Clinical Case Report: Nutritional

Management of Upper GI Bleed

Joanna Fitzmorris, MPH
Queens College Dietetic Internship
MNT: General Medicine & Critical Care
Queens Hospital
1/29/24-4/5/24
Abstract:

This clinical case report explores the nutritional management of upper gastrointestinal

bleeding (UGIB) in a patient admitted to Queens Hospital. UGIB is a significant clinical

condition characterized by bleeding from the upper gastrointestinal tract. The primary cause of

UGIB is often peptic ulcer disease, although other factors such as erosive esophagitis, varices,

Mallory-Weiss tear, and vascular malformations can also contribute. The management of UGIB

involves both medical and nutritional interventions. The nutritional assessment for this case

revealed severe malnutrition, indicating the importance of early initiation of enteral nutrition to

prevent further deterioration. Despite initial challenges with oral intake and nasogastric tube

(NGT) feeding due to aspiration and bleeding, the patient eventually received a percutaneous

endoscopic gastrostomy (PEG) tube for long-term enteral nutrition support. The interdisciplinary

approach involved collaboration with speech-language pathology (SLP) for dysphagia

evaluation, optimizing medication administration, and monitoring for complications such as

pressure injuries and electrolyte abnormalities. Close monitoring of nutritional intake,

anthropometric measurements, and biochemical markers guided the adjustment of nutrition

support to meet the patient's evolving needs and promote recovery. The main findings underscore

the importance of early nutritional support in patients with UGIB to prevent malnutrition,

maintain gut integrity, and support healing. Challenges in providing enteral nutrition, including

dysphagia and aspiration, necessitated a personalized approach and close monitoring to optimize

outcomes. Through interdisciplinary collaboration and individualized nutrition interventions, the

patient's nutritional status improved, and she was ultimately discharged to a nursing home with

ongoing enteral nutrition support. Keywords: Upper gastrointestinal bleeding, peptic ulcer

disease, malnutrition, nutritional intervention, enteral nutrition

DISEASE DESCRIPTION

Etiology

Upper gastrointestinal bleeding (UGIB) is defined as blood loss from a gastrointestinal

(GI) source above the ligament of Treitz.¹ Upper gastrointestinal bleeds can be acute (sudden),

occult (no evidence of blood loss) , or obscure (from unknown source). The main cause of UGIB

is peptic ulcer disease (PUD), accounting for 40-50% of UGIB cases. PUD can result from

Helicobacer pylori, stress-related mucosal disease, and extended NSAID use.¹ UGIB can also

result from erosive esophagitis, duodenitis, varices, Mallory-Weiss tear, and vascular

malformations. Identifying and addressing the underlying cause is essential for effective

management.¹

Clinical Signs/Symptoms

Clinical signs and symptoms of a UGIB include hematemesis or vomiting blood,

hematochezia, bleeding of the anus, or melena characterized as black stool.¹ Due to the

pathophysiology of UGIB, patients may also present with symptoms secondary to blood loss

such as fatigue, weakness, and syncopal episodes.¹

Pathology

Upper GI bleeding refers to bleeding that occurs in the upper part of the gastrointestinal

tract, including the esophagus, stomach, or duodenum. Common causes of upper GI bleeding

include peptic ulcers, esophageal varices, Mallory-Weiss tears, and gastritis. The bleeding can

manifest as hematemesis (vomiting of blood) or melena (black, tarry stools) and can be

life-threatening if not promptly addressed.¹

Epidemiology
Upper GI bleeding is a significant healthcare burden, with a notable impact on morbidity

and mortality. It affects individuals of all ages but is more common in older adults, particularly

those with comorbidities such as cardiovascular disease, chronic kidney disease, or liver

cirrhosis. The incidence and prevalence of upper GI bleeding vary by geographic region and

demographic factors, but overall, it remains a serious medical concern worldwide.¹ Nearly 75%

of all acute GI bleeding is classified as UGIB, occurring in approximately 80 to 150 per 100,000

population.¹ Long-term, low-dose aspirin use has been associated with a higher risk of overt

UGIB, and when aspirin is combined with P2Y12 inhibitors, the risk of UGIB is 2-3 times

higher.¹

Co-morbidities

Patients with upper GI bleeding often have comorbidities that can complicate their

clinical course and affect their prognosis. The patient’s comorbidities include hypothyroidism,

cerebral palsy, and symptomatic anemia. These comorbidities highlight the complex interplay

between medical conditions and nutritional status, underscoring the importance of

multidisciplinary collaboration involving healthcare professionals such as physicians, dietitians,

and therapists to optimize patient care. By addressing both the underlying medical issues and

specific nutritional needs, tailored interventions can improve outcomes and enhance the overall

quality of life for individuals with complex health conditions like those seen in this case.

