Answers to Self-Assessment Questions - ACCP

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However, a 10-kg weight loss in a 1-week period is unlikely to result from inadequate calorie intake; thus, Answer A and Answer B are incorrect. Answer C (obtain a resting energy expenditure study to determine his caloric needs) is also incorrect because it again assumes that the weight loss is caused by inadequate calorie intake. The initial intervention for W.H., given the most likely reason for the weight loss, is to provide additional intravenous fluid either by increasing his PN volume or by adding additional intravenous fluids (Answer D); thus Answer D is the correct answer. W.H.’ s weight and stool output should be followed daily, and the additional fluid reduced to the previous volume once W.H.’s weight has returned to his usual weight and his stool output has decreased to the usual volume. 1. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 2. Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006:130:S43–S51. 3. Jeppesen PB, Mortensen PB. Intestinal failure defined by measurements of intestinal energy and wet weight absorption. Gut 2000;46:701–6. 31. Answer: B W.H.’s wife tells you that he has developed a tremor and is having hallucinations. These symptoms are not normally seen in patients receiving home PN; thus Answer A (do nothing, but reassure W.H.’s wife that these symptoms are normal) is incorrect. Hypermagnesemia can occur in patients receiving long-term home PN when receiving a trace element cocktail daily. Manganese is deposited in the basal ganglia, so hypermagnesemia results in various neurological symptoms including those being experienced by W.H. However, other nutrient imbalances may also lead to similar symptoms. Therefore, Answer B (have the home health nurse draw a basic metabolic panel, complete blood count, and serum manganese concentration) is the best intervention at this time, making Answer B the correct answer. Answer C (have the nurse draw a serum manganese concentration) is one of the appropriate interventions, but Answer C is not the best answer because other laboratory tests should also be checked. Answer D (remove the trace element preparation from W.H.’s PN formulation) is incorrect. It would be premature to remove the trace elements from the PN formulation at this time. If hypermagnesemia is determined to be the cause of W.H.’s new neurological symptoms, then the trace element preparation would have to be removed, but zinc and perhaps chromium would need to be added to the PN formulation to prevent a deficiency state. 1. Dickerson RN. Manganese intoxication and parenteral nutrition. Nutrition 2001;17:689–93. 2. Bertinet DB, Tinivella M, Balzola FA, de Francesco A, Davini O, Rizzo L, et al. Brain manganese deposition and blood levels in patients undergoing home parenteral nutrition. JPEN J Parenter Enteral Nutr 2000;24:223–7. 3. Clark SF. Vitamins and trace elements. In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-based Approach – The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007, 129–59. 32. Answer: A A 25-year-old woman (weight 42 kg, height 163 cm) with chronic intestinal pseudo-obstruction is admitted to the hospital because of continued weight loss over the last 2 years (maximum weight 60 kg). Eating causes abdominal pain, as did continuous jejunal feedings during her last hospitalization. Her symptoms are typical of patients with chronic intestinal pseudo-obstruction. Some patients have severe small intestinal dysmotility with propulsion upward towards the stomach instead of downwards toward the colon. The best plan for this patient is to plan for discharge home on PN therapy (Answer A), making Answer A the correct answer. Answer B (start high-calorie oral supplements) is incorrect because any type of oral feedings will produce the same symptoms and will not be tolerated. Placing a transpyloric feeding tube and starting an elemental feeding formulation (Answer D) is incorrect because this therapy has already been tried and was not successful. Discharging her home with no nutrition support and waiting for her weight to decrease further (Answer C) is incorrect as she is already 12 kg below her ideal weight. Further weight loss will likely occur and result in another hospitalization to initiate PN. 1. Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006:130:S43–S51. 2. Kelly DA. Intestinal failure-associated liver disease: what do we know today? Gastroenterology 2006;S70–S77. 33. Answer: C A 25-year-old man (weight 50 kg, height173 cm) has been receiving home PN for 2 years after being injured in a motor vehicle accident. He has SBS with 20 cm of residual small intestine and 50% of his colon. His medical history includes intravenous drug abuse. His recent laboratory results include a 4-fold increase in his alkaline phosphatase (ALK), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin concentrations. The most appropriate response to the elevation in this man’s liver function tests (LFTs) is to obtain hepatitis serology and conduct a detailed drug history looking for drug-induced causes of his laboratory abnormalities (Answer C), making Answer C the correct answer. Answer A (reduce the intravenous fat emulsion in his PN formulation), Answer B (reduce both the intravenous fat emulsion and dextrose components of the PN formulation), and Answer D (discontinue his home PN therapy immediately) are incorrect because the cause of the elevated the LFTs must be determined before the correct therapy can be determined. This patient has risk factors for hepatitis as well as PN-induced steatosis and cholestasis. Additionally, with this patient’s degree of SBS, discontinuing his PN is not a practical option. 1. Kelly DA. Intestinal failure-associated liver disease: what do we know today? Gastroenterology 2006;S70–S77. 2. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Pract 2007;22:340–50. 3. OKeefe SJ. Bacterial overgrowth and liver complications in short bowel intestinal failure patients. Gastroenterology 2006;130:S67–S69. Gastroenterology and Nutrition Answers 42 Pharmacotherapy Self-Assessment Program, 6th Edition
