins

within the cell wall and inhibits the synthesis during the third stage.

c. Clarithromycin: This drug works to prevent bacteria from interfering with the

protein synthesis. It is often prescribed with amoxicillin to ensure proper

inhibitions of the bacteria cells. Ultimately, this drug inhibits peptide translation

by binding to the subunit 50S.

(WebMD, Health Central, Drugs)

18. GG was not receiving counsel at the time the major bleeding started. If you had the

opportunity to counsel GG just before the bleeding, in what areas would you feel

competent to counsel her and in what areas would you refer her to someone else?

Investigate the agencies in your area that are available to provide assistance to someone

like GG.

I would take on the role to counsel her within my scope of practice, if possible just before the

bleeding. First, I would have helped her with the current diet habits. As she can tell, the great

deal of changes she had made in the past was beneficial. Therefore, she needed to keep pushing

and stick to the “original” plan. Going back to old habits will only worsen symptoms and cause

detrimental problems. In depth details of the counseling sessions would include eating right,

remove smoking (and choose alternate ways to relieve stress and keep herself calm – such as

exercise, diary writing, and spending time with her son), improve her night’s rest by planning out

her day to gain 8 hours per night, decrease or eliminate the coffee intake, eliminate the alcohol

and, finally, eliminate the aspirin. Outside of my scope of practice, I would refer GG to a

therapist that can help with stress management and therapy for the emotional aspects of her life.

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In addition, an alcohol support group would be helpful for GG to attend for a positive future

without alcohol use.

As a Miami University Student, GG can find nutritional services at McCullough-Hyde Memorial

Hospital by calling (513) 524-5320. She can find mental help and stability by going to Miami’s

Health Services Center and conveniently using their Student Counseling Services. The number to

call for this service is (513) 529-4634. Lastly, GG can also use the Student Counseling Services

with her alcohol addiction.

(Client Information obtained from Case Study #14 Packet)

19. What is the significance of the dark stools?

GG’s dark stools are significant because they reveal intestinal bleeding. Usually, the blood

comes from the stomach or upper small intestine. Ulcers are a main cause of intestinal bleeding.

(Medicine Net)

20. Give the pathophysiology for the cause of the following abnormal values: BUN, NH3,

and WBC.

a. BUN: Blood Urea Nitrogen (BUN) measures the amount of waste product in the

blood from protein metabolism (also known as urea nitrogen). GG’s elevated

BUN value of 26 mg/dl is known as “azotemia” and may have been caused by

dehydration, stress, hemorrhage in the GI tract, impaired renal function or

excessive protein intake or protein catabolism. A lack of fluid to excrete waste

products may indicate severe dehydration with a high BUN value. Lastly, blood in

GI tract can increase BUN levels.

b. NH3: Ammonia present in lab values can indicate neurological disorders if found

in the brain. Although GG was not tested for an abnormal NH3 value, a test would

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have been helpful for evaluating the liver and kidney function within her body.

Due to alcohol use and dehydration, her NH3 levels may be elevated.

c. WBC: Leukocytes are tested to determine the number of white blood cells present

in the body. GG’s WBC value of 11.5 x 103/cells/units is elevated out of the

normal reference unit. Elevated WBC may indicate a sign of infection – as the

body’s mechanism to fight back infections. The testing for Helicobacter pylori

showed positive; therefore, her body would be fighting this bacterial infection

with the elevated white blood cell counts.

(Health Central, Web MD)

21. GG was probably dehydrated on admission since she had been drinking. This means

that some of her lab values were probably higher than indicated.

I believe the correct answer is “higher” because the second round blood work revealed a

decrease in most of her lab values – revealing an initial increase due to dehydration and alcohol.

22. After admission, GG received packed cells and IV fluids. How would that affect the

next set of lab values?

Receiving additional fluids will improve GG’s current health status. By decreasing her

dehydration levels, the fluid will also decrease the abnormality of the next set of lab values.