Hypothyroidism:

Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid

hormone. This hormonal imbalance can affect metabolism, leading to weight gain and changes in

appetite. Levothyroxine, a synthetic thyroid hormone, is commonly prescribed to restore

hormone levels. It is essential to monitor the patient's response to medication, as excessive

thyroid hormone replacement can increase metabolic rate and nutrient requirements, particularly

for minerals like calcium and iron.¹⁰

Cerebral Palsy (CP)

CP is a neurological disorder that affects movement and muscle coordination. Individuals

with CP may have difficulties with swallowing (dysphagia) due to muscle spasticity or

weakness, leading to aspiration risk and inadequate oral intake. Nutritional management for

individuals with CP often involves modifying food textures to minimize the risk of choking and

aspiration, ensuring adequate calorie and nutrient intake, and providing feeding assistance as

needed. Speech therapists and dietitians play crucial roles in assessing swallowing function and

developing individualized feeding plans.⁸

Symptomatic Anemia

Upper gastrointestinal bleeding, a common complication in patients with CP, can lead to

iron-deficiency anemia. Iron plays a vital role in red blood cell production, and its deficiency can

result in fatigue, weakness, and impaired cognitive function.¹¹ In addition to treating the

underlying cause of bleeding, such as esophageal varices or peptic ulcers, managing iron

deficiency anemia requires oral or intravenous iron supplementation, along with dietary

modifications to enhance iron absorption.¹¹ Consuming iron-rich foods like lean meats, fortified

cereals, and leafy green vegetables alongside vitamin C-rich foods can improve iron absorption.

Concurrent use of certain medications or dietary factors like caffeine and calcium may impair

iron absorption and should be considered in the overall management plan.⁸

Pressure Injuries:

Pressure injuries, previously known as pressure ulcers, result from necrosis and often

ulceration of skin as a result of soft tissue being compressed by bony prominences and external
hard surfaces.¹¹ The pressure on soft tissue, combined with friction, shearing forces, and

moisture, lead to degradation of the soft tissue. Risk factors include being over 65 years of age,

prolonged immobility such as hospital stay, bed rest, coma, or sedation, exposure to skin irritants

(due to urinary/fecal incontinence), and impaired capacity for wound healing such as

undernutrition or diabetes. Pressure injuries have been reported in patients with neurologic

impairments such as cerebral palsy. Pressure injuries increase a person’s nutrient needs, as well

as increase the risk for hospital-acquired infections such as cellulitis, which can hinder wound

healing. The diagnosis for pressure injuries includes a clinical evaluation and a nutritional

assessment due to the risk for undernutrition.⁵ A high calorie, high protein supplement is

recommended for those with a pressure injury who are malnourished and/or unable to meet their

needs through diet alone. In addition to additional calorie-protein needs, patients with pressure

injuries may benefit from protein supplements high in zinc and antioxidants to assist with wound

healing. The calorie and protein requirements for pressure injuries are 30-35 kcal/kg and

1.25-1.5g/kg, respectively, but estimated needs should be based on the patient’s needs and

require clinical judgment.¹¹ For additional information regarding staging of pressure injuries,

please refer to Appendix 5.

Cellulitis:

Cellulitis is classified as an acute infection diagnosed by its appearance, identified by

pain, warmth, fast-spreading erythema (redness), and edema.¹¹ Cellulitis infects the subcutaneous

tissue, most commonly by streptococci or staphylococci due to a compromised skin barrier, and

is treated with antibiotics.¹¹ As with any infection, increased inflammation adds stress to the

body, increasing cytokines and positive acute-phase reactants, and therefore nutrient needs of the

patient.⁴ Because of cytokines impairing the production of erythrocytes and reorientation of iron
stores from hemoglobin and serum iron to ferritin, laboratory tests to predict nutritional anemia

are not deemed effective in patients with an inflammatory response.⁴

EVIDENCE-BASED NUTRITION RECOMMENDATIONS

Early Nutritional Support:

Early initiation of nutritional support is crucial for patients with upper GI bleeding.

