AHD 4126:IPD 1

Case presentation:
UGIB & perinepric abscess

NURUS SA’ADAH MOHD FADZIL

0616952
 Introduction

•Perinephric abscess (PNA) a.k.a perirenal abcess is defined as an abscess(infection) outside the
renal capsule .They are rare in comparison to other infections involving the genitourinary tract but
they can cause significant morbidity and mortality (Journal International Brazil Urology,2010).

•Renal and perinephric abscess formation usually occur in patients with predisposing factors such
as diabetes mellitus, urinary calculi, urinary obstruction and immune compromised patients.
Systemic diseases such as DM (46.9%) was much more common than renal or urologic diseases
such as malignancy (4.1%) or renal stones (10.2%) (Seung Hwan Lee et al.,2010).

•Upper gastrointestinal bleeding (UGIB) is defined as hemorrhage in the area of upper GI. often
causes hematemesis (vomiting of blood) or melena (passage of stools rendered black and tarry by
the presence of altered blood) (Manish K Varma,2008).

•GI bleeding is a common complication of duodenal ulcers and can have serious consequences
(Alan BR Thomson,2010).
 Preliminary data
DOA:12 Sept 2010 6.15pm Ward 5C

• Mr W (RN 654381)
• 62/C/male
• Occupation : gardener
• Marital status : married + 3 children
• Family background : wife- rubber tapper
• Caretaker : daughter only available at 7pm
everyday
• DOR: 22 Sept 2010 : High protein diet
 Medical history

k/c/o:DM(1 year),HPT(10 years),gout

• July 2010 : ∆duodenal ulcer& perinephric abcess from

HOSHAS
• August : syncopal attack and hemetemesis/melena
• 12 Sept (DOA) : 1. ∆ UGIB 2° duodenal ulcer
2. anemia 2° UGIB
3. R perinephric abcess
 Current condition

• Melena°/hemetema °
• Stable & responsive to questions
• Problem in memory (day/date)
• Not accompanied by caretaker but only available at 7pm everyday
• Non-ambulatory RT afraid of pain at PCD drainage site able to
eat at semi recumbent position but limited ability to prepare
food
• Poor appetite RT pain & being selective on certain foodRT
altered taste in aging
• Good dentition & have proper chewing ability
 Involuntary wt
DM loss

Immuno-
compromised Poor oral
fever
intake

Perinephric Poor Nutritional

Pain
abcess Status

DU UGIB anemic

Candida albicans in immune suppressed and diabetic patients are bacteria found in the
abcess (Patterson JE & Andriole VT,1999)

Rarely, perinephric abscess may be a presentation of infectious disorders of the

gastrointestinal tract. Only two cases GI diorders (ruptured retrocecal appendix &
chronic DU) has been reported(Ching-Tien Kao et al,2002)
 Nutritional Status Assessment

Anthropometry

Date Weight (kg) Height (cm) BMI IWR (18.5- Wt history

(kg/m²) 24.9) (kg)
22/9/10 61.3 165 22.5 50.4-67.8kg 6 y.ago-106
(unfit-IBW) (obtained from 3month ago- 76
patient) Current-don’t know but
keep on loosing

• Usual BW is 106 .Loss 30 kg(>10% of UBW). Indication for high risk of

malnutrition.

An unplanned wt loss of 10% or more is a risk factor

for malnutrition (Manual of Clinical Dietetics,5th edition)
 Biochemistry

Creatinine(59-104 μmol/L) Urea & Creatinine Dehydration on DOA

AEB –ve fluid balance
179
but resolve now

147
141

103 103
90
Urea (2.5-6.4mmol/L)

12.4 12.4 11 6.7 5.5 5.5

12-Sep 13-Sep 14-Sep 15-Sep 16-Sep 22-Sep

stopped
D4 ORS introduced
 IV.Imipenem (anti bact)
Infection on DOA
42.6 WBC and Globulin (with high T°)but
now resolve related
to mx given
Globulin (20-35 gm/L)

30
24 30 30 30 30

9.4 9.4 9.8 8.4

WBC(4-10X 109/L) 7.4

12-Sep 13-Sep 14-Sep 16-Sep 18-Sep 20-Sep

 T.pentoprazole(antiulcer) Hb Persistent low Hb even under
mx(PC& antiulcer) RT anemic
2 θ Platlet Count
Hb condition+poor intake

11.3
9.5 9.1
8.4 8.4 8.3
7.3

Hb(13-17g/dL)

