Andrea Young, RD, LDN



Nutrition Implications of Pancreatic Cancer

Sodexo Dietetic Internship

Andrea Young

Abstract

Pancreatic cancer is the fourth leading cause of cancer related deaths in the United States. The detection of pancreatic cancer typically occurs during advanced stages, causing the prognosis to be poor. Cancer and cancer treatments have many nutritional implications; with the advice of a Registered Dietitian nutritional complications can be minimized and help improve a patient’s quality of life. Upon meeting several patients with pancreatic cancer and knowing little about the condition, I decided to research the topic and find what a Registered Dietitian can do to help these individuals. Patient centered care with goals and advice that are realistic and achievable can help a patient improve their nutrition status and possibly minimize adverse effective from cancer and cancer treatments.

Introduction

After meeting patients in the acute care setting at St. Mary’s Medical Center with pancreatic cancer I became interested in the disease and the complications that may arise from the cancer and the treatments. Having not previously known about pancreatic cancer and its poor prognosis gave me further interest in researching the topic in detail. Being up to date on different treatment options available can help guide the Registered Dietitian to different nutrition implications that can occur. By taking a more detailed look into pancreatic cancer I hoped to learn about current treatments and nutritional advice that can be provided to patients.

Normal Anatomy and Physiology of the Pancreas

The pancreas is a slender complex organ ranging in length from six to nine inches. Located below the liver and posterior of the stomach the pancreas consists of a head, located within the curvature of the duodenum, a body, and a tail, which extends to the spleen. There are two types of active cells within the pancreas consisting of endocrine and exocrine tissues. (1, 2) Refer to figure 1 in the appendix.

The endocrine portion of the pancreas consists of the islets of Langerhan, which primarily secretes the hormones insulin and glucagon into the blood. Alpha cells of the pancreatic islet secrete glucagon and the beta cells secrete insulin. (1) Endocrine glands do not have ducts but rather have extensive blood vessels in the connective tissue of the glands; the hormones secreted by endocrine glands are secreted into the bloodstream. Acinar glands compose the exocrine portion of the pancreas and produces digestive enzymes, which are packaged into granules and released into the pancreatic juice. Clusters of acini cells form lobules, which secrete digestive enzymes into a network of ducts, these ducts join the main pancreatic duct known as the Wirsung Duct, which runs the length of the pancreas. (2)

Ducts are structures that carry fluids within the body and resemble tubes. The pancreas and gallbladder share a duct for entry into the duodenum. Bile ducts carry bile, made in the liver, to the gallbladder. When a food is consumed the gallbladder releases bile into a common bile duct. The pancreatic duct joins the common bile duct at the hepatopancreatic ampulla, which empties into the duodenum at the major duodenal papilla. The hepatopancreatic ampullar sphincter also known as the sphincter of Oddi regulates the opening of the ampulla into the duodenum. (1, 3)

The parasympathetic nervous system and hormones stimulate the pancreas to release pancreatic juice. The hormone secretin is secreted by the proximal small intestine in response to the release of acidic chyme into the duodenum. The pancreas is stimulated by the secretin to secrete water, bicarbonate, and pancreatic enzymes into the duodenum. Cholecystokinin stimulates the release of bile from the gallbladder and stimulates the pancreas to secrete pancreatic juice and enzymes into the duodenum. (2) The presence of fatty acids and other lipids in the duodenum is the major stimulus for the release of cholecystokinin.(1) Vasoactive intestinal polypeptide is located within the neurons of the small intestine and stimulates the pancreas to release bicarbonate into the small intestine. Somatostatin is a hormone that inhibits pancreatic exocrine secretions. Insulin release is inhibited by Amylin, galanin, as well as somatostatin, where as glucose-dependent insulinotropic polypeptide and glucagon-like peptide stimulate insulin secretions. (2)

Functions of the Pancreas

Endocrine and exocrine cells are the main component of the pancreas giving the pancreas hormonal and digestive functions. Insulin, amylin, glucagon, pancreatic polypeptide and somatostatin are the hormones secreted by the pancreas. (1) The role of insulin and glucagon will be reviewed in this section. The pancreas secretes insulin when increased levels of glucose are within the blood; insulin is an anabolic hormone involved in glucose, lipid, and amino acid synthesis and storage. Insulin inhibits the expression of catabolic hormones, which would catabolize glucose, lipids, and proteins. When serum glucose levels drop the pancreas releases glucagon into the blood. Glucagon stimulates the catabolism of stored glucose, lipids, and proteins within the body for energy. (2, 3)

Pancreatic juice, which is the exocrine secretion of the pancreas, has two major components, an aqueous component and an enzymatic component. Pancreatic juice is delivered to the small intestine where its function is digestion. The aqueous component of pancreatic juice contains sodium and potassium as well as bicarbonate. The bicarbonate ions are a major part of the aqueous component and neutralize the acidic chyme coming from the stomach. Pancreatic secretions increase the pH of the duodenum providing the proper environment for the function of pancreatic enzymes. (1, 2)

