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.
 2/8/10 2/9/10 2/10/10
10:48 06:55 02:54
Sodium 142 142 142
Potassium 4.5 3.2 L 3.6
BUN 11 7 4L
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 Ultrasound
 Showed cholelithiasis

 CTscan of the liver and pelvis with IV

contrast
 Thickened small bowel in LLQ and to a lesser
extent RLQ
 Small 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 vitamin
 Group of cobalt-containing compounds, known
collectively as cobalamin
 Commonly 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.
 Functions
 Without 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, 3 oz 84.06
drained solids
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 3 oz 13.29
and fried
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)
 Malabsorption
 60% 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.

 Smoking
 Highcyanide intake that results from smoking
may disturb the metabolism of B12
 IRREVERSIBLE brain and nervous system
damage
 Behavioral changes
 Forgetfulness
 Stupor
 Weakness and soreness in arms/legs
 Difficulty 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
malfunction
 Thickened small bowel in LLQ and to a lesser extent RLQ –
Ileum?
 Bread intolerance (gluten)
 IBS
 Crampy abdominal pain
 Diarrhea
 Malaise
 Night sweats
 Abdominal 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/day
 0.8-1.0 g/kg
 Fluid Needs: 1950-2600 ml/day
 30-40 ml/kg
 Patientis 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
 Constipation
 An overall healthy diet (it may relieve some of her
symptoms)
 GERD
 IBS
 Brief, verbal education
 Short-termnutrition 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.