12-Sep 13-Sep 14-Sep 15-Sep 16-Sep 17-Sep 18-Sep

 Actrapid 2 U
Actrapid 4 U Dextrose Persistently high Dxt even
under insulin & OAD RT
stress condition

17.8 17.8

Actrapid stat

Actrapid 3 U
13
11.9

Dxt(4-7.8 mmol/L)
10
8.2 8.4 8 stopped
Actrapid

12-Sep 13-Sep 14-Sep 15-Sep 16-Sep 17-Sep 18-Sep 19-Sep 20-Sep

 Test (Unit) Normal values* 12/9 Comments

Liver Test function

T.Protein (g/L) 66-83 68.2 Normal total
protein
Albumin (g/L) 35-50 25.6 ↓ Low albumin
indication of
malnutrition AEB
wt loss >10% of
usual BW+poor
intake
T. Bilirubin (μmol/L) 0 - 20 19 Normal T.Bilirubin
 Clinical
Vital Signs Normal Values 12/9/10 20/9/10

BP(mmHg) 130/80 120/80 130/80 Normal BP under mx

Temperature (ºC) 37 39 (t.sponging) 37 Fever resolve

I/O Positive balance -110 +550 Improved into +ve

balance
B/O 1x/d (normal to pt) BNO BNO for 8 days Symptom of
constipation RT no
motility associated
with disease condition

spo2 100% 98 ↓ NP (RT UGIB) 99%↓ RA Improved respiration

Drug (f)

Metformin 500 mg BD OAD

T perindopril 8mg OD anti HPT

T amlodipine 10 mg OD anti HPT

IV imipenem 500 mg BD antibiotic

T pentoprazole 40 mg OD Antireflux/Alleviate ulcer

 Dietary (hospital)

Meal time Food items Amt E (kCal) CHO (g) P (g) Fat (g)

BF(8am) Roti +kaya 2 pcs 157.5 37.5 4 6

+sweet coffee (1tbsp 1cup 60 15 - -
sugar)
L(12pm) White rice ½ exc 37.5 7.5 1 0.25
fish +vegetable soup 1exc 125 - 7 11
papaya 1 slice 60 15 - -
AT(4pm) Roti +kaya 2 pcs 157.5 37.5 4 6
Plain water 1 glass - - - -
Total 112.5 17 23.25
Total (kCal) 727.25 450 68 209.25
% 62 9.3 28.7
 • FFQ: no refine sugar /high salt routine but query on why food served has
sugar (drinks/kaya). Alcohol °smoke°
• No outside food taken
• Plain water 1.5 L/day taken

• Poor appetite
 ½ exc rice during lunch
 < ½ recommended energy meet by total oral intake
• Selective towards HBV protein- Able to finish fish but not chicken since it is
claimed to be “lembik”. Prefer ayam kampung
• Can tolerate milk powder & egg.
• Adequate Fiber (vege& fruit) RT pt’s preference
• Faulty believe- cannot take egg to prevent puss & did not take dinner since
afraid of high blood glucose

Nutrition Diagnosis
Inadequate energy & protein intake RT decreasing appetite AEB Energy intake of
727.25 kcal/d & Protein intake of 17 g/d, less than requirement (energy req~1800
(30 kcal/kgBW) kcal/d & protein req ~67.4 g/d)
Medical Nutrition Therapy
 Intervention
Estimation of energy requirement
Harris-Benedict
BEE= 66.47 + 13.75 (Wt) + 5 (Ht) – 6.76 (Age)
= 66.47 + 13.75 (61.3) + 5 (165) – 6.76 (62)
TEE = BEE x AF x IF
AF= 1.1 (confine to bed) IF= 1.2 (mild stress RT high Dxt)
= 1315 x 1.1 x 1.2
= 1736 kCal

Quick Method
= 30 kCal/kg x IBW
= 30 kCal/kg x 61.3 kg
= 1839 kCal
RNI
Male 60-65 y old= 2010 kcal/d

• To plan for 1800 kCal/day menu

Estimation of protein requirement

= 1.1-1.2 g/kg x IBW(mild stress RT low alb, poor appetite & drainage procedure)
= 1.1-1.2 g/kg x 61.3 kg
= 67.4 -73.6g/day
RNI =59 g/d
Objective
 To provide adequate energy & protein and preserve lean body
mass
 To improve macronutrients and micronutrient  biochem
abnormalities (Dxt)
 To encourage better quality of life (BO) to promote bowel
motility