Acinar cells of the pancreas produce the enzymes of the pancreatic juice. (1) The enzymes produced allow for adequate digestion of protein, carbohydrates, and lipids; these enzymes released by the pancreas digest about 50% of ingested protein, 50% of indigested carbohydrates, and 80-90% of ingested fats. (2) Proteolytic enzymes include trypsin, chymotrypsin, and carboxypeptidase; these enzymes are secreted in their inactive form to prevent digestion of the tissues, which produce them. Pancreatic amylase digests polysaccharides and lastly pancreatic lipases break down lipids into monoglycerides, free fatty acids, and cholesterol. (1)

Process of Cancer

Cancer begins with cell growth that is abnormal and out of control. Cells are what build tissues and tissues form organs. When cells become cancerous they can affect the tissues that them make up. Normal cells grow, divide, and die. DNA is in every cell and is what directs the cells actions. When normal cells have damaged DNA the cell repairs the damage or the cell dies. Cancer cells have damaged DNA, these cells are not repaired and do not die but rather multiply with the same damaged DNA. (3) Refer to figure 2 in the appendix. (4)

Cancer is able to invade other tissues, shed cancer cells, or spread to other organs. Invasion occurs when a malignant tumor grows and invades near by organs. When cancer cells break off from the main tumor the cancer cells are shedding, this may lead to new tumor formation on the surface of nearby organs and tissues. Cancer is considered to have spread when cancer cells break off from the original tumor and spread through the circulatory or lymphatic system, once the cancer has spread the cancer cells can attached to and grow on different tissues. When cancer has invaded, shed, or spread to other tissues it is considered to have metastasized.(4)

Cancer Staging

Staging of cancer is done to determine the severity of an individual’s cancer and generally covers the extent of the tumor, whether the tumor has spread to the lymph nodes, and whether metastasis has occurred. This method of staging is used by the National Cancer Institute and is termed the TNM system, the letters representing tumor, lymph nodes, and metastasis. Using the TNM system a number is added to each letter indicating size or extent of the primary tumor and the extent of the cancer spread. For TNM staging see table 1 in the appendix. (4) TNM staging combinations correspond to one of five stages for many caners. In general Stage 0 indicates carcinoma in situ; Stage I, Stage II, and Stage III indicate more extensive cancer including a larger tumor size and possible spreading of the cancer, beyond the organ in which it first developed, to nearby lymph nodes or organs adjacent to the location of the primary tumor. Stage IV cancer typically has spread to another organ. (4)

Pancreatic Cancer

About 60% of pancreatic tumors originate in the head of the pancreas, 15% in the body, and 5% in the tail, 20% are diffuse within the pancreas. There are two main types of pancreatic cancer; the most common type is exocrine pancreatic cancer, which starts in the ducts that carry pancreatic juices. Endocrine pancreatic cancer, also known as islet cell cancer, is less common and begins within the cells that make hormones. Cancer of the pancreas is a broad definition because as many as twenty different types of tumors are categorized under the term pancreatic cancer. Different tumors of the pancreas have different treatments because of each tumors unique prognosis. See table 2 in the appendix for types of pancreatic tumors. Primary and metastatic are two broad ways to classify pancreatic caner. Primary pancreatic cancer refers to cancer arising from the pancreas where as metastatic pancreatic cancer refers to cancer originating in other organs and later spreading to the pancreas. Primary pancreatic cancer is typical in the majority of cases and can be sub-grouped into cancers showing endocrine differentiation and those that do not. (4, 5, 6)

Epidemiology of Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer related deaths within the United States. Incidence rates seem to be increasing due to pancreatic cancer becoming more common as well as the difficulty in diagnosing until in advanced stages. It was estimated that within the year 2012 43,920 individuals would be diagnosed with pancreatic cancer, and 37,390 deaths would occur due to pancreatic cancer. Survival from pancreatic cancer is poor compared to other cancers; only 6% of pancreatic cancer patients live more than 5 years after diagnosis. Survival rates are generally low with pancreatic cancer due to delayed diagnosis and metastasis of cancer.(7)

The cause of pancreatic cancer is unknown, however it is believed genetics plays a major role. Lifestyle factors may also play a major role in the development of pancreatic cancer; some of these factors include, smoking, exposure to chemicals such as gasoline and fuel oils, as well as being obese and consuming a diet high in red meat or low in fruits and vegetables; doses of alcohol greater than 30 grams per day contributes to only a modest increase. Other risk factors for pancreatic cancer include older age, males, African American, family history, cirrhosis, and chronic pancreatitis. Type II diabetes is not a true risk factor. Although risk factors can increase an individual’s risk of developing cancer, risk factors do not cause the disease. People with none of these risk factors could still develop pancreatic cancer. (8, 9)

