Esophagus Perforation

After the repair of the hole esophagus, we discussed the option with the family and noting that we have taken biopsy of the wall and it showed normal mucosa with no pathological disease of the esophagus.

Thoracic surgeons discus with the family that if this treatment fails the option would be a diversion esophagostomy and removal of the esophagus and stomach pull-up to be done later when the patient resolved her sepsis and condition improve nutritionally.

The family was very reluctant for this kind of management and they where counseled three times regarding that this is the ultimate management of persistent esophageal perforation.

29/8

12/8/13

Wt: 40.4kg, % wt change: 9% sever

Labs: Albumin 33, Na 134, Cl 93, PO4 1.6, K 3.4, BUN 2.3

Vomit 2 X

Medication: Human Albumin

• Continue same feeding Peptamin at 300ml Q 4H
• Recommend antiemetic agent

Second OP on 30 June

Third OP On 8 July

Bulimia Nervosa

Warning Signs of Bulimia Nervosa

3 sever %Wt: 48.5kg, % wt change:

Labs: TG 5.5, AST 110, ALT 87, Albumin 28, Creat 39,PO4 1.53, Na 130

During third exploration, jejunostomy tube for the feeding was put for the pt to avoid the complication of TPN

Jejenstomy tube feeding started with Peptamin at 20ml/H,

increased gradually to 70ml/H that provide:

• Energy:1680 Cal/d 29 Cal/IBW/d
• Protein: 67g/d 1.15 g/IBW/d

Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

Pt transferee to the floor 22/8

She underwent drainage of the collection

Wt: 50kg, Ht: 170cm, BMI 17.3 kg/m2 Under Wt

IBW:58-72kg

Labs: Albumin 27, Creat 39, Na 132

Medications: no drug nutrient interaction

5 Aug On the ICU pt she was kept NPO and start total TPN that provide:

• Energy:1450 Cal/d 25 Cal/IBW/d
• Protein: 116g/d 2g/IBW/d

Evidence of purging behaviors including:

• Frequent trips to the bathroom after meals
• Signs and/or smells of vomiting
• Unusual swelling of the cheeks or jaw area

Pt underwent left sided neck exploration and repair of esophageal perforation, right thoracotomy and evacuation of the fluid in the thoracic cavity.

She was extubated then reintubated due to respiratory distress , her TPN as restarted, she had been septic

Warning Signs of Bulimia Nervosa

Wt: 44kg, Ht: 170cm, BMI 15.2 kg/m2 Under Wt

Previous Wt: 48.9kg, % wt change: 8% Sever

IBW:58-72kg

Lab: Albumin 25, Creat 39, Na 134

Medications: no drug nutrient interaction

No N&V, regular BM, No edema

Physical Activity level: setting & mobilize

• Energy requirement: 1894Cal/d (BEE*10%AF*20%SF)
• Protein requirement: 75g (1.3g/kg/d)
• H2O requirement: 2320ml/d (40ml/IBW/d)

Intermittent infusion started at 300ml Q 4H, H2O Flushing 100ml Q 4H, provide:

• Energy:1800 Cal/d 31 Cal/IBW/d
• Protein: 72 g/d 1.24 g/IBW/d

• Discoloration or staining of the teeth.
• Bulimia nervosa is frequently associated with symptoms of depression and changes in social adjustment.
• People struggling with bulimia nervosa usually appear to be of average body weight.

Mallory–Weiss syndrome

longitudinal mucosal lacerations in the distal esophagus and proximal stomach that are usually associated with forceful retching, the lacerations often lead to bleeding from submucosal arteries.

The prevalence of such tears among patients presenting with upper gastrointestinal bleeding is approximately 5 %.

Rarely, perforation can occur with repeated, protracted vomiting.

Preparing Pt for Discharge

13/10

Psyche service

25/9

No depression, negative view against primary team, pt refused any psychic intervention or medication

First OP on 10 June 2013

Wt: 40.5kg, % wt change: 2% sever

Lab: BUN 8, Na 133

Add BeneProtein 20g & switch to intermittent infusion at 170ml Q 4H, provide:

• Energy:1598 Cal/d 28 Cal/IBW/d
• Protein: 77 g/d 1.3 g/IBW/d

Mental health consolation 24/9

The pt underwent surgery right thoracotomy and evacuation of the mdiasttinal collection and left neck incision and repair of the esophageal perforation.

Not cooperative, sensitive, suffering from

difficulty to take decision, inner conflict.