Malnutrition is common in these patients due to reduced oral intake, increased metabolic

demands, and potential blood loss. Prompt initiation of enteral nutrition, preferably within 24-48

hours of admission, helps prevent malnutrition, maintain gut integrity, and support healing.²

Enteral Nutrition:

Enteral nutrition, which involves the delivery of nutrients directly into the gastrointestinal

tract, is preferred over parenteral nutrition in patients with upper GI bleeding. Enteral feeding

helps maintain gut mucosal integrity, preserves gut-associated lymphoid tissue, and reduces the

risk of infectious complications compared to parenteral nutrition. It also stimulates the release of

gut hormones and trophic factors, promoting mucosal healing and gut function.²

Formula/Solution Selection:

The selection of enteral formula or solution should be based on various factors, including

the patient's nutritional requirements, gastrointestinal tolerance, and underlying conditions. For

patients with upper GI bleeding, easily digestible formulas or solutions that are low in residue

and osmolality are often preferred to minimize the risk of gastrointestinal complications.

Specialized formulas may be required for patients with specific nutrient deficiencies or

intolerances.²

Insertion of Feeding Tube:

In patients who are unable to tolerate oral intake or have impaired swallowing reflexes,

insertion of a feeding tube may be necessary to deliver enteral nutrition effectively. Nasogastric

or nasoenteric tubes are commonly used for short-term enteral feeding, while gastrostomy or

jejunostomy tubes may be considered for long-term support. The choice of feeding tube depends

on factors such as anticipated duration of nutritional support, gastrointestinal function, and

patient preferences.²

Prophylactic Measures:

Prophylactic measures aimed at reducing the risk of complications associated with upper

GI bleeding should be considered in high-risk patients. For example, tracheal intubation before

esophagogastroduodenoscopy (EGD) may be recommended in patients with severe bleeding or

hemodynamic instability to prevent aspiration and facilitate airway management during the

procedure. Prophylactic measures should be individualized based on the patient's clinical

condition and risk factors.²

Close Monitoring:

Regular monitoring of nutritional status is essential to evaluate the effectiveness of

nutrition support and guide adjustments as needed. This includes monitoring of anthropometric

measurements such as body weight, height, and body mass index, biochemical markers such as

serum albumin, prealbumin, transferrin, and clinical assessment to look for signs of malnutrition

or gastrointestinal tolerance. Close monitoring allows healthcare providers to identify nutritional

deficiencies or complications early and implement appropriate interventions.⁶

Individualized Approach:

Nutrition recommendations should be individualized based on the patient's specific

clinical condition, nutritional requirements, comorbidities, and response to treatment.⁶ Factors

such as age, sex, underlying medical conditions, nutritional requirements, and response to

treatment should be taken into account when developing nutrition plans. An individualized

approach ensures that patients receive optimal nutrition support tailored to their specific clinical

situation, which can improve outcomes and enhance overall well-being.⁶

CASE PRESENTATION: NCP ASSESSMENT

The patient is a 74-year-old female who has a past medical history of Cellulitis, Cerebral

palsy, hypothyroidism, and Dysphagia. The primary encounter diagnosis was Symptomatic

anemia, diagnoses of Sepsis, due to an unspecified organism, unspecified whether acute organ

dysfunction was present, inability to eat, and UGIB (upper gastrointestinal bleed) were also

pertinent to this visit. The patient presented to the ED with altered mental status, necessitating

elective intubation for airway protection. She was initially admitted to the ICU, where further

examinations could be performed. Upon further investigation, her main problem was determined

to be an upper GI bleed causing her symptomatic anemia and abnormal laboratory values.

Throughout the duration of her admission, the main nutrition intervention plan was for her to

tolerate enteral nutrition to improve her malnutrition status, as she arrived to the ED

malnourished. The medical team also worked to determine the cause of her gastric bleed, which

was ultimately unknown, as well as monitor the status of her bleed and improve her electrolyte

and renal profile. Over her stay, she developed bilateral edema of the lower extremities +2,

multiple pressure injuries, and needed to be taken off of tube feeding continuously due to

aspiration, bleeding, failed speech-language pathology (SLP) evaluations, and failed nasogastric

tube (NGT) placements. She was ultimately given a Percutaneous Endoscopic Gastrostomy

(PEG) tube and discharged on enteral nutrition.

Client History

The patient is a 74 y.o. female with a recent hospitalization elsewhere for upper GI

bleeding presenting with drowsiness and coffee ground emesis. The patient recently underwent

esophagogastroduodenoscopy and colonoscopy, significant for esophagitis, hiatal hernia, gastric

ulcer, and non-bleeding duodenal diverticulum. Due to concern for upper-GI bleeding and

desaturation due to aspiration, she was intubated. Due to her cerebral palsy, she was unable to

communicate but was alert and oriented to herself.

