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Example research essay topic: Research Has Shown Type Of Treatment - 1,705 words

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Admitting Diagnosis: Ca of the Duodenum W. F. is divorced and lives alone in a private dwelling. He has worked as a city bus driver for the past 10 yrs and plans to return to his job when he is able. W. F.

also works part time as a carpenter with a friend doing custom carpentry after his day job ends. W. F. received support by regular visits from his girlfriend and family located in the city. Other family members live elsewhere but were in contact with him.

W. F. was a pack / day smoker for approximately 30 yrs and is currently trying to quit he also usually has 2 beer or glasses of wine / day after work with supper. W. F.

has had an appendectomy as well as nasal surgery 1991 to correct his snoring difficulties. In the summer of 1995 W. F. experienced heartburn & epi gastric pain and was diagnosed (Dx) with having an active duodenal ulcer and treated with Histamine H 2 receptor blocking agent Ranitidine to reduce gastric acidity and alleviate the ulcer. The symptoms eased but persisted so in August 1996 the Dr. booked W.

F. for a gastroscope and a biopsy was taken from the lesion. At this time a Dx of Adenocarcinoma, moderately differentiated, was made. The occurrence rate of cancer of the small intestine in Canada is approximately 17 / 100, 000. Adenocarcinoma of the small intestine is said to form less than one percent of all intestinal carcinomas but is the most common small intestinal malignancy (1). Epidemiological studies have shown that there are many different possible causative agents for the development of cancer.

They include viruses, a wide variety of chemicals, both ionizing and ultraviolet radiation, and even inherited forms of tumors such as retinoblastoma (1). The common element amongst all the causative factors is that they cause damage to or alteration of the DNA in the cells leading to improper reproduction of the genetic information in the next cell generation (1). Most normal cells are differentiated, a term that indicates that they have developed specific morphology and function. A series of errors in the reproduction of the DNA can lead to a reduction in the degree of differentiation i. e. the loss of original morphology or function.

In a cancer cell, proliferation usually continues independent of a requirement for new cells and as differentiation decreases the cells begin to adopt proliferation as their primary function (1). Early diagnosis is necessary for the successful treatment of cancer. If the cancer has metastasized, the prognosis for survival in not good. It has been shown that in patients with staged tumors the only patients who survived 5 years were those without lymph node involvement, which is an indicator of a lack of metastasization (2).

If the cancer is caught early it can be destroyed or removed while it is still isolated (1). Nutritional intervention therefore is concerned with the type of treatment and the location of the cancer (3). The three traditional treatments for cancer are radiation, surgical removal of the cancer and chemotherapy. Each has specific consequences which can predispose the patient to nutritional problems based on the location of tumors and the type of treatment used (3).

A full list of possible nutritional consequences is given in Appendix A as well nutritional problems based on location of tumor and type of treatment are shown in Appendix B. The majority of patients with preambulary neoplasms are candidates for operative resection of the tumor. This treatment is usually followed by a combination of radiation and chemotherapy which has show to prolong survival after curative Whipple resection (4). Duodenal tumors are often asymptomatic but when symptoms do arise, they are usually related to either obstructive phenomena or bleeding. Epigastric discomfort or cramping pain associated with nausea and / or vomiting can increase with the severity of the lesion while preambulary tumors may be associated with painless jaundice. Weight loss is also a common symptom of these tumors (4).

Cancer of the head of the pancreas and three periampullary neoplasms (ampulla ry carcinoma, duodenal carcinoma, and carcinoma of the distal common bile duct) are the most common reasons this procedure is done. All of these have been found to have similar risk factors for their development. These include cigarette smoking, diabetes mellitus, industrial exposure to chemical irritants, alcoholism, dietary factors, exposure to radiation, and ethnic and racial factors (3) The Whipple's procedure is the standard for removal of a duodenal or preambulary carcinoma. It involves a pancreaticoduodenectomy, first described by Whipple in 1935. The procedure involves the resection of the head of the pancreas, the distal portion of the common bile duct, the distal portion of the stomach, and the entire duodenum. A segment of the jejunum is brought up and sewn to the remaining portion of the stomach, common bile duct, and pancreas to maintain the integrity of the gastrointestinal tract (3).

