1. Case Report: Nutrition Support in Pancreatic Cancer
Neha Bhakta
ARAMARK Dietetic Internship
St. Luke’s Medical Center
December 20,2013

2. Disease Description
Pancreatic carcinoma is a highly aggressive type of cancer and is known to be nearly chemotherapy resistant.
It spreads quickly and is associated with cachexia. Survival rate is less than five percent.
Patients suffer from abdominal pain, nausea, emesis, taste alterations, early satiety, fatigue, malabsorption, and maldigestion.
The disease progresses quickly and patients are unable to meet nutrition needs due to symptoms such as nausea, vomiting, abdominal pain, etc.

3. Disease Description
In 2013, the estimated number of new cases of pancreatic cancer was 45,220 and 38,460 of those resulted in death.
The rate of pancreatic cancer has increased over the last 10 years. The cost of cancer care has doubled to $48 billion in the U.S. alone over the past 20 years.
RISK FACTORS:
The risk of pancreatic cancer increases as one ages, 9 out of 10 pancreatic cancer patients are age 55 or older.
The male population is 30 percent more likely to develop pancreatic cancer than the female population and is known to be linked to tobacco use as it is more common in men.
Other risk factors include cigarette smoking, increased BMI, family history, diabetes, chronic pancreatitis, previous history of peptic ulcer surgery, diet high in red meat, cholesterol, fried food and nitrate containing foods.

4. Evidence-Based Nutrition Recommendations
Proactive nutrition care can prevent or reduce complications of cancer treatment.
Problems sometimes stem from effects of the tumor such as tumors in vital organs, which can cause obstruction:
Nausea
Vomiting
Impaired digestion
Malabsorption
Weight loss, wasting and malnutrition
Oral nutrition is preferred in patients who are able to eat.
Small, frequent, nutrient dense meals are recommended along with liquid nutrition supplements.
In severe pancreatic cancer cases, enteral nutrition by tube is necessary due to the severity of nausea, vomiting, and abdominal pain.

5. Evidence-Based Nutrition Recommendations
Pelzer et al, 2010
Controlled trial
32 patients
Intervention: Additional parenteral nutrition
Results:
27 out of 32 patients showed improvement in nutrition status (gained or maintained weight)
15 out of 32 patients had increased BMI
Limitations:
The study did not allow them to conclude clinical relevance such as over all survival and quality of life

6. Evidence-Based Nutrition Recommendations
Dintinjana et al, 2008
Controlled, randomized trial
44 patients (17 of which had liver mets)
Intervention: Nutrition support (enteral)
Results:
Weight gain and appetite improvement in 32 patients
8 patients continued to lose weight in the study
Limitations:
Degree of disease progression, some patients had operable tumors, others had inoperable tumors.

7. Case Presentation Case Patient: 59 year old male
Recently diagnosed with unresectable pancreatic cancer with metastasis to the liver.
Admitted to the hospital from the oncology office with complaints of abdominal pain, weight loss and continuous diarrhea.
Other complaints include nausea, vomiting, and dizziness over the week before admission.

8. Nutrition Care Process: Assessment
The Nutrition Care Process was developed for use by medical professionals when implementing medical nutrition therapy to ensure quality individualized care for patients and provide a standardized process for care.

9. Patient History Patient History
Gastroparesis
Gastric outlet obstruction
Biliary obstruction
AKI secondary to dehydration
His family history includes hypertension and cancer, both mother and father had cancer.
Social history includes alcohol use, about 9 shots of liquor and 1 can of beer per week prior to cancer diagnosis.

10. Food/Nutrition-Related History
Case patient has been in and out of the hospital due to pancreatic cancer that metastasized to the liver.
At his last visit, he was placed on TPN then transitioned to enteral nutrition.
Due to severity of cancer, during his past hospital visit he was discharged on a tube feeding regimen: continuous Peptamen AF at 55cc/hr for 24 hours.
He changed his tube feeding regimen to 16 or 18 hour cyclic feeding to improve quality of life.

11. Nutrition-Focused Physical Findings
At admission, the case patient complained of:
Abdominal pain
Continuous diarrhea
Nausea
Vomiting
Weight loss.
He was not tolerating his home tube feed regimen due to change in rate and time.
After admission he was also found to be dehydrated. Patient was not able to tolerate any intake by mouth, caused nausea and vomiting. Along with his report of weight loss, loss of muscle mass and loss of subcutaneous fat were noted upon admission. He was also having moderate G-tube output.

12. Anthropometric Measurements
Height: 6’ tall
Weight: 143 pounds.
BMI: 19.4
Upon admission, he reported weight loss of approximately ten pounds over last two months.

13. Biochemical Data, Medical Tests, and Procedures
The x-ray confirmed pancreatic head and uncinate process mass. The repeat CT of the abdomen showed pneumatosis.
Pneumatosis intestinalis is defined as gas in the bowel wall, in this case most likely associated with chemotherapy. Treatment approach that the physicians took was bowel rest, at this point patient was placed on TPN.