Active Problems:

Symptomatic Anemia

Sepsis

Hypothyroidism

Unable to Eat

Cerebral Palsy

Respiratory Infection

Aspiration Pneumonia of the Left Lung

UTI

Transaminitis

Reactive Thrombocytosis

Severe protein-calorie malnutrition

Severe malnutrition

Food & Nutrition-Related History

A nutrition history was not able to be obtained from this patient. Emergency medical

services brought her in for inability to eat and for hematemesis. The notes received from the

nursing home where she had previously been residing revealed that she had preexisting

dysphagia and malnutrition. There were no mentions of a modified diet or enteral nutrition

support provided by the nursing home. Per the nursing home, she had arrived in October for

rehabilitation, but her condition worsened over 4 months and she was brought to the emergency

room multiple times for circumstances similar to this admission.

NFPE and Identification of Malnutrition⁶

% of estimated energy intake: 0%

Body fat: severe wasting

Muscle mass: severe wasting

Fluid accumulation:B/L UE +2

Reduced grip strength: UTD

Malnutrition Assessment: Minimum of 2 of the 6 characteristics above is indicative of

Severe Malnutrition of Chronic Illness

**Patient presents with severe muscle wasting and bone prominences in thighs, patella, and

calves. Temporal and clavicle wasting present, orbital and buccal wasting indicative of fat loss

Skin: intact @ admission

Anthropometrics

Age: 74

Gender: Female
Ht: 152.4 cm (5’)

Wt, Admit 42.9 kg (94 lb)

UBW: 32.7 kg (72 lb)

%UBW: 131%

% wt Δ: 27% wt gain

DBW: 90-110 lb

% DBW: 92%

Medical Tests/Procedures

Percutaneous Endoscopic Gastrostomy (PEG) tube placement

Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure

used to provide long-term enteral nutrition support for patients who are unable to swallow or

tolerate oral intake. This procedure involves the insertion of a feeding tube directly into the

stomach via the abdominal wall under endoscopic guidance.² PEG tube placement is

recommended for patients who require long-term enteral nutrition support, such as those with

upper GI bleeding who are unable to tolerate oral intake. Current research outlines the benefits of

selecting enteral nutrition over parenteral nutrition in this population, emphasizing the

importance of maintaining gut integrity and function. The Academy of Nutrition and Dietetics

emphasizes the importance of individualizing enteral nutrition interventions, including PEG tube

placement, based on the patient's specific nutritional requirements, gastrointestinal tolerance, and

clinical condition.⁸ PEG tube placement plays a crucial role in providing long-term enteral

nutrition support for patients with upper GI bleeding who are unable to tolerate oral intake, with

individualized interventions tailored to each patient's needs.

Esophagogastroduodenoscopy (EGD)

Esophagogastroduodenoscopy (EGD) is a diagnostic and therapeutic procedure

commonly used in the evaluation and management of upper GI bleeding. During EGD, a flexible

endoscope is passed through the mouth into the esophagus, stomach, and duodenum to visualize

the upper GI tract and identify the source of bleeding. EGD is an essential tool in the

management of upper GI bleeding, allowing for the identification of bleeding lesions, tissue

sampling for histological analysis, and the application of hemostatic measures such as thermal

coagulation or injection therapy.² EGD plays a major role in the assessment and management of

upper GI bleeding, particularly in determining the need for prophylactic measures such as

tracheal intubation.⁷ ² Laine et al.³ discuss the severity and outcomes of upper GI bleeding based

on the presentation of hematemesis during EGD. Their study compares the outcomes of patients

with bloody versus coffee-ground hematemesis, highlighting the importance of EGD findings in

predicting clinical outcomes and guiding management decisions. EGD is a valuable diagnostic

and therapeutic tool in the management of upper GI bleeding, providing essential information for

guiding treatment decisions and optimizing patient outcomes.

Biochemical Data & Labs

Several nutrition-related laboratory values should be considered for patients with an

upper GI bleed to assess their nutritional status, evaluate the extent of blood loss, and monitor the

effectiveness of nutritional interventions. The pertinent laboratory values for this case include

Glucose, potassium, sodium, chloride, partial pressure of carbon dioxide (PaCO2), bicarbonate

(HCO3), hemoglobin (HGB), hematocrit (HCT), iron, alkaline phosphatase (ALP), and bilirubin.

By monitoring these nutrition-related laboratory values, healthcare providers can assess the
nutritional status of patients with upper GI bleeding, identify deficiencies or imbalances, and

implement appropriate interventions to optimize nutritional support and improve outcomes.