Signs and Symptoms

Symptoms of pancreatic cancer typically occur once the cancer has progressed to advanced stages. Each individual can experience the common symptoms that occur differently. Severe abdominal pain, which radiates into the back, is a common symptom of most patients. Weight loss due to malignant cancer cells depriving healthy cells of nutrients, as well as digestive problems, which may occur due to the pancreas’ integral part of digestion are common in pancreatic cancer patients. (9, 10) Nausea and vomiting can occur during advanced stages of pancreatic caner, this can occur when the tumor grows large enough to block part of the digestive tract, typically the duodenum. (7) Diabetes occurs in 25-50% of patients and may lead to symptoms of glucose intolerance such as polyuria and polydipsia. Jaundice, a yellowing of the skin and whites of the eyes, occurs in about 80-90% of patients with adenocarcinomas of the head of the pancreas. Jaundice occurs when a tumor blocks the flow of bile, when blood cells break down into bilirubin once worn out, bilirubin is eliminated into the bile, if the flow of bile is obstructed jaundice occurs. Severe itching may also occur due to the build up of bile acids. When cancer is in the body and tail of the pancreas splenic vein obstruction can occur leading to splenomegaly, gastric and esophageal varices, and GI hemorrhage. Because many of these symptoms occur late in diagnosis 90% of patients have locally advanced tumors, cancer has spread to regional lymph nodes or metastasized to the liver or lungs. (10)

Diagnosis of Pancreatic Cancer

Pancreatic cancer can be difficult to diagnose. As stated before symptoms do not typically arise until advanced stages and many symptoms may be mistaken as signs of other conditions. The pancreas is also located deep behind other organs and can be difficult to see and assess without proper equipment. The first step of diagnosing is to determine the size and extent of the pancreatic tumor; this will ensure the most appropriate and effective treatment. There are many ways to diagnose a patient with pancreatic cancer including physical exam, imaging, blood test, biopsy, as well as several other methods. The doctor may first start with a physical exam of the patient, feeling the abdomen for abnormal changes around the pancreas, liver, gallbladder, and spleen; checking for abdominal fluid buildup is also common as well as checking the skin and eyes for signs of jaundice. Although a physical exam will not confirm diagnosis of pancreatic cancer it can be a starting point to initiate further testing to be completed. (4, 11, 12, 13)

Blood tests can be completed to help support a diagnosis of pancreatic caner as well as monitor the progression of the disease and the effects of treatment. Hepatic function tests can be completed to assess levels of bilirubin and liver enzymes. Higher bilirubin levels can indicate a blockage of the bile duct, however pancreatic cancer is not the only cause of increased bilirubin levels. Another blood test is the CA 19-9, which is a tumor marker. CA 19-9 is an antigen existing on the surface of cancer cells. Elevated levels of CA 19-9 can indicate a presence of a pancreatic mass or biliary obstruction, and may support pancreatic cancer as a diagnosis. However CA-19-9 can be elevated for multiple reasons and cannot be used alone to make a diagnosis. (12, 14)

Diagnostic imaging is important and needed to determine the extent of the tumor and whether cancer cells have spread to other tissues. Several imaging tests can be done including the CT scan, MRI, MRCP, EUS, and ERCP. Computer tomography scan, which is abbreviated CT scan, is done to identify the location of a tumor and the extent of the pancreatic tumor. The scan allows for a detailed picture of the pancreas and nearby organs, and blood vessels. (4, 12) Magnetic resonance imaging, or MRI, is another type of imaging used; this procedure uses large magnetic radiofrequency to create a detailed image of the pancreas. Magnetic resonance cholangiopancreatography, abbreviated MRCP, is a type of MRI, this is used to create an image of the pancreatic ducts and channels in the pancreas. An endoscopic ultrasound, also known as EUS, can be done to provide a detailed picture of the pancreas and remove pancreatic cells and fluid for a biopsy. The EUS procedure is completed by inserting an endoscope through the mouth down to the stomach, at the end of the endoscope is an ultrasound probe. The endoscopic retrograde cholangiopancreatography, also known as ERCP, is another type of imaging that can be done. This procedure allows for images of the pancreatic duct, which allow the physician to determine if the ducts have narrowed or have become blocked. The ERCP also allows for removal of pancreatic cells for biopsy and to guide for placement of a bile duct stent to relieve jaundice. (4, 6, 11, 12)

The findings of the imaging techniques can determine the diagnostic technique to be used next. Percutaneous needle aspiration of an accessible lesion may be considered for tissue diagnosis if the CT or MRCP shows unresectable or metastatic disease. MRCP or endoscopic ultrasound may be used to stage pancreatic cancer or detect small tumors unseen by a CT scan; this is done when the CT scan shows a possible resectable tumor or no tumor. ERCP may be used as a first diagnostic procedure if a patient has obstructive jaundice. (10, 11)

After having a physical examination, laboratory work, and imaging test, a biopsy is the next tool needed. Biopsy remains the gold standard for diagnosing pancreatic cancer. The biopsy is important to determine the type of tumor that is present, there are about 20 different types of tumors and each responds differently to different types of treatment. The endoscopic ultrasound and the endoscopic retrograde cholangiopancreatography are the most common techniques for biopsy. A laparoscopic procedure can also be performed to obtain a biopsy; this procedure is completed by inserting a laparoscope through the abdomen, allowing for a visual of the pancreas as well as the ability to remove a small amount of tissue and fluid. (11, 12)

The best treatment option is chosen after learning the extent or stage of the cancer. Often times a laparotomy is performed to view the extent of the pancreatic tumor and determine whether successful removal of the tumor would be possible without causing undue harm to the patient. Once all the procedures have been completed the stage is typically able to be determined. When staging cancer tumor size, whether the tumor has invaded nearby tissue, and whether the cancer has spread are considered. (4, 12)

