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7937500Sodexo Dietetic InternshipsDisease Specific Rotation Assignment – Pancreas & Liver Disease00Sodexo Dietetic InternshipsDisease Specific Rotation Assignment – Pancreas & Liver DiseaseIntern Name: Pamela JohnsonPart 1: Medical Abbreviations and Terminology.In your own words, briefly describe the following terms: Hepatitis- inflammation of the liver commonly caused by a virus- hepatitis A, hepatitis B, hepatitis CCirrhosis- inability for the liver to function properly due to chronic injury, blood flow is blocked through the liver due to replacement of scar tissue instead of liver tissueHepatic encephalopathy (include the stages with signs and symptoms of each)- decreased brain function due to the livers inability to remove toxins from the blood Minimal- coordination can be affected Mild- short attention span, mood changes, depression, irritability, sleeping problemsModerate- forgetfulness, lack of energy, inappropriate behavior, slurred speech, inability to perform mental tasks, difficulty writing and thinkingSevere- confused, sleepy, inability to perform basic mental tasks, anxious, and strange Coma- unconscious in a comaNon-alcoholic fatty liver disease (NAFLD)- accumulation of fat in the liver due to alcoholism Jaundice-yellowing of the skin and whites of the eyes due to too much bilirubin Hepatorenal syndrome- syndrome where the kidneys no longer work due to serious liver problems such as cirrhosis and can lead to kidney failure and deathAscites- edema of the abdomen (abdominal swelling)Esophageal varices- enlarged veins in the lower esophagus due to obstructed blood flow to the liver by scar tissue or a clotPortal hypertension- increased pressure in the portal vein due to a blockage in blood flowBranched chain amino acids (BCAA)- essential nutrients the body gets from protein found in meat, dairy, and legumes. Wernicke’s Encephalopathy- thiamin deficiency which causes neurological disordersKorsakoff Syndrome- chronic memory disorder due to thiamine deficiency (commonly caused by alcoholism) Part 2: Pertinent MedicationsFor the following medications, describe its primary use and mode of action. Also include any pertinent nutrition-related side effects or interactions of which patients and dietitians should be aware:Furosemide- (Diuretic) treats fluid retention and hypertension-symptoms: weakness, nausea, vomiting, stomach pain, severe diarrhea, loss of appetite, Spironolactone- (Antimineralocorticoid) treats hypertension and fluid retentions related to heart failure-symptoms: swelling, tingling in mouth and throat, vomiting, blood in stools, dark stools, dry mouth, increased thirst, weakness, nauseaNeomycin- (Aminoglycoside antibiotic) treats hepatic coma-symptoms: sore throat, nausea, vomiting, diarrhea, change in stools Lactulose- treats constipation and symptoms from liver disease- symptoms: swelling and tingling in mouth or throat, severe diarrhea, gas, burping, nausea, vomiting, and stomach cramps Part 3: Pertinent ProceduresParacentesis- procedure to remove fluid in the stomachBalloon tamponade- procedure where a balloon is used to apply pressure on bleeding blood vessels, become compressed, and stop bleeding in the esophagus or stomachTransjugular intrahepatic portosystemic shunt (TIPS)- procedure to create new connections between blood vessels in the liverEndoscopic Retrograde Cholangiopancreatography (ERCP) – combination procedure of endoscopy and x ray to treat issues of bile and pancreatic ductsWhipple procedure- procedure where parts of the pancreas, small intestine, and gallbladder is removed. Part 4: PathophysiologyAnswer the following questions below like you are explaining it to one of your peers. Do not copy and paste textbook information. Provide references for each of your answers. The answers don’t need to be exhaustive. Focus on what would be important for a dietitian to know. Briefly describe the many functions of the liver. Be sure to include the exocrine and endocrine functions of this organ as it relates digestion and metabolism. The liver provides many important functions for the body including storage for vitamins, production and removal of cholesterol, regulation of clots, removal of bacteria from the blood stream, and bile release to help digest food and absorb nutrients. Exocrine functions include bile production and endocrine functions include the release of albumin, lipoprotein, globulins, liver glycogen, and thyroid hormone. Describe the pathophysiology of fatty liver secondary to alcoholism. Alcoholism can lead to fatty liver disease due to the fact that alcohol damages and destroys liver cells. An increased amount of fat accumulates in the liver