Mini Case Study: Pt S.O. Pancreatitis s/p ERCP Melissa Ronis Sodexo Mid-Atlantic Dietetic Internship January 5, 2015

Description of Pt Admitted 11/27/14 41 YOM No significant PMH Chief complaint: RUQ and epigastric pain Ultrasound and CT scan showed cholelithiasis Medical Dx: Acute cholecystitis

Description of Pt (cont.) 172 cm (5’ 8”) 90.9 kg (200 lbs) BMI: 30.3; Obese Class I Hispanic origin Social Hx Pt current tobacco smoker Works at Domino’s Pizza Lives with son in basement of friend’s house Uninsured

Cholelithiasis Gallstone formation within the gallbladder Stones composed of cholesterol, bilirubin, and calcium salts Affect millions of Americans Most cases are asymptomatic Can lead to cholecystitis

Cholecystitis Causes Risk factors High dietary fat intake- inc production of cholesterol for bile synthesis Risk factors Female gender, pregnancy, older age, family history, obesity and truncal body fat, DM, IBD, certain drugs, rapid weight loss Ethnic groups- Pima Indians, Scandinavians, Mexican-Americans

Hospital Course S/p cholecystectomy on 11/30 ERCP performed 12/1 Pt complained of nausea, bloating following surgery Elevated bilirubin, dilated CBD (common bile duct) ERCP performed 12/1 Scheduled for discharge 12/2

Hospital Course Severe pain developed immediately after meal consumption on 12/1 No flatus/BM, abdominal distention New dx: Pancreatitis s/p ERCP

Surgical Procedure: ERCP Endoscopic retrograde cholangiopancreatography Used to examine common bile ducts for stones, strictures, or blockages Inserted through mouth directed through GI tract to duodenum Dye is inserted into bile duct and pancreatic duct Series of X-rays Ability to crush stones or place stents if need

Surgical Procedure: ERCP

Surgical Complications: ERCP Pancreatitis Most common serious complication Occurs in 1-15% of patients (depending on population) Causes Mechanical injury of pancreatic duct by instruments Adverse reaction from contrast dye

Nutrition Care Manual: Pancreatitis Moderate to severe pancreatitis 25-35 kcal/kg 1.2-1.5 g protein Current SOC for mild to moderate pancreatitis NPO and progress toward PO diet Choose high-protein, low-fat modifications for Obesity DM Alcocholism

Initial Visit (Intern) Pt visited 12/2/14 Screen Referral for NPO status Lab values 12/1 K 3.3 (L), Cl 108 (H), Glucose 122 (H), Bilirubin 1.5 (H), Lipase 26,817 (H) Medications Colace, Toradol, KCl tablet, Lactated Ringer’s 1,000 mL, PRN pain medication Pt in severe pain and was unable to provide any additional information

Initial Visit (Intern) Nutritional Assessment Height= 172 cm ; 5’8” Weight= 90.9 kg ; 200 lbs IBW: 70 kg ; IBW: 130% BMI 30.3 ; Obese Class I

Initial Visit (Intern) Nutritional Assessment Energy Requirements: Miflin: REE x 1.1 x 1.1 + 200 kcal 2200 kcal; 24 kcal/kg Protein Requirements: 84-105.5 g protein Used Adjusted BW : 70.3g 1.2- 1.5 g/kg

Initial Visit (Intern) High Priority (see pt again 3-4 days) Nutritional Diagnosis: Clinical Inadequate oral/food beverage intake RT cholecystitis, pancreatitis AEB current NPO status and poor appetite Nutritional Diagnosis: Biochemical Altered nutrition-related laboratory values RT pancreatitis AEB lipase 25,817 and bilirubin 1.5

Initial Visit (Intern) Intervention Rec advance pt from NPO to PO diet as tolerated Rec Ensure Clear when pt is advanced to clear liquid diet for additional nutrition Monitor/ Evaluation Monitor length of NPO status Monitor lipase levels Monitor GI symptoms

2nd Visit (Intern) Visited pt on 12/5 (4 days after initial) Pancreatitis improving Now on full liquid diet Labs 12/5 Albumin 2.8 (L), Bilirubin 2.8 (H), Ca 7.9 (L) Lipase 253 (much lower than previous) Medications Colace, Toradol, Lactated Ringer’s Solution KCl d/c

2nd Visit (Intern) Nutritional Assessment Appetite good No NVDC BM 12/5 Still small amount of abdominal pain with eating Discussed low fat diet/ small meals upon discharge s/p cholecystecomy, pancreatitis

2nd Visit (Intern) Moderate Risk (improved appetite, 50% meals) Nutritional Diagnosis Inadequate oral/food beverage intake RT cholecystitis, pancreatitis AEB current full liquid diet Food and nutrition knowledge deficit RT lack of previous diet education AEB pt stated he did not know what dietary modifications to make s/p cholecystectomy and recovering pancreatitis

2nd Visit (Intern) Intervention Monitor/Evaluation Pt d/c 12/6 Rec advancement of full liquid diet to regular diet as tolerated Rec continue Ensure Clear supplement Performed brief diet education Monitor/Evaluation Monitor tolerance of diet Monitor understanding of diet modifications Monitor GI symptoms (abdominal pain) Pt d/c 12/6

References ERCP- MedlinePlus (2014). United States National Library of Medicine. Retreived from http://www.nlm.nih.gov/medlineplus/ency/article/007479.htm ERCP Complications (2012). American Society for Gastrointestinal Endoscopy. 72:3. Retrieved from: http://www.asge.org/assets/0/71542/71544/076fbf43-9959-4859-8286- bc62fec2b5dc.pdf Mahan L.K, Escott-Stump S., Raymond J.L. (2012). Krause’s Food and the Nutrition Care Process. St. Louis, MO: Elsevier Saunders Nutrition Care Manual (2015). Academy of Nutrition and Dietetics

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