Available labs shortly after admission were limited. The patient’s glucose was 127 at

admission, which could be attributed to stress as she was in sepsis. Her HGB was 4.7, HCT was

16.1, and iron was 17; all of these anemia markers are low, indicating blood-loss anemia in the

context of the patient’s UGIB. Her ALP was high at 205. High ALP can be indicative of

impaired protein metabolism, which supports her diagnosis of severe protein-energy malnutrition

and the development of slow-healing pressure ulcers during her stay.⁵ The patient’s blood gas

panel provides insight into the patient’s respiratory and metabolic status. Her PaCO2 was 27 and

HCO3 was 16, both low.⁵ Her low PaCO2 indicates hyperventilation, which was observed in the

patient, and respiratory alkalosis.⁵ The patient’s metabolic imbalances, indicated by her

respiratory alkalosis, hyperventilation, fever, could be linked to sepsis as per her diagnosis.⁵ At

admission, the patient’s electrolyte panel, including sodium, potassium, and chloride, were

within normal limits despite the patient’s vomiting and inability to eat. These available

laboratory values can be used to indicate which blood tests should be ordered to continue

monitoring the patient's status.

Anemia markers provide insight into Hemoglobin and hematocrit levels are fundamental

markers for evaluating the extent of blood loss in upper GI bleeding.¹ A decrease in these values

indicates anemia resulting from acute or chronic blood loss.⁴ Changes in hemoglobin and

hematocrit levels over time reflect the patient's response to treatment, including interventions to

control bleeding and replenish blood volume. Increasing levels indicate a positive response,

while persistent or worsening anemia may necessitate further investigation or adjustments to

therapy. Iron studies, including serum iron, total iron-binding capacity (TIBC), and ferritin
levels, aid in the evaluation of iron metabolism and the identification of iron deficiency anemia,

which may occur secondary to chronic blood loss from UGIB.⁴ Low serum iron levels and high

TIBC suggest iron deficiency, whereas low ferritin levels indicate depleted iron stores.⁴

Monitoring iron studies helps identify patients at risk of iron deficiency anemia and guide

appropriate iron supplementation or transfusion therapy to optimize hemoglobin levels and

mitigate the consequences of anemia associated with UGIB.

Electrolyte panels, including potassium and sodium levels, provide valuable information

regarding the patient's fluid and electrolyte status, which can be significantly altered in cases of

upper gastrointestinal bleeding (UGIB). Electrolyte imbalances, such as hypokalemia or

hyponatremia, may occur due to excessive fluid loss from bleeding, vomiting, or diarrhea

associated with UGIB.⁴ Monitoring electrolyte levels helps guide fluid resuscitation and

electrolyte replacement therapy to restore normal balance and prevent complications such as

dehydration, cardiac arrhythmias, or neurologic abnormalities. Additionally, assessing electrolyte

levels can help identify underlying renal dysfunction, which may affect fluid and electrolyte

management strategies in patients with UGIB.

Liver function tests, including alanine aminotransferase (ALT), aspartate

aminotransferase (AST), alkaline phosphatase (ALP), and bilirubin levels, offer insights into the

liver's health and function, which can be pertinent in cases of UGIB.⁴ Elevated liver enzymes,

particularly ALT and AST, may indicate underlying liver injury or disease, such as alcoholic

liver disease, viral hepatitis, or hepatic ischemia, which could predispose patients to UGIB or

influence its management.⁴ ALP levels may be elevated in conditions affecting bile ducts, such

as cholangitis or biliary obstruction, which may present with UGIB-related symptoms.

Abnormalities in bilirubin levels can also provide clues regarding liver function and the presence
of hepatic dysfunction, contributing to the overall assessment and management of patients with

UGIB.

Nutrition Needs¹¹ Based on Wt, Admit 42.9 kg (94 lb), Older adults

Estimated Energy Need: Estimated Protein Need: Estimated Fluid Need:

1072-1287 kcal / day 54-64 g/day 1287- 1501 ml / day
Based on: 25-30 Kcal/kg Based on: 1.2-1.5 g/kg Based on: 30-35 mL/kg¹¹
(repletion)¹¹ (repletion)¹¹

NCP DIAGNOSIS: PES

1. 1. Altered GI function related to GI bleed as evidenced by Per H&P: Per ems they

told them she had coffee ground emesis sometime earlier today.⁷

2. NI-5.2 Severe malnutrition related to chronic illness as evidenced by severe muscle

and severe subcutaneous fat loss, <75% estimated nutrition needs for >/= 1 month.⁷

NCP INTERVENTION

Medical intervention

Intubation for prevention of aspiration 2/2 UGIB

Blood transfusion x2

BIPAP w frequent deep nasal suctioning

Aerosol mask + vest therapy

Nutritional intervention

(ND-2.1) Enteral Nutrition - Formula/solution, Insert feeding tube⁸

● Determine the appropriate enteral formula or solution based on the patient's nutritional

requirements, medical condition, and any specific dietary restrictions or preferences