A diagram of the reconstructed intestinal tract with the resected specimen can be found in Appendix F. This procedure has a perioperative mortality of less than 5 percent as evidence of its low risk and safety. At present the overall 5 year survival rate for recipients of the Whipple's procedure is 15 to 25 percent but the survival rate of individuals with respectable cancers of the duodenum is 40 to 60 percent (4). There is currently an optional method of performing the procedure which preserves the pylorus of the stomach in an attempt to alleviate some of the gastrointestinal problems associated with the procedure (4). While there is no difference in the survivability rates between these two modalities there are some differences in the nutritional / digestion and absorption concerns created by the procedure (5). A common concern for post Whipple's procedure patients is dumping syndrome which is the early emptying of the stomach contents into the gastrointestinal tract leading to possible symptoms of nausea, weakness, sweating, palpitation and often diarrhea (6).

The pylorus preserving method was theorized to prevent this and research has shown that patients with this procedure do not show the tendency towards dumping (7). This version of the procedure also helps to prevent enterogastric reflux (7) and has shown to improve the nutritional repletion of both the body weight and the serum albumin level at 6 months after discharge over that experienced by patients with pylorus resection (8). The pylorus resecting method does not cause a large amount of dumping to occur due to the loss of duodenal and pancreatic hormones that effect upper gastrointestinal motility but it does however allow for enterogastric reflux by removing the blocking action of the pylorus (7). There is also a reduction in gastric volume from the resection of the lower portion of the stomach which leads to a feeling of fullness and early satiety. The early satiety can lead to an insufficient intake of food and if the patient attempts to eat preoperative amounts they can precipitate the dumping (9). The pylorus resecting method may indirectly reduce the late dumping syndrome side effect of a hypoglycemic rebound.

This due to excess insulin released in response to the rapid uptake of the carbohydrates dumped into the small intestine which can occur in gastric resection alone (6). The resection causes a reduction in insulinotropic hormones such as gastrin and gastric inhibitory polypeptide. This leads to a reduction in the reaction time of insulin release and can reduce the excess insulin level thereby avoiding the hypoglycemic rebound. Whether there is dumping syndrome or not the hormone alteration will cause a slightly elevated blood glucose level (110 - 120 mg / dl ) = (6. 16 - 6. 72 mmol/L) that will last approximately 1 & 1 / 2 to 2 hours (10). The pylorus resecting method may also lead to anemia over the long term as a possible insufficiency of intrinsic factor necessary for vitamin B 12 absorption can occur depending on the degree of gastric resection (6). Other nutritional concerns stem from the resection of the pancreas.

This is due to the fact that the pancreas is the source of both the exocrine secretion of many of enzymes necessary for digestion and the endocrine secretion of insulin necessary for blood glucose control. However research has shown that not until exocrine pancreatic secretion has been reduced by more than 90 % of the normal secretion does mal digestion with steatorrhea result (11). Diabetes mellitus can be the result of insufficient insulin however it does not usually develop until more than 70 % of the pancreas is removed (3). The removal of the gallbladder may also effect the nutrition of the patient post operative by restricting the amount of bile salts necessary for fat digestion and absorption leading to steatorrhea (3).

To reduce the risk of dumping syndrome and to ensure adequate nutritional intake the patient is encouraged to eat small, frequent, dry meals with fluids taken at least half and hour before and one hour after the meal. Limiting of simple sugars which can increase the rate of gastric emptying will also aid in avoiding dumping from occurring. As well a low fat diet may initially be required to avoid steatorrhea (3). If there are signs of malabsorption the patient will require enzyme replacement. There are many types available and the amount required will depend on the degree of insufficiency which can be determined by pancreatic functional tests such as serum-PLT or PABA test or measurement of stool fat (11).

Joanne Frank PDt at St. Pauls hospital stated that the standard practice is to give 3 enzyme tablets with meals and 2 with snacks to ensure adequacy. If the patient shows signs of blood sugars over 11. 1 mmol / l without any other contributing factors, they can be considered diabetic and will require insulin. While values that are consistently above the normal range of 5. 5 mmol / l may require oral glycemic agents to help control the blood sugar levels (12).

If the patient shows signs of anemia a test for B 12 deficiency such as the Shillings Test should be performed and if a deficiency is discovered the patient will need regular injections of B 12 for the rest of their l...


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Research essay sample on Research Has Shown Type Of Treatment

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