Principle
 By providing high calorie high protein diet and top up with
nourishing fluid with:
E=1800 kcal/d protein:67.4- 73.6g/d (1.1-1.2g/kgBW)
fluid=1.8L/d (1kcal/ml)
 Implementation
1. Encourage orally as much as pt tolerated to meet Energy recommendation by
promoting small & frequent feeding

2. Correct on faulty believe

 High BG RT ①stress condition ② prolonged fasting (skip dinner) that lead to
rebounce hyperglycemia
 Puss RT improper hygiene that lead to infection. Egg white is ok to take not yellow
coz yellow have sulphur(worsen the puss)

3. Explain on high protein diet

 Need to increase HBV protein intake for early recovery+ boost immunity against
infection
 Encourage to finish fish/chicken(if fish is not possible)/egg provided (ratah lauk)
 Discuss with cook to provide fish only

4. Discuss regarding LSDD diet to pt and cook

suppose pt should not get kaya bun. Pt must report if order is not correct

5. Glucerna SR as oral supplement according to nurse shift (3 shifts/d).

High protein,high cal
have fiber for bowel open
SR of glucose to alleviate stress induced hyperglycemia

6. Compliment good attitude & motivate changes

 Cont current fluid intake for good hydration status & for BO
 Motivate movement when there is no pain for bowel motility
Menu planning
FULL HOSPITAL Meal Energy CHO P Fat
Menu planning
BF – 2pcs White Bread + 1 nos egg + 2 tsp margerine 215 30 11 15
L – 4exc White rice+ 1 exc fried fish + 1exc fruit 531 75 15 19
AT-2pcs White Bread + 1 nos egg + 2 tsp margerine 215 30 11 15
D-4 exc White rice+ 1 exc fried fish + 1 exc fruit 531 75 15 19
Glucerna SR– 2 ½ scp (x3*/d) 278 36 13.5 9.8
Total : 1770 246 65.5 77.8

HALF HOSPITAL Meal Energy CHO P Fat

BF –2pcs White Bread + 1 nos egg + 2 tsp margerine 215 30 11 15

L –2 exc White rice+ ½ exc fried fish + 1exc fruit 363 45 7.5 17
AT-2pcs White Bread + 1 nos egg + 2 tsp margerine 215 30 11 15
D- 2 exc White rice+ ½ exc fried fish + 1 exc fruit 363 45 7.5 17
Glucerna SR– 6 scps (x3*/d) 666 86.4 32.4 23.4
Total : 1822 236.4 69.4 87.4
LITTLE HOSPITAL Meal Energy CHO P Fat

BF –1pcs White Bread + ½ nos egg + 2 tsp margerine 185.5 15 5.5 11.5
L –1 exc White rice+ ½ exc fried fish + 1exc fruit 291 30 5.5 16.5
AT-1pcs White Bread + ½ nos egg + 2 tsp margerine 185.5 15 5.5 11.5
D- 1 exc White rice+ ½ exc fried fish + 1 exc fruit 291 30 5.5 16.5
Glucerna SR– 6 scps (x4/d) 888 115.2 43.2 31.2
Total : 1841 205.2 65.2 87.4
Monitoring
Biochemical

Albumin progression

30

28

27-Sep 5-Oct
 Dxt Progression Relate to 2 HPP.
did pt just take meals?2 hpp is 7-11

Dxt Progression

10
9
8 8

23-Sep 24-Sep 25-Sep 26-Sep

 Dietary

Meal on 23 sep-5 oct 2010 Energy CHO P Fat

BF –1pcs White Bread + 1 nos egg + 2 tsp margerine 239 15 11 15

L –2 exc White rice+ 1 exc fried fish + 1exc fruit 377 45 11 17
AT-1pcs White Bread + 1 nos egg + 2 tsp margerine 239 15 11 15
D- 2 exc White rice+ ½ exc fried chicken + 1 exc fruit 381 15 7.5 19
Glucerna SR– 6 scps (x3*/d) 666 86.4 32.4 23.4
Total : 1902 176 73 89.4

Able to finish half of hospital diet

Tolerate supplementation provided
Pt is taking dinner served
Improved appetite
 Discussion/Conclusion
No. Problems
1. P. abcess+ UGIB with poor
nutritional status
2. Nutritional intervention goals
has not been met yet
Interventions
-High calorie, high protein diet is priority to
improve nutritional status + boost immunity
against infection+ early recovery
-Glucerna SR has been chosen as oral
supplementation since it has high cal and high
protein content
-Progression of improvement is slow goodAEB
biochem value. However, pt’s appetite has
improved.
-increasing age was strongly and independently
correlated with poor nutritional status (Sarah
F & Salah G,2005) .