Pancreatic Cancer Staging

Stage 0 is pancreatic carcinoma in situ. The tumor at this stage remains of the surface of the pancreatic duct cells; the cancer has not invaded deeper tissue or spread outside of the pancreas. Stage IA pancreatic cancer indicates the tumor is less than 2cm and is contained within the pancreas. Stage IB indicates the tumor is greater than 2cm and is contained within the pancreas. Stage IIA pancreatic cancer indicates the tumor has begun to grow outside the pancreas. At this stage the cancer has not spread to lymph nodes, major blood vessels, or distant sites. Stage IIB indicates the tumor is confined to the pancreas or growing outside the pancreas. At this stage the cancer has not spread into nearby large blood vessels, major nerves, or distant sites but has spread to nearby lymph nodes. Stage III pancreatic cancer indicates the tumor is growing outside of the pancreas and within nearby large blood vessels or major nerves, it may or may not have spread to nearby lymph nodes but has not spread to distant sites. Stage IV pancreatic cancer indicates the cancer has spread to near by organs such as the liver, lungs or peritoneum. (3, 6, 12)

Treatment options for pancreatic cancer depend on the stage of the cancer. Stages IA and IB are local and resectable, meaning because the cancer is only in the pancreas or has spread just beyond the pancreas a surgeon can remove the entire tumor. Stages IIA and IIB are locally advanced and potentially resectable. Stage III is locally advanced and unresectable. When using the term locally advanced it indicates the cancer has not yet spread to distant organs but still cannot be completely removed, many times the cancer cannot be removed due to the cancer being present in nearby blood vessels. If surgery is done it is typically to relieve symptoms or problems such as blocked bile ducts. Lastly Stage IV is metastatic and unresectable. When the cancer is metastatic, surgery is typically done to relieve symptoms and not for a cure. (3,15)

Treatment

Treatment options for pancreatic cancer include surgery, chemotherapy, targeted therapy, radiation therapy and symptomatic therapies. As stated previously, pancreatic cancer diagnosis tends to occur in advanced stages and treatment strategies tend to exclude surgery. Only a small percentage of pancreatic cancer patients have surgery. The surgeries that are available include the Whipple procedure, distal pancreatectomy, and total pancreatectomy. Although treatments are available, the prognosis of pancreatic cancer remains poor. (9)

Surgery

The Whipple procedure, also called a pancreaticoduodenectomy, is the most common surgery for pancreatic cancer. This procedure is done to remove cancer that is in the head of the pancreas; the surgery also removes part of the small intestine, the lower half of the bile duct, the surrounding lymph nodes, the gallbladder, and the pylorus. Part of the portal vein may also be removed if it has been invaded by the pancreatic tumor. The surgeon then reconnects the remaining pancreas, stomach, and bile duct to the small intestine allowing for the pancreatic digestive enzymes, bile, and stomach contents to flow into the small intestine during digestion. If the pylorus is preserved and not removed the surgery is called a pylorus preserving Whipple. The most common complication following the Whipple procedure is gastroparesis, which occurs on average for 7-10 days but can occur up to a few weeks following the procedure. In 10% of patients serious abdominal infection occurs due to a fistula, which causes leakage, where the pancreas has been connected to the intestine, this typically requires draining tubes, antibiotics, and supplemental feedings. Long-term effects including digestive difficulties may occur following the Whipple procedure. (12, 15)

The distal pancreatectomy is performed in patients with exocrine tumors located in the tail of the pancreas. In this procedure the tail of the pancreas is removed, sometimes part of the body of the pancreas is also removed as well as the spleen. Pancreatic juice leaking is the most common complication of this surgery. Serious complications include leakage and infection. (12,15)

Total pancreatectomy is rarely performed but is done when the entire pancreas, head, body, and tail have been invaded by the tumor. In addition to the entire pancreas being removed the gallbladder, pylorus, duodenum, lower half of the bile duct, nearby lymph nodes, and occasionally the spleen are removed. Due to the removal of the entire pancreas the patient will be diabetic following the procedure and must use insulin to control blood glucose. The patient will also require pancreatic enzymes to be taken with food for appropriate digestion. (12,15)

Chemotherapy

Surgery as previously states is not for all patients, however many times chemotherapy is used in conjunction with radiation and surgery to provide the most optimal outcomes. Chemotherapy can be used alone but often is used in conjunction with other treatments such as radiation therapy. Chemotherapy is a systemic treatment attacking all rapidly dividing cells in the body by preventing them from growing and dividing, including cancer cells and healthy cells. Chemotherapy can prevent pancreatic tumors from growing and sometimes shrinks them. Extended survival with the use chemotherapy has been shown in many pancreatic cancer patients including patients who have chemotherapy in addition to surgery or radiation for tumors confined to the pancreas, patients using chemotherapy for primary treatment of inoperable tumors which are confined to the pancreas, and for patients using chemotherapy for treatment of metastatic pancreatic tumors. The most common type of chemotherapy to be used for pancreatic cancer is Gemzar; the generic name is gemcitabine, this drug was approved to be the standard of care for pancreatic caner in 1996. Fluorouracil was the standard chemotherapy used prior to gemcitabine. Gemzar is typically used after a patient has had surgery for tumors, which were confined to the pancreas. Used in combination with other chemotherapy drugs Gemzar can be used to control the metastasis of cancerous cells and improve survival. (12, 15)