cells which inhibits the typical breakdown of alcohol in the liver. Describe the functions of the pancreas. Include exocrine and endocrine functions of the pancreas.Pancreas is made up of two glands which work together as one organ. The Pancreas is made up of exocrine cells which produce enzymes to help with the digestion of food. The produced enzymes release into ducts and form the pancreatic duct which drains fluid produced from exocrine cells into the duodenum. The endocrine portion of the pancreas is made of of islets that release insulin and glucagon hormones into the blood stream which regulate blood sugar levels. Describe the most common causes of pancreatitis. Alcohol abuse, medications, smoking, gallstones, family history, abdominal surgery, high TG levels, infection, pancreatic cancerPart 5: Review of MNTAnswer the following questions below in your own words. Do not copy and paste textbook information. Provide references for each of your answers. The answers don’t need to be exhaustive. Focus on what would be important for a dietitian to know.Discuss the Academy’s recommendations for MNT for patients with acute pancreatitis and chronic pancreatitis. Acute: Patient NPO until abdominal pain and tenderness diminishes. IV fluids are important to keep the patient hydrated. Painkillers are used to if pain is severe. PO intake may resume within 7 days. Once pain is reduced diets can be slowly administered started with a clear liquid and reaching a low fat diet before discharge. Vitamin and mineral supplementation. Chronic: High calorie, high protein diet, with moderate amounts of fat and carbohydrate used to minimize symptoms of pancreatitis and promote weight retention or weight gain. Vitamin and mineral supplementation. Pancreatic enzymes given in capsule form may be useful before meals. When are pancreatic enzymes prescribed and why? Pancreatic enzymes are prescribed for those whose pancreas is unable to secrete enzymes necessary for digestion. If a patient has a decreased or insufficient amount pancreatic enzymes are prescribed. These enzymes are important for the breakdown of food and the absorption of food and its nutrients. Low protein diets are often prescribed for individuals with liver disease. Is this usually an appropriate diet order? When would one prescribe a low protein diet to individuals with liver disease? Yes, a low protein diet for patients with liver disease enables the liver to function at a steady pace rather than working too hard. This is because protein may not be properly processed or digested through the body which results in a build up of waste products. A low protein diet for patients with liver disease would be prescribed as a last resort in order to improve diagnosis of encephalopathy. Why might a patient with liver disease be prescribed a sodium or fluid restriction?Patients with liver disease may develop fluid accumulation (edema and ascites) therefore requiring a low sodium diet to decrease water retention as well as a fluid restriction in order to avoid excessive fluid accumulation. Describe the digestion and absorption of long chain triglycerides and medium chain triglycerides (MCT). What is the reason for using MCT oil as a dietary supplement in patients with liver disease? Part 6: Case StudyMr. Toppa is a 48-year-old car mechanic. He has been a casual drinker for several decades, but after a back injury five years ago, which has left him with chronic pain, he is now self-medicating with alcohol. He typically drinks 4-6 beers on weeknights while watching TV and on weekend nights he often binge drinks. On Friday, Saturday, and Sunday night he drinks several shots of whiskey and several beers. He is unable to provide an exact number. For the past four days he has been having what he calls ‘stomach’ pains and has also vomited at least once daily. He says that his ‘stomach’ seems swollen and his pants are now tight in the waist. When he vomited blood, his wife insisted that he go to the emergency room. The emergency room physician admitted Mr. Toppa for pancreatitis and alcohol withdrawal. Past medical history: alcohol abuse, hypertension, hypercholesterolemia, hypertriglyceridemia.Social history: lives with spouse, married 26 years, one adult married child. Completed high school. Medications at home: Zocor, NorvascLabs - drawn in the ER: Sodium: 132 mEq/LGlucose: 136 mg/dLAlbumin: 2.6 g/dLPotassium: 3.0 mEq/LMagnesium: 1.2 mEq/LLipase: 326 u/LAmylase: 340 u/LALT: 117 u/LAST: 142 u/LTotal Bilirubin: 2.6 mg/dLAmmonia: 145 u/LHeight: 5’ 8” Weight: UBW 168#, admit weight 178#Medications ordered by ER physician:IV: banana bag – 1 LLactulosePotassium chlorideLasixZocorPhysician ordered diet: Clear liquids. When