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

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. Surgical Procedure: ERCP

10. 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

11. Nutrition Care Manual: Pancreatitis
Moderate to severe pancreatitis
25-35 kcal/kg
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

12. 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

13. 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

14. Initial Visit (Intern)
Nutritional Assessment
Energy Requirements:
Miflin: REE x 1.1 x kcal
2200 kcal; 24 kcal/kg
Protein Requirements:
g protein
Used Adjusted BW : 70.3g
g/kg

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. References
ERCP- MedlinePlus (2014). United States National Library of Medicine. Retreived from
ERCP Complications (2012). American Society for Gastrointestinal Endoscopy. 72:3. Retrieved from: 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

22. Questions?