1. Pancreatitis By: Barrie Lynne Sutton Keene State Dietetic Intern 2014/15 Clinical Case Study

2. Outline: Concord Hospital Whipple Procedure Pancreatitis Case Review

3. Concord Hospital Location: Concord, NH Bed Size: 238 staffed beds -5 centers of excellence (Payson Center, Center for Cardiac Care, Center for Urologic Care, the Orthopedic Institute, Women’s Health Services) -17, 898 admissions during fiscal year 2014

4. The Nutrition Department 5 Diet Techs (2-3 on per day) -screen patients within 24 hours of admission -patients determined to be high, moderate, or low risk -provide brief education -follow up with moderate and low risk patients 9 Inpatient RDs (5 full time, 4 per-diem) -assess and follow up with all high risk patients -interview patients, assess nutrition needs, determine nutrition diagnosis, and provide nutrition intervention -provide education -follow up with high risk patients

5. Whipple Procedure AKA “pancreaticoduodenectomy” -removal of the gallbladder, distal common bile duct, part of the duodenum, the head of the pancreas, and sometimes the first couple centimeters of the jejunum and part of the stomach

6. Standard Whipple Procedure http://pathology.jhu.edu/pc/whipplePop.php

7. Why Whipple? To treat pancreatic cancer and sometimes chronic pancreatitis. Pancreatic cancer is usually at stage 4, or metastatic before it is diagnosed. The 5-year survival rate is only 1.8% Surgery is currently the mainstay treatment, as it is the most likely hope for a cure at that point.

8. Whipple Procedure Significant Post-Surgery Morbidities (affect 30-60% of patients): -fistula -delayed gastric emptying -intra-abdominal abscess -drain/surgical site infections

9. Whipple Procedure Long Term Nutritional Considerations: -altered GI motility -exocrine pancreatic insufficiency -diabetes -small bowel bacteria overgrowth -nutrient deficiencies

11. Whipple Procedure Reduced production of: gastrin- from cells in stomach, duodenum & pancreas to aid in gastric motility cholecystokinin- stimulates digestion of fat & protein secretin - regulates secretions in the stomach & pancreas Leading to  reduced bicarbonate & high acidity in stomach

12. Whipple Procedure Nutrients absorbed in duodenum & proximal jejunum: -iron, folate, fatty acids, proteins, calcium, zinc, copper **also potential for mismatched timing for release of bile to aid in digestion

13. Pancreatitis: pancreat/o- pancreas itis- inflammation inflammation of the pancreas -Digestive enzymes attack the pancreas due to damage or blockage of the pancreatic duct that releases the enzymes Usual etiology: -ETOH abuse -genetics -cystic fibrosis -hyperlipidemia -medications -some autoimmune disorders -unknown causes

14. Pancreatitis - Pathophysiology -May have upper abdominal pain or be asymptomatic -Pain may spread to the back and worsen when eating or drinking -Sometimes pain will go away while the condition worsens (usually because the pancreas will stop making enzymes) -Other symptoms include nausea, vomiting, diarrhea, oily stools, development of diabetes -Weight loss despite normal eating habits -Blocked biliary duct or biliary sludge -Malnutrition

15. Chronic Pancreatitis – Labs & Diagnosis -X ray or ultrasound of abdomen, ERCP (endoscopic retrograde choliangiopancreatography) CT scan, EUS (endoscopic ultrasound) -Blood, urine, and stool tests -Elevated lipase (WNL= 0-160u/L)

16. Pancreatitis- Medical Intervention -Hospitalization for pain management during acute phases -IV hydration if necessary -Pancreatic enzymes

17. Pancreatitis – Medical Nutrition Therapy -NG tube feedings may be necessary after 6-7 days if pain persists & weight loss continues -NPO during acute phase -Depending on tolerance, may need to be on clear liquids for a short time -Long term: low fat diet, small and frequent meals

18. Case Study- “E” 80 y/o F admitted with radiating pain on right side from abdomen to back

19. Assessment Client’s History: Patient lives independently at home and has family that frequently visits. Her son goes grocery shopping with her. Denies any alcohol or drug use. No change in ostomy output. No known food allergies. Since 2008 has had pancreatitis 2-3x a year, but it has become increasingly more frequent in past year. Believed to be d/t dislodged biliary stent.