14. Lab measurement
Patients value
Normal range
Sodium
123L
meq/L
Potassium
3.1L
meq/L
BUN
58H
10-26 mg/dL
Creatinine
1.22H
gm/dL
WBC
16.8H
^3/mL
HGB
12.2L
GM/DL
HCT
34.9L %
Alk Phos
176H
IU/L
Total Bilirubin
3.2H
mg/dL
ALT
358H
7-55 U/L
AST
91H
8-48 U/L

15. Nutrient Needs REE Protein 65 kg x 30 kcal/kg = 1950 kcal
kcal/day
65 kg x 1.0 g/kg = 65 g
65 kg x 1.5 g/kg = 97.5 g
64-96 g/day

16. ARAMARK Nutrition Status Classification
Based on the ARAMARK Nutrition Status Classification form, the case patient was classified as severely compromised. He has a score of NSC 4, which means he had greater than or equal to 12 priority points.
Nutrition History: 3 points for diarrhea
Feeding Modality: 4 points for unstable TF
Weight Status: 4 points for weight loss of >5% usual body weight
Diagnosis: 2 points.
This is a total of 13 points, indicating severely compromised.

17. Nutrition Care Process: Nutrition Diagnosis
Domain
Problem/N utrition Diagnosis
Etiology
Signs/Sympto ms
Intake
(NI-2.1)
Inadequate oral intake
related to
diarrhea and unintentional weight
as evidence d by
increased energy needs

18. Nutrition Care Process: Intervention(s)
Enteral and Parenteral Nutrition: Parenteral Nutrition/IV Fluids- Formula/Solution (ND-2.2.1). Recommended parenteral nutrition:
For TPN
Total Volume: 1080 mL
Amino Acid: 70 grams 10%,
Dextrose: 150 grams 70%
Lipids: 15 grams 20%
standard electrolytes/L
Additives: 10 milligrams of zinc sulfate. This TPN regimen provided 940 kcal and 150 g protein.
It ran continuously for 6 days before enteral feedings were reintroduced.
Tube Feeding: Peptamen AF at goal rate of 55cc/hr

19. Nutrition Care Process: Monitoring and Evaluation
Food and Nutrient intake: Parenteral nutrition intake- Formula/solution (FH ). Parenteral nutrition orders were reviewed to establish calorie and protein intake.
The order met the patient’s estimated energy needs of about 50% of estimated needs on TPN alone for 6 days.
Once tube feeds of Peptamen AF stated, patient was meeting closer to 75% estimated nutrition need.
TPN was discontinued once he was tolerating Peptamen AF at goal rate of 55cc/hr.
Other discharge recommendations: intermittent clamping, daily IV fluid boluses to replace G-tube output.

20. Conclusion
Oral nutrition is preferred in patients who are able to eat.
Small, frequent, nutrient dense meals are recommended along with liquid nutrition supplements.
Easy to prepare or ready to eat foods, nutrient dense snacks frequently throughout the day, drink plenty of healthy fluids, and be as physically active as possible based on physician recommendations.
Many cancer patients follow a neutropenic diet, this requires frequent hand washing and keeping kitchen surfaces and utensils clean.
Research shows enteral/parenteral nutrition for pancreatic cancer helps patients gain weight, improves appetite and increases BMI.
In severe pancreatic cancer cases, enteral nutrition by tube is necessary due to the severity of nausea, vomiting, and abdominal pain.
The research shows that majority of pancreatic cancer patients benefit from enteral tube feedings.

21. References
American Cancer Society. Pancreatic Cancer. What are the key statistics about pancreatic cancer?Web cite. Available from:
Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders Elsevier; 2008:
American Cancer Society. Pancreatic Cancer. What are the risk factors for pancreatic cancer?Web cite. Available from:
Nutrition Care Manual. Gastrointestinal. Web cite. Available from:
American Cancer Society. Pancreatic Cancer. What is Cancer? Web cite. Available from:
Hirshberg Foundation for Pancreatic Cancer Research. FREQUENTLY ASKED QUESTIONS ABOUT PANCREATIC CANCER. Web cite. Available from:
National Cancer Institute. Web cite. Available from:
Pelzer U, Arnold D, Gövercin M, et al. Parenteral nutrition support for patients with pancreatic cancer. Results of a phase II study. BMC Cancer. 2010;10:86.
Dobrila dintinjana R, Guina T, Krznarić Z. Nutritional and pharmacologic support in patients with pancreatic cancer. Coll Antropol. 2008;32(2):505-8.
Rivadeneira DE, Evoy D, Fahey III TJ, Lieberman MD, Daly JM. Nutrition Support of the Cancer Patient. CA Cancer J Clin 1998:48:69-80.
American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 3rd ed. Chicago, IL
Pronsky ZM, Crowe Sr JP. Food Medication Interactions. 17th ed. Birchrunville, PA
Malnutrition Codes and Characteristics/Sentinel Markers. Academy of Nutrition and Dietetics Web site. Available from:
Up To Date. Pneumatosis Intestinalis. Web cite. Available from:

22. Questions