Nicole Hermann

Spring 2010

V.E. 53 YOWF, 62”, 143 lbs. Unemployed Lives with husband Admitted 02/08/10 Attending Physician: Shamant Tippor

MD Surgical Unit

• Abdominal pain – diffuse in nature – had been going on for the past 2-3 days.

• There was associated nausea, acid reflux, vomiting and increased pain when food was consumed.

• Diarrhea had also been present – 6 to 7 times per day for the past 2-3 days.

• Unable to eat sufficient amounts due to symptoms.

Recent wt loss: 12# in past 2 weeks Anemia Hemorrhoids IBS GERD Vitamin B12 deficiency Constipation Smokes 1 pack daily for the last 45

years Depression and anxiety

Admitted to ER in past:Sore throat on 12/16/09 – viral pharyngitis Irregular menstrual bleeding 08/26/05 –

fractional D & C Treatments: Supplemented vitamin

B12 for diagnosed deficiency, hemorrhoidectomy in 1988, rhinoplasty in 1970 that resulted from a motor vehicle accident.

Estroven menopause supplement – 1 tablet PO daily

Vitamin B12 – 500 mcg 1 tablet PO twice daily

Xanax as needed for anxiety

Cholecystitis and Cholelithiasis

Vitamin B12 Deficiency

(Currently being treated with oral tablet supplementation)

1. General: The pt looks agitated, anxious, nervous, shaky, and is complaining of abdominal pain.

2. Vital Signs: Temp: 36.4, Pulse: 82 per min, Resp. rate: 16 per min, BP: 124/93, pulse ox 96% on room air.

3. HEENT: PEERLA. EOMI. 4. Neck: No lymphadenopathy. 5. Cardiovascular: S1 and S2 heard. No murmurs. 6. Respiratory: Normal breath sounds, but mild

wheezing. 7. Abdomen: Bowel sounds +, tenderness in right

upper quadrant and epigastric region, Murphy’s sign +.

8. Extremities: No pedal edema. No pressure ulcers present.

9. CNS: Alert and oriented x3. No focal neurological deficits.

2/8/1010:48

2/9/1006:55

2/10/1002:54

Sodium 142 142 142

Potassium 4.5 3.2 L 3.6

BUN 11 7 4 L

Creatinine 0.77 0.67 0.65

Hgb 14.4 11.9 L 12.8

Hct 44.2 37.5 38.5

Glucose 84 110 H 102 H

Calcium 9.8 9.0 9.2

Bilirubin 0.4 0.1 L 0.2

Albumin 4.3 3.4 L 3.3 L

Vitamin B12

703

Abdominal UltrasoundShowed cholelithiasis

CT scan of the liver and pelvis with IV contrastThickened small bowel in LLQ and to a

lesser extent RLQSmall amount of fluid in the right pericolic

gutter and pelvis

Endoscopic cholecystectomy Intraoperative cholangiogram Excision of esophageal cyst (Incidental

finding during intubation for general anesthesia)

Pt did fine after surgery per discharge summary.

Pt was put on soft diet which she tolerated very well. I agreed with diet prescription; it eliminates foods that are hard to chew and swallow, and allows the GI system to rest after surgery.

Abdominal pain, N/V had all ceased Pt was sent home with orders to follow

up with PCP, surgery and ENT in 1-3 weeks.

What is Vitamin B12?Vitamin B12 is an essential water-soluble

vitaminGroup of cobalt-containing compounds,

known collectively as cobalaminCommonly found in a variety of foods such

as fish, shellfish, meat, eggs and dairy products.

Also in fortified cereals, fortified soy products, and others

Vitamin B12 is bound to the protein in food.

FunctionsWithout B12, folate cannot function in DNA

or blood cell synthesis, nor can it metabolize homocysteine. (All folate functions are blocked)

Thus, B12 deficiency will cause folate deficiency, even when folate levels are normal.

B12 also helps maintain the myelin sheath in nerve cells

What process does it go through in the body?Hydrochloric acid in the stomach releases

B12 from protein during digestion. Once released, B12 combines with a

substance called intrinsic factor (IF)The IF-B12 complex binds to receptors in

the ileal mucosa and absorption occurs in the ileum

Liver takes up approx 50% and the rest is transported to other tissues

May be 800,000 older adults in the U.S. who have undiagnosed and untreated B12 deficiency.