23. Define the following terms:

a. Packed cells: packed cells are blood cells that have been prepared and separated from

the liquid plasma (WebMD)

b. Abdominal tap: This procedure involves removing fluid from the abdominal cavity

(area between belly wall and spine). (Medline Plus)

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c. Perforated ulcer: When a defect in the stomach lining or in the duodenum is present, it

is classified as a peptic ulcer. Most of the peptic ulcers damage to first layer of the inner

lining of the stomach. If a hole has developed through the stomach or duodenum, a

perforated ulcer has developed. (Medline Plus)

d. Fistula: A fistula is “an abnormal opening (or passageway) between two internal

organs or from an internal organ to the surface of the body” (Nelms G-9)

e. Exploratory Laparotomy: Laparotomy is surgery involving an abdominal wall

incision for the medical professional to have “access” to the abdominal cavity. An

exploratory laparotomy allows the medical professional to determine medical

information that a clinical test would not show or reveal. (Medline Plus)

f. Billroth I: Also known as Billroth’s Operation I, involves the removal of the pylorus. It

also involves reconnection (anastomosis) of the proximal stomach to the duodenum.

(Medline Plus)

g. Vagotomy: The procedure of vagotomy includes “severing the vagus nerve.” This

procedure is a component of gastric surgery. (Nelms 341)

24. Sketch a Billroth I

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25. Compare a Billroth I to a Billroth II as to anatomical changes as well as to dietary

changes, if any.

Billroth I involves the removal of the pylorus and reconnection of proximal stomach to the

duodenum. Billroth II involves the side-by-side connection of the greater curvature of the

stomach to the first part of the jejunum. Post – surgery diet changes would include an increase of

protein intake to aid in healing process and the maintenance of muscle mass. Consuming a high

fiber diet will aid in the anti-dumping diet. In addition, the diet would include 6 or more small

meals per day, eating slowly to encourage proper digestion, drinking liquids 30-60 minutes pre-

or post- meals, avoid high sugar foods, and taking vitamins and minerals to prevent deficiencies.

As for Billroth I, the duodenum is responsible for folate, calcium, magnesium and iron

absorption. As for Billroth II, poor absorption from Billroth I may occur in addition to jejunum

poor absorption of proteins, Vitamin A, D, E, K C, B vitamins, fat, cholesterol, and some

starches. Therefore, with both procedures, it is often recommended to take a multivitamin, iron,

vitamin D, calcium, and vitamin B12 supplement.

(WebMD, Medline Plus, Nelms 364)

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26. Calculate GG’s energy and protein needs

For GG’s current weight of 98 pounds (44.5kg), she would need 1,250 kcal to maintain her

weight.

REE = 655.1 + 9.6(44.5) + 1.9(157.5) – 4.7(27) = 1254.65

Her activity factor includes: post-surgery infection, and confined to bed. Therefore, I assigned

her an activity factor of 1.3 because her medical staff would also like to eventually see a weight

increase. Therefore, she would need 1,600 to 1,700 kcal/day.

1254.65 * 1.3 = 1,631

As for her protein needs, she would need an increased amount due to metabolic stress, trauma

and disease. Therefore we, her medical staff, would provide her with 1.5g protein/kg/day.

Therefore, she would need to consume a minimum of 67g of protein per day.

1.5g (44.5 kg) = 66.75g protein per day

(Nelms 60-61)

27. List the principles of a post gastrectomy diet and briefly describe the scientific basis for

each principle.

A post gastrectomy diet (also known as “anti-dumping” diet) includes a well-balanced diet with

an increased amount of proteins and fats. All simple sugars should be eliminated for the

prevention of hyperosmolality and hypoglycemia – two possible outcomes of dumping

syndrome. In addition, lactose should be avoided and replaced with lactose-free items because of

the body’s inability to tolerate the lactose. Due to the lack of dairy products, calcium and

Vitamin D supplements are often recommended for the proper intake of these vital nutrients.

