CASE NO.

7
GASTROESOPHAGEAL REFLUX DISEASE
Jack Nelson, a 48-year-old male, visits his physician for evaluation of increasing complaints of
severe indigestion. Intra-esophageal pH monitoring and a barium esophagram support a
diagnosis of gastroesophageal reflux disease.
Patient Summary: 48-yo male here for evaluation and treatment for increased indigestion
History: Onset of disease: Patient has been experiencing increased indigestion over last year.
Previously it was only at night but now he experiences indigestion almost constantly. He has
been taking Tums several times daily. Mr. Nelson has gained almost 35 lbs since his knee
surgery, which he attributes to a decrease in his ability to run and not being able to find a
consistent replacement for exercise. Patient states he plays with his children on the weekends,
but that is the extent of his physical activity. He states he probably has been eating and drinking
more over the last year, which he attributes to stress. He is worried about his family history of
heart disease, which is why he takes an aspirin each day. He has not really followed any diet
restrictions.
Medical history: Essential HTN—Dx 1 year ago
Surgical history: s/p R knee arthroplasty 5 years ago
Medications at home: Atenolol 50 mg daily; 325 mg aspirin daily; multivitamin daily; 500 mg
ibuprofen twice daily for last month
Tobacco use: No
Alcohol use: Yes; 1–2 beers 3–4 times/ week
Family history: What? CAD. Who? Father
Demographics:
Marital status: Married—lives with wife and 2 sons
Spouse name: Mary
Number of children: 2
Years education: BA
Language: English only
Occupation: Retail manager of local department store
Hours of work: M–F, works consistently in evenings and on weekends as well
Ethnicity: Caucasian
Religious affiliation: Protestant
MD Progress Note:
Review of Systems
Constitutional: Negative
Skin: Negative
Cardiovascular: No carotid bruits
Respiratory: Negative
Gastrointestinal: Heme 1 stool
Neurological: Negative
Psychiatric: Negative
Physical Exam
General appearance: Mildly obese 48-year-old white male in mild distress
Heart: Noncontributory
HEENT: Noncontributory
Genitalia: WNL
Neurologic: Oriented 3 4
Extremities: No edema; normal strength, sensations, and DTR
Skin: Warm, dry
Chest/lungs: Lungs clear to auscultation and percussion
Peripheral vascular: Pulses full—no bruits
Abdomen: No distention. BS present in all regions. Liver percusses approx 8 cm at the
midclavicular line, one fingerbreadth below the right costal margin. Epigastric tenderness
without rebound or guarding.
Vital Signs: Temp: 98.6 Pulse: 90 Resp rate: 16
BP: 119/75 Height: 5'9" Weight: 215 lbs
Assessment and Plan:
Rule out GERD, decrease aspirin to 75 mg daily
Dx: Gastroesophageal reflux disease, HTN
Medical Tx plan: Hematology, Chem 24, Ambulatory 48-hour pH monitoring with BravoTM pH
Monitoring System, Barium esophagram—request radiologist to attempt to demonstrate reflux
using abdominal pressure and positional changes; Endoscopy with biopsy to r/o H. pylori
infection; Begin omeprazole 30 mg every am; Decrease aspirin to 75 mg daily; D/C self-
medication of ibuprofen daily; Nutrition consult P. Phelps, MD
Nutrition History: Patient relates he has gained almost 35 lbs since his knee surgery. He
attributes this to a decrease in his ability to run, and he has not found a consistent replacement
for exercise. He plays with his children on weekends, but that is the extent of his physical
activity. He states he probably has been eating and drinking more over the last year, which he
attributes to stress. He is worried about his family history of heart disease, which is why he takes
an aspirin each day. He has not really followed any diet restrictions.
Usual dietary intake:
AM: 11⁄2–2 c dry cereal (Cheerios, bran flakes, Crispix), 1⁄2–3⁄4 c skim milk, 16–32 oz orange
juice
Lunch: 11⁄2 oz ham on ww bagel, 1 apple or other fruit, 1 c chips, diet soda
Snack when he comes home: Handful of crackers, cookies, or chips, 1–2 16-oz beers
PM: 6–9 oz of meat (grilled, baked usually), pasta, rice, or potatoes,1–2 c fresh fruit, salad or
other vegetable, bread, iced tea
Late PM: Ice cream, popcorn, or crackers. Drinks 5–6 12-oz diet sodas daily as well as iced tea.
Relates that his family’s schedule has been increasingly busy, so they order pizza or stop for fast
food 1–2 times per week instead of cooking.
24-hr recall:
(at home PTA): Crispix—2 c, 1 c skim milk, 16 oz orange juice
At work: 3 12-oz Diet Pepsis
Lunch: Fried chicken sandwich from McDonald’s, small French fries, 32-oz iced tea
Late afternoon: 2 c chips, 1 beer
Dinner: 1 breast, fried, from Kentucky Fried Chicken, 11⁄2 c potato salad, 1⁄4 c green bean
casserole, 1⁄2c fruit salad, 1 c baked beans, iced tea
Bedtime: 2 c ice cream mixed with 1 c skim milk for milkshake
Food allergies/intolerances/aversions: Fried foods seem to make the indigestion worse
Previous nutrition therapy? No
Food purchase/preparation: Wife or eats out
Vitamin intake: One-A-Day for Men multivitamin daily
CASE QUESTIONS
I. Understanding the Disease and Pathophysiology
1. How is acid produced and controlled within the gastrointestinal tract?
2. What role does lower esophageal sphincter (LES) pressure play in the etiology of
gastroesophageal reflux disease? What factors affect LES pressure?
3. What are the complications of gastroesophageal reflux disease?
4. The physician biopsied for H. pylori. What is this?
5. Identify the patient’s signs and symptoms that could suggest the diagnosis of gastroesophageal
reflux disease.
6. Describe the diagnostic tests performed for this patient.
7. What risk factors does the patient present with that might contribute to his diagnosis? (Be sure
to consider lifestyle, medical, and nutritional factors.)
8. The MD has decreased the patient’s dose of daily aspirin and recommended discontinuing his
ibuprofen. Why? How do aspirin and NSAIDs affect gastroesophageal disease?
9. The MD has prescribed omeprazole. What class of medication is this? What is the basic
mechanism of the drug? What other drugs are available in this class? What other groups of
medications are used to treat GERD?
II. Understanding the Nutrition Therapy
10. Summarize the current recommendations for nutrition therapy for GERD.
III. Nutrition Assessment
11. Calculate the patient’s %UBW and BMI. What does this assessment of weight tell you? In
what ways may this contribute to his diagnosis?
12. Calculate energy and protein requirements for Mr. Nelson. How would this recommendation
be modified to support a gradual weight loss?
13. Complete a computerized nutrient analysis for this patient’s usual intake and 24-hour recall.
How does his caloric intake compare to your calculated requirements?
14. Are there any other abnormal labs that should be addressed to improve Mr. Nelson’s overall
health? Explain.
15. What other components of lifestyle modification would you address in order to help in
treating his disorder?
IV. Nutrition Diagnosis
16. Identify pertinent nutrition problems and corresponding nutrition diagnoses and write at least
two PES statements for them.
V. Nutrition Intervention
17. Determine the appropriate intervention for each nutritional diagnosis.
18. Using Mr. Nelson’s 24-hour recall, outline necessary modifications you could use as a
teaching tool.

Food Item Modification Rationale

Crispix
Skim milk
Orange juice
Diet Pepsi
Fried chicken sandwich
French fries
Iced tea
Chips
Beer
Fried chicken
Potato salad
Green bean casserole
Fruit salad
Baked beans