Although chemotherapy has many positive effects on treating cancer it also has many adverse effects due to the attack of rapidly dividing cells, including healthy cells. Healthy rapidly dividing cells within the body include bone marrow, bloods cells, cells of hair follicles, and cells of the reproductive and digestive tract. Side effects generally depend on the type of chemotherapy, the dose, and length of treatment. Common side effects include fatigue, hair loss, low blood cell count, gastrointestinal discomfort, diarrhea, abdominal cramping, nausea, vomiting, neuropathy, as well as loss of appetite and change of taste. (12, 15)

Targeted Therapy

In addition to surgery and chemotherapy, targeted therapy is an additional option. Tarceva, generic name erlotinib, was FDA approved in 2005. Tarceva used in combination with chemotherapy drug Gemzar is used in locally advanced and metastatic pancreatic cancer, which cannot be removed surgically. Targeted therapy works in two ways, both of which cause little to no harm to healthy cells. The first way targeted therapy works is by stopping abnormal growth behavior of a tumor by blocking the process that changes normal cells into cancer. The second way targeted therapy works is by preventing the formation of blood vessels that bring nutrients to the tumor. Specifically Tarceva targets Human Epidermal Growth Factor Receptor 1, which is found in abnormally high levels on the surface of some pancreatic cancer cells. By targeting this growth factor, Tarceva blocks the growth of the cancerous cells. The side effects of this target therapy include fatigue, rash, nausea, loss of appetitive, and diarrhea. (15)

Radiation

Radiation treatment is the last treatment option for pancreatic cancer aside from symptomatic treatment. Radiation can be used in combination with surgery and chemotherapy, however when radiation is given along with chemotherapy the chemotherapy is at a lower dose than when it is administered alone. Chemotherapy acts as a radiosensitizer, which enhances the effects of the radiation on the tumor. Unlike chemotherapy radiation cannot kill cancer cells, which have spread, radiation is considered a local treatment. Radiation therapy uses high-energy waves to kill cancer cells or prevent them from dividing, prevent tumors from growing, and sometimes shrinks the tumor. There are two main types of radiation therapy including external beam radiation and internal radiation also known as brachytherapy. External beam radiation, as its name indicates, is delivered by a linear accelerator located outside of the body, which focuses x-rays directly on the tumor. Internal radiation, rarely used in pancreatic caner, involves the implantation of small amounts of radioactive materials in or near the caner.

Radiation does have some adverse side effects associated with it. Patients may experience some abdominal discomfort towards the end of treatments, however the treatments are not painful. Overtime however, the effects of radiation can build up. Common side effects include loss of appetite, nausea, diarrhea, and fatigue. Side effects typically peak from four to five weeks after the first radiation treatment and resolve one to two weeks after completed treatment. (4, 12, 15)

Symptomatic Treatment

Surgery, chemotherapy, targeted therapy, and radiation therapy all can help by varying degrees the treatment of pancreatic cancer. However, as pancreatic cancer does progress it can affect multiple organs causing multiple side effects such as pain, nausea, and jaundice. Side effects from surgery, chemotherapy, targeted therapy and radiation can cause decreased ability of digestion, nausea, vomiting, and fatigue. Pain management is important throughout the process of treating pancreatic cancer. Pain, which radiates from the abdomen to the back, occurs when the pancreatic cancer cells invade the celiac plexus, a cluster of nerves in the lower abdomen from which sensory nerves in the pancreas, gallbladder, biliary tract, and other nearby organs grow. Pain management using opioid analgesics, such as morphine can effectively relieve pain in most patients. (12)

As mentioned previously pancreatic tumors can block the bile duct causing a buildup of bilirubin in the liver leading to jaundice and itching. For relief from jaundice a stent can be placed into the bile duct relieving the blockage. This treatment can relieve the patient from discomfort and improve the patient’s quality of life. (12)

Rehabilitation services may be necessary for patients following treatments and surgery in order to help build strength, flexibility, balance, and endurance. Treatments for depression may also be necessary as well as supportive measures throughout the treatment. (12)

Treatments that help decrease the progression or eliminate pancreatic cancer can interfere with the production of digestive enzymes and insulin. Patients typically require medications and enzymes to aid in digestion and maintain blood sugar levels. Nutrition is essential in these patients. (10, 12) Many of the medications patients take are for the nutrition implications that occur. Pancreatic enzymes including pancrelipase and pancreatin are commonly taken. Enteric coating of the enzyme aids in maintaining the integrity of the enzyme until it reaches the small intestine. As much as 20,000-30,000 units of lipase may be needed per meal and 10,000 units may be needed with snacks. In addition insulin may be needed if the patient is hyperglycemic, however with islet cell tumors hypoglycemia may occur, it is important to monitor glucose at meals. Acid reducing medications such as proton pump inhibitors or H2 blockers are typically needed. Water-miscible fat-soluble vitamins A, D, E, and K, such as Vitamax, Source CF, and ADEKs, will be needed until intake of pancreatic enzymes is sufficient. Appetite stimulants such as Megace may be appropriate if the patient’s intake is declining. Antiemetics and diuretics may be needed. If the patient has loose stool Calcium Carbonate twice daily may be useful. Imodium and Lomotil are antidiarrheal medications, which may be useful if loose stools are persistent. Pain medications are often needed to treat pain associated with pancreatic cancer. Often opioids such as codeine, hydrocodone, hydromorphone, oxycodone, and morphine are needed for the treatment of pain, however acetaminophen and NSAIDs, such as aspirin and ibuprofen are also commonly used as well. (9) For nutrition implications of these medications refer to the Medication Bibliography on page 42.