Next, dumping syndrome also allows liquid to move quickly through the small intestine and

therefore, liquid should not be consumed around the same time as a meal. While meals are

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encouraged in small portions roughly 5-6 times per day, it is also recommended for patients to lie

down after their meal to ensure proper digestion.

(Nelms 366)

28. Is it possible that GG’s diet will ever change or do you believe she will be on the post

gastrectomy diet for the rest of her life? Explain your answer.

Although GG can lessen the intensity of a gastrectomy diet, I do not believe that she will ever be

able to totally remove herself from the diet. Since a gastrectomy is permanent, these lifestyle

changes will also need to be permanent to ensure a healthy lifestyle. If she were to go back to her

old habits post-surgery, further complications and issues would arise in her medical analysis.

Therefore, I would encourage GG to follow the strict diet plan and hope that as time goes on, she

may be able to make slight alterations.

29. If GG were to be hospitalized for an extended period of time and required a tube

feeding via duodenum or jejunum, what characteristics would be appropriate for the

tube feeding you would use?

If GG required a tube feeding, I would use the tube feeding supplement including high calories

and protein. Our client should be gaining weight and is in the healing process – thus the high

calories and protein. As for nutrients, folate, calcium, magnesium and iron absorption have been

altered from the duodenum after Billroth I. In addition, poor absorption of proteins, Vitamin A,

D, E, K C, B vitamins, fat, cholesterol, and some starches are altered from the jejunum after

Billroth II. Therefore, I would search for a product that provides the client with the proper

nutrients needed.

(University of Pittsburg Medical Center, Nelms)

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30. Using the table below, compare several of the enteral nutritional supplements that

would be appropriate for GG.

Product

Producer Form Cal/ml Non-pro cal/g N

g/L Na mg

K mg

mOsm /kg water

Vol to meet RDA in ml

g of fiber/L

Free H2O/L in mlPro CHO Fat

Nutren 1.5

Nestle Liquid 1.5 131 60 169 67.6 1168 1872

430 1000 mL

n/a 76

Nutren 2.0

Nestle Liquid 2.0 131 80 196 104 1300 1920

745 750 mL

n/a 70

Crucial Nestle Liquid 1.5 67 94 134 67.6 1168 1872

490 1000 mL

n/a 77

(Nestle 78, 80, 30)

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February 9, 2014, fromhttp://umm.edu/health/medical/altmed/condition/gastritisHow Does Cigarette Smoking Cause Gastritis? - HealthCentral. (n.d.). Health Central.

Retrieved February 7, 2014, from http://www.healthcentral.com/copd/h/how- does-cigarette-smoking-cause-gastritis.htmlJohnson, K. (2012, July 7). Gastritis: Symptoms, Causes, Treatments, and More. WebMD.

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Nelms, Marcia Nahikian. Nutrition therapy and pathophysiology. 2nd ed. Belmont, CA: Wadsworth, Cengage Learning, 2011. Print.

Ogbru, O. (n.d.). Sucralfate (Carafate).MedicineNet. Retrieved February 8, 2014, from http://www.medicinenet.com/sucralfate/article.htm

Parrish, C. (n.d.) Dietary and Nutritional Recommendations For Patients with Dymping Syndrome. American Neurogastroenerology and Motility Society. Retrieved February 7, 2014, from http://www.motilitysociety.org/patient/pdf/Dumping%20Diet%205%204b%202006.pdf

Ratini, M. (2013, April 15). Dumping Syndrome: Causes, Symptoms, Foods to Avoid, and Treatments.” WebMD. Retrieved February 7, 2014, from http://www.webmd.com/ digestive-disorders/dumping-syndrome-causes-foods-treatments

2009 HealthCare Products (pp. 30, 78, 80). (2009). Nestle Healthcare Nutrition. n.c.p.: Nestle.