20. Assessment Patient stated she followed a low fat diet at home and avoided sugar. She recognized that ostomy output was more watery with certain foods (like sugar and sugar alcohols)

21. Assessment Past surgeries: Whipple, CABG, cholecystectomy, subtotal colectomy with end ileostomy, gastrostomy tube, jejunostomy tube PMH: HTN, CAD, hyperglycemia, hiatial hernia, GERD

22. Assessment Home Medications: -statin (crestor) -ACEI (enalapril) -antacid (for GERD) -multivitamin -beta blocker (metoprolol) -vitamin D

23. Assessment Physical Findings Wt47.1 kg Ht61” BMI19.6 UBW52 kg on 4/23/2014 %UBW98% IBW50.9 kg %IBW93%

24. Assessment Medications in the Hospital -statin (crestor) -beta blocker (metoprolol) -anticoagulant (heparin) -antacid -multivitamin/mineral -vitamin D -IV fluids (D5 ½ NS)

25. Assessment Admission Labs: Na 139 K 4.2 Cl 106 (slightly high, normal 95-105) Bicarbonate 28 BUN 14 Creatinine.70

26. DateLipaseBGCapsticks 1/27/15121041 1/28/1568033 1/29/1521642*, 57, 145 1/30/15120180 WNL Ranges Lipase 73-393 BG and Capsticks 70-125 mg/dL *MD was notified and apple juice was given (normal lactate and WBC was documented) Lab Values

27. Nutrition Needs 1155 kcal, Mifflin 1.3 47-56 g protein, 1-1.2g/kg Patient dislikes: Boost, Ensure, Carnation Instant Breakfast, Beneprotein (per last admission)

28. Nutrition Diagnosis PES Statements 1. Inadequate protein/energy intake r/t altered GI function aeb NPO status 2. Inadequate energy intake r/t altered GI function aeb low BMI for age, weight loss, poor intake

29. Nutrition Intervention Goals: to progress diet as tolerated to a low fat regimen; weight maintenance; weight gain; blood glucose control -Patient declined CHO diet education

30. Nutrition Intervention NPO status 1/26- 1/28 Clear Liquids 1/28 -PO intake 100% lunch & dinner NPO 1/29-1/30 up to discharge

31. Nutrition Intervention After failed removal of biliary stent during stay, recommended that patient follow a low fat diet and be prescribed pancreatic enzymes. Alternate medical course: Consider a nasal jejunal tube & receive surgical jejunal tube if successful

32. Intervention: Low Fat Diet Allows for up to 50g of fat per day – May range from 30-50g based on pt tolerance and needs 4-6 small meals a day Spread out fat intake through the day Sparingly use butter, oil, margarine

33. Low Fat Diet Bake, grill, roast, broil, or steam foods – Avoid frying and stir frying Daily include fruits, vegetables, whole grains, low fat and fat free dairy products Add a lean protein to each meal – Skinless poultry, beef, fish, egg whites, soy, beans, etc.

34. Low Fat Diet Avoid all alcohol and foods made with alcohol Read food labels – “low fat”, “non fat”, “fat free”, “light”

35. Monitoring & Evaluation -Weight changes -BG control -Ability to progress diet -Education needs/desire

36. Monitoring & Evaluation Discharge Labs Na 141 K 3.5 Cl 103 Bicarbonate 29 (slightly high, normal 22-28) BUN 8.4 Creatinine.66 BG 180 (High, normal 70-125) Wt: 48 kg (.9 kg gain, likely r/t IV fluids)

37. References Decher N and Berry A. “Post Whipple: A Practical Approach to Nutrition Management”. Nutrition Issues in Gastroenterology. (108) p30-42. http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/clinical- care/nutrition-support-team/nutrition-articles/Decher_Berry_Aug_12.pdf http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/clinical- care/nutrition-support-team/nutrition-articles/Decher_Berry_Aug_12.pdf US Department of Health and Human Services. NIH Publication No. 08-1596. July 2008. http://www.niddk.nih.gov/health-information/health-topics/digestive- diseases/pancreatitis/documents/pancreatitis_508.pdf http://www.niddk.nih.gov/health-information/health-topics/digestive- diseases/pancreatitis/documents/pancreatitis_508.pdf University of Virginia Health System. PE 16010-eng (2014-07). p1-3. http://www.virginia.edu/uvaprint/HSC/pdf/16010.pdf http://www.virginia.edu/uvaprint/HSC/pdf/16010.pdf