tolerated, advance to soft, cardiac, low fat, low protein. Diet history: When you visit Mr. Toppa he is too sleepy to provide any information but his wife who is present tells you that his appetite has been very poor and for the past five days he has been consuming little more than broth, Jell-O and juice. Mrs. Toppa provides his usual daily intake: Breakfast: A large coffee from a donut shop with cream and three sugarsA bagel with cream cheese or a couple of donuts Mid-morning:A large coffee with cream and three sugarsA donut or pastryLunch:Take out from a local sub shop- usually a large sub, chips and large sodaDinner:Prepared by his wife at home- steak or chicken, rice or potato, and a vegetable. Case Study QuestionsCalculate Mr. Toppa’s IBW and BMI. IBW= 68.4 kgBMI= 27 (overweight) Assess his protein, kcal and fluid needs. Show your calculations and the predictive equation used. Protein= 80.9 kg x 1.5 g (according to Sharp pancreatitis guidelines) = 121g PROKcal= 80.9 kg x 25 = 2022 kcal/day 80.9 kg x 30 = 2427 kcal/day 2000-2400 kcal/dayFluid= 2000-2400 mL/day (1 x kcal/day) Write a PES statement and care plan for Mr. Toppa.Excessive alcohol intake related to diagnosis of pancreatitis and admit of alcohol withdrawals as evidence by 4-6 beers each night on weeknights and weekend binge drinking. Assess his diet order, is it appropriate? What would you recommend? I believe his diet order is appropriate. Starting with clear liquids will allow him to slowly gain back his appetite and then gradually increasing him to an ideal diet of low fat which would be ideal based on his current diet recall he eats quite a bit of saturated fats daily. Low protein would also be a good choice in order to ensure it is properly broken down. What diet would you recommend for Mr. Toppa when he is discharged? I would recommend Mr. Toppa to abide by a low fat diet. I would also encourage Mr. Toppa to limit his alcohol intake. Using the diet history obtained from Mrs. Toppa, make recommendations for improvement to his diet. Mr. Toppa consumes a large amount of fat and saturated fat in his diet so I would recommend he incorporate more fruits and vegetables and leaner cuts of meat. His first two meals of the day consist of coffee with cream and sugar and donuts or some type of pastry with smear which add additional calories and fat. I would encourage more of a well balanced breakfast with examples of whole wheat toast and peanut butter with a piece of fruit or oatmeal with fruit. I would recommend him to try using a low fat creamer in his coffee or half and half to cut down on fat. I would encourage him to choose leaner cuts of meat at lunch and opt for a piece of fruit or baked chips versus regular fried chips. I would also recommend more water consumption and to substitute his regular cola for diet cola. Reduced alcohol consumption would also be recommended. Do you expect to see any weight changes during his hospital stay? If so, why? How often would you recommend that Mr. Toppa be weighed? I would expect to see weight changes (weight loss) during his hospital stay due to the inflammation and pancreatitis. He is also detoxing from increased alcohol consumption. I would recommend he is weighed every two days. Which lab values are indicative of liver disease?ALT and AST are indicative of liver disease and shown to be elevated in Mr. Toppa. Which lab values are indicative of pancreatitis?Amylase and Lipase are indicative of pancreatitis (both of which are extremely elevated for Mr. Toppa). Billirubin, ALT, and AST can be assessed as well. Explain the rationale for the medications prescribed by the ER physician. Banana bag- commonly used for increase in fluids containing vitamins and minerals used to replenish the body after severe alcohol consumption. Lactulose- reduce elevated ammonia levels in the blood (patients with liver disease) Potassium chloride- used for hydrating those who are dehydrated Lasix- diuretic used to prevent the absorbance of too much saltincrease of urine output Zocor-lipid lowering medication most likely used due to his history of increased cholesterol, HTN, and triglyceride levels Why might alcoholics be at risk for refeeding syndrome (RFS)? What labs should be monitored to assess for RFS?Alcoholics may be at risk for refeeding syndrome because their electrolytes are off balance and may be deficient in vitamins and minerals due to their excess alcohol intake. Refeeding syndrome occurs in those with recent significant weight loss, prolonged fasting, chronic alcoholism, and prolonged fluid repletion. Glucose, Phosphate, Potassium, Magnesium should be monitored. References: ................
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