Major psych intervention is psychotherapy no need for medication.

27/10

19/9

Wt: 40.6kg no change

Lab: Na 135

No nausea and vomiting

• Pt tolerate the feeding
• Pt start clear liquid diet, to be advanced to full liquid
• Encourage pt to take the full liquid diet

22/9:Increase feeding of Vivonex Plus to 60ml/H provide:

• Energy: 1400Cal Cal/d 24Cal/IBW/d
• Protein: 58 g/d 1g/IBW/d

24/9:C/O nausea, vomit 1X

Increase Vivonex Plus concentration 1.5Cal/ml at 44ml/H provide:

• Energy: 1584Cal Cal/d 27Cal/IBW/d
• Protein: 63 g/d 1.1/IBW/d

On clear liquid diet

H2O flushing decreased to 30ml Q 4 H

8/9: Pt vomit 3X Switch to continuous infusion with Peptamin at 50ml/H

Pt on sips of water only

9/9: C/O nausea, no vomiting or loose stool Increase feeding concentration of Peptamin to 1.5Cal/ml at 30ml/h

16/9: Increase feeding concentration of Peptamin to1.5Cal/ml to 44ml/H

20/10

Wt: 41.5kg, % wt change: % 1 insignificant

Labs: Na 133, Cl93

C/O vomiting 2X

Change feeding to Vivonex Plus at 40ml/H; provide:

Energy: 960Cal Cal/d 17Cal/IBW/d

Protein: 41 g/d 0.7g/IBW/d

Recommend antiemetic agent

Wt: 40.6kg no Wt change

Lab: BUN 9.9, Na 133

Pt C/O nausea, no vomiting

Decrease feeding of “Vivonex Plus 1.5Cal/ml+ BeneProtein20g” to 160ml Q 4H, provide:

• Energy:1512 Cal/d 26 Cal/IBW/d
• Protein: 73 g/d 1.25 g/IBW/d

H2O 10ml Q4H

Recommend antiemetic agent

30/10

29/10

Switch to Osmolite at 90ml/H over 12H as nocturnal feeding, Provide:

• Energy: 1080Cal/d 19Cal/IBW/d
• Protein: 43g/d 0.7Cal/IBW/d

Esophagus was seen healthy and intact. Pt discharged on full liquid diet as tolerated and Osmolite feeding through jejunostomy tube as nocturnal feeding

Wt: 40.6kg no change, BMI 14 kg/m2 Under Wt

Labs: WNL

• Change Jejenstomy tube feeding to “Peptamin 1.5Cal/ml+Beneprotein20g” at 63ml/H; as nocturnal feeding from 8pm to 7am (Provide 60% of pt nutrional needs)
• Continue full liquid diet

5/9

Thank You for listening

Any Questions?

25/9

Wt: 42.1kg, Pt gain 1.7 kg

Lab: Albumin 39, Creat 80n, Na 129, K 3.2, PO4 1.6, Cl 89

C/O Bloating, loose stool 3X, Vomit 3 X

Start clear liquid diet, pt refuse to drink anything except water.

The feeding decreased to 230ml Q 4H, H2O flushing decreased to 50ml Q 4 H, provide:

• Energy: 1380Cal Cal/d 24 Cal/IBW/d
• Protein: 55 g/d 0.9 g/IBW/d

Wt: 41.5kg No Wt change

Lab: Na 130, Cl94 Pt takes 300ml/d of water PO only & 30ml Q 4H H2O flushing

C/O vomiting 2X,

Decrease feeding of Vivonex Plus 1.5Cal/ml to 40ml/H, provide:

Energy: 1440Cal Cal/d 25Cal/IBW/d

Protein: 58 g/d 1g/IBW/d

H2O flushing decreased to 10ml Q 4 H

A 19 years, female, transferred from King Saud hospital Onaiza as case of esophageal perforation. There she presented with fever, neck pain and swelling associated with backache for two days. She gives history of foreign body i.e. bread piece choking in her throat for two days.

Perforated esophagus 5X in 4 years, seems bulimic ?

Pt family refused esophagectomy

They transferred this patient with the diagnosis of:

• Perforation of the esophagus at the level C6-7.
• Mediastinitis
• Pneumomediastinum
• Bilateral pleural effusion
• Sepsis 

She was brought intubated and ventilated

Admitted under thoracic surgery in emergency critical care

Esophagus Perforation

Rawan Alolayan

Surgical Clinical Dietitian I