● Coordinate with the healthcare team to insert the feeding tube using the appropriate

method (PEG) based on the patient's clinical status and nutritional needs

● Develop a feeding schedule that specifies the rate and duration of enteral nutrition

administration, considering factors such as tolerance, optimal absorption, and alignment

with the patient's daily routine

● Monitor the patient's response to enteral nutrition, including signs of tolerance, adequacy

of nutrient intake, gastrointestinal symptoms, and hydration status. Adjust the feeding

regimen as needed based on ongoing assessment and clinical indicators.

● Recommend Juven (Arginine and Glutamine) 2 packet/day. Juven contains Arginine,

Glutamine, HMB, C, E, and Zinc

NCP MONITORING & EVALUATION

Regular monitoring of nutritional intake, tolerance, and response to enteral nutrition:

(FH-1.3.1.1) Enteral Nutrition Intake – Enteral Formula/solution⁹

● Administer EN via PEG to meet >75% of caloric needs and 100% protein needs

● Monitor signs and symptoms of complications related to enteral or parenteral nutrition to

assess the patient's tolerance to enteral nutrition and identify any adverse reactions or

complications.

(AD-1.2.1.1) Weight – measured weight⁹

● conduct regular anthropometric measurements and assess changes in the patient's body

composition over time.

● evaluate the patient's medical history and anthropometric data for signs of malnutrition,

including weight loss, muscle wasting, and changes in BMI.

(PD-1.1.8) Skin - pressure injuries⁹

● Assess skin integrity and presence of pressure injuries to monitor the development and

progression of pressure injuries, which may indicate compromised nutritional status and

tissue integrity.

(BD-1.4.23) Gastrointestinal profile- Swallow study⁹

● Collaborate with other healthcare professionals to optimize patient care to work closely

with the SLP team in assessing the patient's dysphagia and determining the

appropriateness of oral intake.

● Assess swallowing function and risk for aspiration to evaluate the patient's swallowing

function and risk for aspiration, collaborating with the SLP team to implement

appropriate dietary modifications and feeding strategies.

(BD-1.2) Electrolyte and renal profile - BUN, hematocrit, hemoglobin⁹

● Monitor hemoglobin, hematocrit, and blood urea nitrogen (BUN) levels to assess for

changes indicating ongoing bleeding or improvement.

(PD-1.1.5) Digestive System Finding - Monitor status of GI bleed⁹

● Document any signs or symptoms of recurrent bleeding such as melena, hematemesis, or

hematochezia.

● Evaluate stool color and consistency for evidence of ongoing bleeding or resolution.

● Monitor the patient's level of consciousness, skin condition, and peripheral perfusion as

indicators of hemodynamic stability or deterioration.

Follow-Ups (Initial 2/7 in ICU)

2/10
● TF started 2/8, reached goal rate of 40ml/hr on 2/9

● 2/10: B/L UE +2 edema

● Diet, tube feeding no tray: Vital AF 1.2 (semi-elimental) - formula: continuous -

titrated to tolerance; 40; 10; 5; 24; 150; every 6 hours; NGT diet affective now

(provides 1152 kcal, 72g Pro, 779mL water + extra 600 mL water flush. Total

formula volume = 960 mL)

2/13

● Saw SLP 2/11:

○ Intubated on 2/6 and extubated 2/11 for clinical dysphagia evaluation

● Saw SLP 2/12:

○ Pt refused to participate w formal oral motor assessment

○ Recs: NPO, continue NGT

● Scheduled meds:

○ acetylcysteine, 3mL, nebulization, resp q6h

○ Ipratropium-albuterol, 3ml, nebulization, resp q6h

○ Levothyroxine, 75 mcg, ng tube, qam ac

○ Metronidazole, 500mg, Iv infusion, q8h sch

● Patient pulled out feeding tube this morning. Had previously been at TF goal rate

x3 days

● Per SLP: Severe orophangeal dysphagia

● B/L UE +2

2/16

● Saw SLP 2/14:

○ Attempted fiberoptic endoscopic eval of the swallow, aborted due to

epistaxis

○ Severe xerostomia marked by dry/cracked lips and tongue

○ Rec: continue NPO

○ Patient NPO for PEG placement today 2/2 multiple failed NGT

placements

2/19

● Stage 1 pressure injury: npn/blanchable erythema of intact skin (plantar

surface of left foot & heel)

● Stage 1 pressure injury: npn/blanchable erythema of intact skin (left

buttock)

