Question

Patient Summary: After undergoing chest X-ray, endoscopy with brushings and biopsy, and CT scan, Mr. Hamilton (age 56) was diagnosed with Stage 2B (T1, N1, M0) adenocarcinoma of the esophagus.

History:

Onset of disease: Dysphagia by 3-4 months; odynophagia by 5-6 months

Medical History: Patient describes significant heartburn for the previous year. He has been taking TUMS, Alka-Seltzer, or Pepcid consistently for the past year. He has noted weight loss of over 30lbs, in the last several months. He states that he just has not been able to eat because of the pain and heartburn. Now, difficulty swallowing foods---especially anything with texture---has brought him to this physician. Patient also describes a recurrent cough at night.

Medications at home: TUMS, Alka-Seltzer, and Pepcid

Tobacco use: Yes, 2ppd; quit 5 years ago

Alcohol use: Yes. 1-2 drinks a week

Vital Signs:       Temp: 98.3 F                 Pulse: 88                      Resp rate: 12

                        BP: 132/92                    Height: 6’3’’                  Weight: 198lbs

Nutriton-Focused Physical Exam:

Eyes: sunken; sclera clear without evidence of tears

Nose: Dry mucous membranes

Throat: Dry mucous membranes, no inflammation

Shoulders: Some boney projections

Extremities: Joints appear prominent with evidence of some muscle wasting. No edema. Slight clubbing of fingers.

Nutrition:

General: Prior to admission has noted decreased appetite, feeling full all the time, and regurgitation of some foods. He notes pain upon swallowing as well as constant heartburn.

Usual dietary intake:

AM: Used to eat eggs, bacon, toast every morning but has not eaten this for at least the past month. Most recently has had just coffee and thin oatmeal (instant oatmeal made with water).

Lunch: Previously, ate cold lunch packed for the work site. Included sandwich, cold meat or other leftovers from previous dinner, fruit, cookies, and tea. Currently drinks a milkshake or Smoothie.

Dinner: All meats, pasta or rice, 2-3 vegetables, 1-2 beers. Lately patient’s wife prepares soup because it is easier to swallow. He hasn’t been able to drink beer more recently due to burning pain.

1. What are the likely side effects that Mr. Hamilton will experience during his treatment of chemotherapy and radiation therapy? (5 points)
2. Mr. Hamilton has a PEG placed. The physician asks you, the dietitian, to recommend a formula and rate. What are your recommendations? (5 points)

Answer 1

What are the likely side effects that Mr. Hamilton will experience during his treatment of chemotherapy and radiation therapy?

common side effects caused by chemotherapy

• Fatigue
• Hair loss
• Easy bruising and bleeding
• Infection
• Anemia (low red blood cell counts)
• Nausea and vomiting
• Appetite changes
• Constipation
• Diarrhea
• Mouth, tongue, and throat problems such as sores and pain with swallowing
• Peripheral neuropathy or other nerve problems, such as numbness, tingling, and pain
• Skin and nail changes such as dry skin and color change
• Urine and bladder changes and kidney problems
• Weight changes
• Chemo brain, which can affect concentration and focus
• Mood changes
• Changes in libido and sexual function
• Fertility problems

Radiation not only kills or slows the growth of cancer cells, it can also affect nearby healthy cells. Damage to healthy cells can cause side effects.common side effects of radiotherapy for oesophagus in the case of Hamilton

• Fatigue
• Hair loss
• Mouth changes
• Skin changes
• Taste changes
• Throat changes, such as trouble swallowing
• Less active thyroid gland

Mr. Hamilton has a PEG placed. The physician asks you, the dietitian, to recommend a formula and rate. What are your recommendations?

Tube Feed Recommendations

Jevity (1.2 Cal) @ 80 mL/hr

• Start at 20 mL/hr, titrate by 10-20 mL/hr every 4 hours to goal
• 250 mL free water flushes every 4 hours (62.5 mL/hr)

1. Macronutrients

   Feed calories	2304 kcal (26 kcal/kg)
   Total protein	107 gm (1.2 gm/kg)
   Total carbs	325 gm
   Total fat	75 gm

Fluid

Feed water	1549 mL
Water flushes	1500 mL (250 mL Q4hr)
Total fluids	3049 mL (34 mL/kg)
Daily needs	3150 mL (35 mL/kg/day)