Labs to Review for Pancreatic Cancer

It is necessary to monitor lab values especially glucose, amylase, lipase, bilirubin, aspartate aminotransferase and alanine aminotransferase, prealbumin, C-reactive protein, fat soluble vitamins, as well as sodium, potassium, chloride, phosphorus, magnesium, and calcium. If a patient is receiving chemotherapy monitoring WBC and platelet count is also important. (9, 14)

Monitoring blood glucose levels is necessary to determine if the patient is having problems producing insulin or glucagon causing either hyper or hypoglycemia. In these cases a patient may require insulin or Diazoxide, a drug which blocks insulin release from the pancreas to prevent hypoglycemia. (9, 14)

Amylase and lipase levels may increase if there is an obstruction of the pancreatic duct causing an outpouring of amylase into the intrapancreatic lymph system and free peritoneum. Blood vessels drain the free peritoneum and absorb the lymph picking up excess amylase. Lipase levels are less useful in chronic pancreatic diseases such as pancreatic carcinoma. (9,14)

Bilirubin is another lab value that is important to monitor. Bilirubin metabolism begins with the breakdown of red blood cells; hemoglobin is released from red blood cells and broken down to heme and globin molecules. Heme is then catabolized to form biliverdin, which is transformed into bilirubin, also known as indirect bilirubin. In the liver, indirect bilirubin is conjugated forming conjugated or direct bilirubin. The conjugated bilirubin is then excreted from the liver and eventually into the common bile duct. High levels of conjugated bilirubin may indicate extrahepatic duct obstruction or among other possibilities extensive liver metastasis. (9,14)

An increase in alanine aminotransferase, also known as ALT, levels may indicate injury or disease affecting the liver parenchyma causing a release of this hepatocellular enzyme into the blood stream. In general most ALT elevations are caused by liver disease. When disease or injury affects the cells of the liver tissue, the cells lyse. The aspartate aminotransferase, also known as AST, is released and picked up by the blood causing the serum levels to rise. The amount of AST elevation is directly related to the number of cells affected by the disease or injury. Increased levels may indicate hepatic metastasis. (9,14)

Prealbumin is one of the major plasma proteins and can be used to determine protein status, however prealbumin is significantly reduced in hepatobiliary disease because of impaired synthesis. Serum levels of prealbumin can decrease with inflammation, infection, malignancy, malnutrition, and with zinc deficiency. To help determine the degree of inflammation occurring in the body C-reactive protein, CRP, is a nonspecific, acute-phase reactant used to diagnosis infectious disease, and inflammatory disorders. The liver primarily produces CRP during an acute inflammatory process and other diseases. (9, 14)

Monitoring fat-soluble vitamins is necessary to indicate if the patient is able to absorb fats. Lastly monitoring electrolytes, such as sodium, potassium, chloride, phosphorus, magnesium, and calcium is also important for monitoring hydration status and acid base balance. (9,14)

When a patient is undergoing chemotherapy the patient’s white blood cell count can become very low due to the failure of the bone marrow to produce more cells. During times that white blood cells are low the patient is considered to be under neutropenic precautions meaning the patient is very vulnerable to infection and cannot effectively fight infections. The platelet count may also be low during this time. Platelets are essential for blood clotting; platelet count can be used to monitor the course of a disease such as thrombocytopenia or bone marrow failure. (9, 14)

Palliative Care and Hospice

When the patient is looking for symptomatic relief rather than a cure palliative care is an option. The focus of palliative care is to prevent, treat, reduce, or remove discomfort. Length of life and quality of life are equally important when talking about palliative care. Palliative care respects the cycle of life and recognizes death as a natural end of life cycle.

Hospice is appropriate for patients wanting high quality end of life during the last months, day, and hours of life. Life expectancy for these patients is generally no longer than six months. Hospice focuses on relieving symptoms and increasing comfort. (15)

Medical Nutrition Therapy

An interdisciplinary approach to the treatment of pancreatic cancer is necessary for optimal outcomes; once pancreatic cancer is diagnosed there are many nutritional implications that can compromise the patient’s outcome. The advice of a registered dietitian can help prevent nutritional deficiencies, preserve lean body mass, reduce and control nausea and vomiting, control side effects of therapies, manage pancreatic cancer related diabetes, manage nutrition support and weaning of nutrition support, and maximize the patients quality of life. (9) When pancreatic cancer is present, many conditions that affect nutritional status occur including malabsorption, anorexia, early satiety, abdominal pain, and constipation from medications, and pancreatic fistula, to name a few. Physical observations of a patient may reveal the presence of dehydration and cachexia, which typically occurs with advanced stages. All of the factors previously mentioned are necessary to consider when assessing the patient and choosing the most appropriate nutrition. (9, 15, 16)