○ Based on Wt, Admit 42.9 kg (94 lb) and presence of pressure injuries

Estimated Energy Need: Estimated Protein Need: Estimated Fluid Need:

1287-1501 kcal / day 54-64 g/day 1287 ml / day
Based on: 30-35kcal/kg¹¹ Based on: 1.25-1.5g/kg ¹¹ Based on: 30 mL/kg¹¹

● Meds:

○ acetylcysteine, 3mL, nebulization, resp q6h

○ Ampicillin-silbactam, 3g, IV infusion, Q6H SCH

○ Ipratropium-albuterol, 3ml, nebulization, resp q6h

○ Levothyroxine, 75 mcg, ng tube, qam ac

○ Pantoprazole, 40 mg, intravenous, Q24h SCH

○ Vanomycin 15mg/kg, IV infusion, Q24H SCH

2/26
● TF Order: Jevity 1.5 at 5ml/hr q4h to goal rate of 15ml/hr x 14 hrs from 6am to

8pm

○ 315 kcal, 15g pro, 160ml h2o

○ Prosource 2x/day (+ 120 kcal 30g pro)

○ FW flushes per MD discretion

● Dark bleeding coming from PEG tube

○ PPI IV twice daily, sucralfate, held feeding, PEG tube connected to

suction

○ Mild drop in HGB, no transfusion required

Med Dx: UGIB, Symptomatic anemia, sepsis (unspecified org)

3/4:

● Feeding resumed gradually until tolerated, no other bleeding episodes

● FU chest x ray shows pleural effusion

○ Ordered IV lasix for diuresis

● ALK Phos 330, GI consulted - cholecystitis ruled out

● Thyroid @ 150, endocrine consulted

○ Levothyroxine 125 mcg

○ Changed feeding from continuous to 18 hours 8am-2am

■ Give space of 6 hours for better action of levothyroxine on empty

stomach

● FU T4 testing in 1 week

● TSH ordered
● PES: Inadequate intake related to increased brownish secretions upon

suction/high risk of aspiration as evidenced by patient NPO

3/5: discharged to nursing home

Conclusion:

Upper gastrointestinal bleeding (UGIB) presents a complex clinical challenge, often

necessitating multidisciplinary care and tailored interventions. Understanding the etiology,

clinical manifestations, and comorbidities associated with UGIB is essential for effective

management. Collaborative efforts involving healthcare professionals from various disciplines,

including physicians, dietitians, and therapists, are crucial in addressing the diverse needs of

patients with UGIB.

Conclusion:

In this case, the patient's nutritional status was significantly compromised due to factors

such as dysphagia, malnutrition, and comorbidities including hypothyroidism and cerebral palsy.

Early initiation of enteral nutrition, careful selection of enteral formulas, and close monitoring of

nutritional status played pivotal roles in addressing these challenges. Additionally, tailored

interventions aimed at managing pressure injuries and cellulitis were essential components of the

patient's care plan. Despite the challenges posed by UGIB and its associated complications,

diligent monitoring, proactive interventions, and coordinated follow-up care contribute to

successful patient outcomes. By addressing the underlying causes of UGIB, optimizing

nutritional support, and managing comorbidities effectively, healthcare providers can improve

the quality of life and prognosis for individuals affected by this condition. A comprehensive
approach to the management of UGIB, encompassing medical, nutritional, and rehabilitative

interventions, is essential for achieving favorable outcomes and promoting patient recovery.

Continued research and collaboration within the healthcare community are vital for advancing

our understanding of UGIB and optimizing strategies for its prevention, diagnosis, and treatment,

with specific attention to the unique nutritional implications of each case.

Appendix 1 ASPEN Criteria to Diagnose Malnutrition⁴
Appendix 2. Food/Drug Interactions¹⁰

Meds:

● acetylcysteine, 3mL, nebulization, resp q6h (none)

● Ampicillin-silbactam, 3g, IV infusion, Q6H SCH

○ Ampicillin should be administered one hour before or two hours after

meals

● Ipratropium-albuterol, 3ml, nebulization, resp q6h

○ Moderate caffeine Interaction. Coadministration of two or more

sympathomimetic agents may increase the risk of adverse effects such as

nervousness, irritability, and increased heart rate. Central nervous system

(CNS) stimulants, particularly amphetamines, can potentiate the

adrenergic response to vasopressors and other sympathomimetic agents.

Additive increases in blood pressure and heart rate may occur due to

enhanced peripheral sympathetic activity.