More common in geriatric population because they have less gastric acid secretions

Up to 30% of people over the age of 50 may malabsorb B12 from foods.Take supplements, fortified foods

Description Measure

Content (mcg)

Mollusks, clam, mixed species, canned, drained solids

3 oz 84.06

Beef, variety meats and by-products, liver

3 oz 70.66

Turkey, all classes, giblets, cooked 1 cup 48.21

Mollusks, clam, mixed species, raw 3 oz 42.02

Mollusks, oyster, eastern, wild, raw 6 medium

16.35

Chicken, broilers or fryers, giblets, cooked

1 cup 13.69

Mollusks, oyster, eastern, cooked, breaded and fried

3 oz 13.29

Soup, clam chowder, new england, canned

1 cup 12.00

Braunschweiger (a liver sausage), pork

2 slices 11.39

Crustaceans, crab, alaska king, cooked

3 oz 9.78

RDA for adults is 2.4 mcg/day Body can store enough to last 2 years Liver stores approx 1 mcg/g of tissue Estimates of avg total-body pool B12

pool in adults ranges from 0.6-3.9 mg Average intake from food in the U.S. 5

mcg/day for men and 3.5 mcg/day for women

Major cause is pernicious anemia Gastrectomy Atrophic gastritis Bacterial overgrowth of S.I. Terminal ileal disease or resection Pancreatic insufficiency (inability to

digest protein-bound B12)

Malabsorption60% of those with neurological or

psychological abnormalities malabsorbed food-bound B12

When there is damage to the intestinal lining, significant B12 deficiency occurs. This can happen in celiac disease.

SmokingHigh cyanide intake that results from

smoking may disturb the metabolism of B12

IRREVERSIBLE brain and nervous system damageBehavioral changesForgetfulnessStuporWeakness and soreness in arms/legsDifficulty walking/speaking

Macrocytic anemia – large immature RBCs Interference in production of rapidly

forming RBCs in bone marrow

Oral supplementation Shots NOT the same as folate deficiency

anemia Proper treatment is B12 shots or

megadose supplements

Celiac disease?Connections between celiac disease and

gall bladder malfunctionThickened small bowel in LLQ and to a

lesser extent RLQ – Ileum?Bread intolerance (gluten) IBSCrampy abdominal painDiarrheaMalaiseNight sweatsAbdominal distention

RLQ LLQ

Chronic constipation GI symptoms were worsened when she

consumed broccoli, bread, and red meat.

Excessive sugar intake –up to 5 pounds in 1 week Excessive soda and coffee intake Processed foods, high fat meats, refined carbohydrates

Energy Needs: 1700-1800 kcal/day (BEE x 1.3 (Out of bed))

Protein Needs: 52-65 g/pro/day0.8-1.0 g/kg

Fluid Needs: 1950-2600 ml/day30-40 ml/kg

Patient is at mild nutritional risk due to diagnosis and unintentional weight loss.

Inadequate Food/Bev Intake related to unhealthy eating habits as evidenced by excessive intakes of sugar, soda, and caffeine per pt statements.

Altered GI function related to cholelithiasis and IBS as evidenced by nausea, vomiting, constipation and severe abdominal pain.

Nutrition Education – Survival tips Handouts for

ConstipationAn overall healthy diet (it may relieve some

of her symptoms)GERD IBS

Brief, verbal educationShort-term nutrition intervention for her

gallbladder removal

Fair – patient needed more time to do a full assessment of her eating habits with an RD

If patient continues to eliminate foods that cause discomfort and she utilizes the handouts, she may see improvements.

Suggested Celiac disease to a physician Recommended pt see a specialist to see

if she had Celiac Highlighted the importance of quitting

smoking

(1998). Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academy of Sciences. Institute of Medicine. Food and Nutrition Board.

Shils M E, Shike M. (2006). Modern nutrition in health and disease. Lippincott Williams & Wilkins.

Kirschmann, J D. (2007). Nutrition Almanac – 6th Edition. Nutrition Search, Inc.

Eitenmiller R R, Ye L, Landen W O. (2008). Vitamin analysis for the health and food sciences. Taylor and Francis Group, LLC.

Escott-Stump S. (2008). Nutrition and Diagnosis Related Care. Lippincott Williams & Wilkins.

U.S. Department of Agriculture, Agricultural Research Service. 2009. USDA National Nutrient Database for Standard Reference, Release 22. Nutrient Data Laboratory Home Page, http://www.ars.usda.gov/ba/bhnrc/ndl

Insel P, Turner E R, Ross D. (2010). Discovering Nutrition. Jones and Bartlett Publishers, LLC.