Nutrition Implications of Cancer

Cancer is a catabolic disease and process. Cancer cachexia is very common among cancer patients; this wasting syndrome is characterized by weight loss, anorexia, early satiety, progressive debilitation, and malnutrition. Tumor factors such as proteolysis-inducing factor, tumor necrosis factor, and lipid mobilizing factor all promote catabolism. High protein turnover and loss of nitrogen, significant loss of muscle mass, and impaired physical capacity are common in malnourished cancer patients. A loss of lean body mass due to mobilization of protein stores is common, as well as altered nutrient utilization causing glucose intolerance, insulin resistance, increased glucose turnover, lipolysis, hyperlipidemia, and increased protein turnover. Cachexia is typically characterized by a disproportionate loss of muscle mass, involuntary weight loss greater than 5% within 6 months, typically low serum albumin, and increase serum C-reactive protein. (9)

Nutrition status of patients with cancer can vary. When beginning cancer therapy patients with anorexia, weight loss, and other symptoms of nutritional problems may complicate the treatments and expected recovery. In addition some patients may have preexisting comorbid diseases that may further complicate treatment. Cancer patients that best tolerate treatments and have better recovery are those who typically have had early interventions to side effects, maintained their weight, and maintained nutritional stores. (4) Many cancer patients experience a decrease in food and beverage intake, which many times are due to a decrease in appetite, change in small and taste, nausea, vomiting, diarrhea, and lethargy. It is important for cancer patients to maintain a well balanced diet, providing them with adequate calories, proteins, fluids, vitamins and minerals. (4, 9)

Nutrition Assessment

The nutrition assessment of a patient includes an evaluation of calorie, protein, and fluid needs, as well as an evaluation for the need of pancreatic enzymes, acknowledging anorexia, and among other nutritional assessments evaluating for malnutrition. When calculating patient’s nutritional needs it is important to consider an individual’s diagnosis, comorbidities, anticancer therapies, and the presence of fever, infection. Nutrition requirements for cancer patients are determined based on the individual patient as well as cancer-specific requirements. Many patients have typical needs of 25-30kcal/kg to maintain their body weight. However, some patients have an increase resting energy expenditure, which increases their nutritional needs. Energy needs can typically be calculated at 30kcal/kg of body weight for maintaining weight or at 35-45kcal/kg of body weight if a patient has lost weight, is febrile, septic, or very active. Other equations are available to calculate energy needs; using indirect calorimetry is ideal to determine energy needs. (3, 9)

Protein needs may be higher for cancer patients, to maintain body weight 1.0 – 1.5gm/kg is needed where as for repletion of lean body mass 1.5 – 2.0gm/kg would be appropriate to protect against muscle wasting, malnutrition, cachexia, and losses from treatments. When assessing protein needs it is important to take into consideration if the patient’s body is under stress, experiencing malnutrition, and the extent of the cancer. Protein needs are generally increased when the body is under stress due to its many important functions, including maintaining a healthy immune system and repairing tissues. (3, 9)

Appropriate fluid intake to avoid dehydration is also important; consuming 1ml/kcal is typically appropriate. When calculating fluid requirements, it is important to ensure the patient is maintaining hydration and electrolyte balance. It is also necessary to take into consideration fever, ascites, edema, vomiting, diarrhea, IV fluids, impaired renal function, and medications when determining fluid needs. (6, 9)

It is important to monitor for weight loss; weight loss can contribute to fatigue, delay in the length of recovery, and adversely affect quality of life. Reevaluation of patient’s nutritional needs is necessary to ensure the appropriate amounts of calories, proteins, and fluids are being provided. (6, 9)

Pancreatic insufficiency is common when diagnosed with pancreatic cancer, when this occurs the pancreas is unable to secrete enzymes needed for digestion. Typically the Whipple procedure, total pancreatectomy, blockage or narrowing of the pancreatic or biliary duct, or pancreatic or duodenal tumors can specifically cause the need for pancreatic enzymes. Patients should consider initiation of pancreatic enzymes when they have feelings of indigestion, cramping after meals, large amounts of gas, foul smelling gas or stools, floating or fatty stools, frequent stools, loose stools, and weight loss. In addition to taking the pancreatic enzymes for pancreatic insufficiency medium chain triglycerides, fat-soluble vitamins, and essential fatty acids should also be included to prevent deficiencies due to possible malabsorption of fats. According to the Academy of Nutrition and Dietetics supplementation of Omega-3 fatty acids has not been shown to have anticachetic effects leading to changes in body composition and is not recommended for patients with pancreatic caner. Eicosapentaenoic acid also was not associated with an increase in lean body mass. In addition the use of eicosapentaenoic acid after 12 weeks of supplementation did not show a decrease in C-reactive protein. (9, 15, 16, 17)