● Levothyroxine, 75 mcg, ng tube, qam ac

○ Avoid taking within 4 hours before or 4 horus after the following: calcium

carbonate (Alka-Mints, Caltrate, Os-Cal, Oyster Shell Calcium, Rolaids

Soft Chew, Tums, and others), sevelamer, lanthanum; cholestyramine,

colesevelam, colestipol; iron supplements; sucralfate; sodium polystyrene

sulfonate (Kalexate, Kayexalate, Kionex); stomach acid reducers -

esomeprazole, lansoprazole, omeprazole, rabeprazole, Nexium, Prilosec,

Prevacid, Protonix, Zegerid, and others (this applies to most brands of

levothyroxine except for Tirosint-SOL); or antacids that contain aluminum

or magnesium - Gaviscon, Maalox, Milk of Magnesia, Mintox, Mylanta,

Pepcid Complete, and others.

● Pantoprazole, 40 mg, intravenous, Q24h SCH (none)

● Vanomycin 15mg/kg, IV infusion, Q24H SCH (none)

Appendix 3. Laboratory values⁴

Component Lab Value Normal Range Date

Glucose 127 H 74 - 110 mg/dl 2/6/24

Potassium 4.3 3.6-5 mEq/L 2/6/24

Sodium 138 135-145 mEq/L 2/6/24

Chloride 102 95-107 mEq/L 2/6/24

PaCO2 27 L 35-45 mm Hg 2/6/24

HCO3 16 L 22-26 mEq 2/6/24

HGB 4.7 L 12.0-16.0 g.dL 2/6/24

HCT 16.1 L 37.0-47.0 g/dL 2/6/24

IRON 17 L 37-145 ug/dL 2/6/24

ALP 205 H 30-120 U/L 2/6/24

Bilirubin <.2 L Total bilirubin 0.3-1 mg/dL 2/6/24

4. Standards of Nutrition Care: Nutrient Need Calculations¹¹

Patient Population Daily Kcal Needs Daily Daily Fluid Other Reference
Protein Needs Recommendati
Needs ons/Comments
Adults 25-30 Kcal/kg 0.8-1.0 g/kg 1mL/kcal NCM1
(maintenance) (maintenance OR ASPEN3
30-35 Kcal/kg ) 25-35 mL/kg
(repletion) 1.2-2.0 g/kg ABW
BMI > 25: 20-25 (repletion)
kcal/kg ABW *May be
BMI 30-40: 15-20 1.2-1.5 g restricted for
kcal/kg ABW pro/kg IBW medical
BMI > 40 use 11-15 for BMI 30-40 condition
kcal/kg ABW 1.5-2.0 g
OR pro/kg IBW
Mifflin-St Jeor (MSJ) for BMI > 40
+ AF as applicable
Older adults 20-25 Kcal/kg 1.0-1.25 g/kg 30-35 mL/kg NCM1
(maintenance) 1.2-1.5 g/kg EAL2
25-30 Kcal/kg (repletion)
(repletion)
OR
MSJ

Pressure ulcer 30-35kcal/kg 1.25-1.5g/kg 30ml/kg Juven (Arginine NPUAP7

(Stages I-IV, DTI, (Stages I-IV, (Stages I-II) and Glutamine) NCM1
Unstageable) Unstageable, 30-35ml/kg 1 packet BID
DTI) (Stages III-IV, (Stages II-IV,
DTI, Unstageable,
Unstageable) DTI). Juven
contains
Arginine,
Glutamine,
HMB, C, E, and
Zinc. Consider
d/c additional
zinc. TUL for
elemental zinc is
40 mg.

**These are standard guidelines. Clinical judgement always prevails**

Ideal Body Weight (IBW) Calculation (Hamwi Formula):

Female: 100# for 60” tall, add 5# for every additional inch of height, subtract 2-3# for each inch under 60”
Male: 106# for 60” tall, add 6# for every additional inch of height, subtract 2-3# for each inch under 60”
5. EN Orders

● TF Order 1:Vital AF 1.2 (semi-elimental) -continuous - at 10ml/hr continuous to

goal rate of 40ml/hr + 150mL free water flush q6h; via NGT (Total formula

volume = 960 mL)

○ 1152 kcal, 72g Pro, 779mL water + extra 600 mL water flush

● TF Order 2: Jevity 1.5 at 5ml/hr q4h to goal rate of 15ml/hr x 14 hrs from 6am to

8pm via PEG (Yotal formula volume = 1050 ml)

○ 315 kcal, 15g pro, 160ml h2o

○ Prosource 2x/day (+ 120 kcal 30g pro)

○ FW flushes per MD discretion

Appendix 6. Staging of Pressure Injuries⁵
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