34. Answer: D T.O. is obese (i.e., 300% of IBW) and is continuing to gain weight with her current PN formulation, which provides 29 kcal/kg/day based on her actual weight and 58 kcal/kg/ day based on an adjusted body weight for obesity. Thus, Answer A (continue the current PN formulation and follow up in 1 month) is not a good option for T.O. and is incorrect. Reducing the calories delivered by the PN formulation to 2500 kcal/day with 150 grams of protein per day (Answer C) is an appropriate intervention, but Answer D (decreasing the PN to 2500 kcal/day, maintaining 150 grams of protein per day, and attempting slow enteral feedings, is the best answer because T.O. should be given another trial of enteral feeding. Therefore, Answer C is incorrect and Answer D is the best answer. Stopping the PN and initiating either tube or oral feedings (Answer B) is not an appropriate option for T.O.; it will fail because she does not have adequate bowel length to have sufficient nutrient absorption to discontinue the PN. 1. Siepler J. Principles and strategies for monitoring home parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 2. ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN 2002;26(1 Suppl):1SA– 138SA. 3. Seres DS. Surrogate nutrition markers, malnutrition, and adequacy of nutrition support. Nutr Clin Prac 2005;20:308–13. 35. Answer: C T.O. has had an increase in stool output for the past 2 days. The stool is foul-smelling, and she has crampy abdominal pain but is afebrile. She is concerned that the diarrhea will soon lead to dehydration without intervention. The best therapeutic intervention for T.O. is to start metronidazole 500 mg intravenously three times/day and order intravenous replacement fluids for her stool losses (Answer C), making Answer C the correct answer. Simply reassuring her that her PN formulation provides adequate volume for increased stool losses and having her call back in 2–3 days (Answer A), is incorrect because her PN provides only 3 L/day, which will not be adequate if the stool volume has increased significantly. Answer B (start metronidazole 500 mg intravenously three times/day and order intravenous replacement fluids) is not the best answer because with the severity of her SBS and the increased stool output, the transit time for metronidazole taken orally will likely be too fast to allow for efficacy. Admitting T.O. to the hospital for broadspectrum intravenous antibiotics (Answer D) is incorrect because T.O.’s symptoms suggest bacterial overgrowth, which can be treated with metronidazole alone. Unless dehydration develops, bacterial overgrowth can usually be managed without hospital admission. 1. Di Stefano M, Miceli E, Missanelli A, Corazza GR. Treatment of small intestine bacterial overgrowth. Eur Rev Med Pharmacol Sci 2005;9:217–22. 2. Van Citters GW, Lin HC. Management of small intestinal bacterial overgrowth. Curr Gastroenterol Rep 2005;7:317–20. 3. Parrish CR, Krenitsky J, Willcutts K, Radigan AE. Gastrointestinal disease. In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-based Approach – The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007, 508–39. 36. Answer: B A 70-year-old woman is admitted to the hospital because of weight loss of unknown etiology. She has diabetes mellitus and gastroparesis (diagnosed 10 years ago) and is receiving nasojejunal feedings with a polymeric formula. After 2 weeks, she is gaining weight and her prealbumin concentration has increased. She is ready for discharge but is refusing to go home on tube feedings and would rather go home on PN. She has Medicare with no secondary provider. Because she is tolerating and responding to EN, Medicare will not cover the cost of PN therapy. Therefore, Answer A (place a tunneled CVAD, initiate PN, plan for discharge on home PN) and Answer C (discharge the patient to home on peripheral PN) are not good options for this patient who likely would not be able to pay for the cost of PN therapy. Additionally, peripheral PN is not a good option for use in the home because of the need to frequently replace the peripheral infusion site. Because she came into the hospital with unexplained weight loss, sending her back home on a oral diet with intravenous hydration is not optimal. She likely will not continue to gain weight on this regimen, and the cost of intravenous hydration will not be reimbursed by Medicare. The best option for this patient is to discuss the complications of long-term PN with her and the fact that Medicare will not cover the cost of PN therapy, and try to convince her to go home with jejunostomy tube feedings (Answer B), making Answer B the correct answer. 1. Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006:130:S43–S51. 2. Howard L. Home parenteral nutrition: survival, cost, and quality of life. Gastroenterology 2006;130:S52–S59. 37. Answer: D R.C.’s laboratory reports indicate that he is dehydrated. Therefore, doing nothing (Answer A), is not an appropriate response. The best response to R.C.’s current situation is to continue the PN formulation and give lactated Ringer’s 2 L followed by lactated Ringer’s replacement for his jejunostomy losses (Answer D). Increasing the PN volume to 4.5 L may help correct the existing dehydration, but it may not be adequate depending on the jejunostomy output; therefore Answer B is not the best option. Correcting the dehydration first, then replacing the losses proactively is the best approach to prevent dehydration in the future. Answer C (increase the sodium acetate in the current PN formulation to150 mEq/day) would help to acutely correct R.C.’s metabolic acidosis, but it would not correct the dehydration; thus Answer C is not the best response. 1. Parrish CR, Krenitsky J, Willcutts K, Radigan AE. Gastrointestinal disease. In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-based Approach – The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition, 2007, 508–39. 2. Buchman AL, Scolapio J, Fryer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterology 2003;124:1111–34. Pharmacotherapy Self-Assessment Program, 6th Edition 43 Gastroenterology and Nutrition Answers
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Answers to Self-Assessment Questions - ACCP

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