Malnutrition and Cancer

Anorexia can become a serious problem and progress to cause malnutrition for patients with pancreatic cancer. Although a lack of appetite can be increased through medications it may first be appropriate to try adding nutritional supplements in between meals, increase the calorie contents of foods, and eat small frequent meals throughout the day. The etiology of the anorexia is important when providing recommendations. Abdominal and back pains caused by pancreatic cancer may also cause the patient to have anorexia, the use of pain medications in this scenario may help decrease the patient’s anorexia. In addition to anorexia, delayed gastric emptying may become a concern for the patient, which would cause early satiety. It is important to avoid simple sugars when having delayed gastric emptying and consuming about six to eight small meals per day. (9, 15)

Malnutrition is a common problem that may arise for many reasons with pancreatic cancer patients. One indicator for malnutrition is BMI, a BMI of 18.5kg/m2 or less indicates a patient is underweight. However, BMI is not the only indicator for malnutrition and individuals with a healthy BMI or are considered overweight and obese may be malnourished. Many laboratory tests also can help indicate malnutrition, such as low levels of albumin, prealbumin, total protein, C-reactive protein, transferrin saturation, lymphocytes, and electrolytes. In addition the Subjective Global Assessment, SGA, is a tool that is found to be predictive of nutrition associated complications. The SGA identifies malnutrition, distinguishes malnutrition from a disease state, predicts outcomes, and identifies patients in whom nutritional therapy can alter outcomes. Malnutrition may also be identified when a patient is losing weight or has an alteration in gastrointestinal symptoms, such as vomiting and diarrhea. Malnutrition requires an increase in a patients calories and protein needs. (9)

Surgery and Nutrition

As discussed previously there are several surgical options for pancreatic cancer patients. Including the Whipple procedure, pylorus preserving Whipple procedure, distal pancreatectomy, and a total pancreatectomy. All of these surgeries cause an alteration of the gastrointestinal tract and initially require additional nutrition recommendations. Following surgery, one complication that can occur is the formation of a pancreatic fistula, when this occurs there may be leakage of pancreatic secretions from disrupted pancreatic ducts from the site of the resection. Pancreatic fistulas can lead to morbidity due to malnutrition and infection. The majority of patients with pancreatic fistulas can be managed with either maintenance of an oral diet or parenteral nutrition until closure of the fistula depending on the patient’s condition. (18,19,20)

Following the Whipple procedure the most common complication is delayed gastric emptying, which typically resolves in 7-10days but could last a few weeks. If the patient is not receiving adequate nutrition, enteral nutrition support may be considered. The patient may also experience digestive difficulties, requiring the use of pancreatic enzymes. Initially the patient will only eat small amounts of easily digestible foods. Parenteral nutrition is not necessarily required following this procedure and many patients show better outcomes from standard nutrition. Diarrhea is also a common problem for the fist few months after the procedure. Most patients will experience weight loss, however to avoid malnutrition it may be necessary to consume supplements between meals. Diabetes may also develop depending on how much of the pancreas was removed and how many insulin producing cells were removed. The same complications occur following the pylorus preserving Whipple procedure, however some studies have shown increased delayed gastric empty following the pylorus preserving procedure. (15,18, 21,22)

The distal pancreatectomy has minimal nutrition complications compared to the other procedures. However the total pancreatectomy has the most nutritional implication following the procedure. The patient will have diabetes and require insulin injections following the procedure due to the entire pancreas being removed, in addition the patient will lack pancreatic digestive juices and with everything consumed will need to take pancreatic enzymes for proper digestion of food. With total pancreatectomy vitamin B12 supplementation may be required, particularly with steatorrhea. (15)

Postoperative feeding can be done through enteral feeds supplemented with fiber and a combination of prebiotics and probiotics administered through a jejunostomy. This may reduce infections and antibiotic use. If enteral nutrition is not possible, parenteral nutrition should be initiated in critically ill patients who are malnourished with a weight loss of more than 10% prior to admission or if the patient is less than 90% of their ideal body weight. If enteral nutrition is not possible, parental nutrition is to be used, the parenteral nutrition should be provided for five to seven days preoperatively and continued into the postoperative period. Only initiate parenteral nutrition if support is to be provided for seven or more days. (16)

Chemotherapy, Targeted Therapy, and Radiation: Nutrition Implications

Chemotherapy, as previously discussed, kills rapidly dividing cells, which can cause many nutritional complications. Some nutrition related side effect include anemia, neutropenia, electrolyte imbalance, constipation, diarrhea, malabsorption, dysphagia, stomatitis, mucositis, dehydration, nausea, vomiting, anorexia, dysgeusia, fatigue, weight loss, and pain. Management of these side effects can help improve outcomes and improve the patient’s quality of life. When these side effects of chemotherapy are present, the patient may become malnourished and decline in overall health if not appropriately handled. There are many techniques to help resolve these side effects. As with chemotherapy, targeted therapy has similar but less, nutritional side effects. The side effects include fatigue, loss of appetite, nausea, and diarrhea. As with many drugs the severity of the side effects depends on the dose of the drug and the duration of its use. (9, 15, 16, 23)

Radiation therapy’s effects can build up over time with additional treatments. The side effects include loss of appetite, nausea, diarrhea, and fatigue. The side effects typically peak at four to five weeks after the initial treatment and resolve within one to two weeks after the treatment is complete. Skin redness may occur as well as “burning” of the skin and within the abdomen, this may occurs after multiple treatments, however it is less likely in pancreatic cancer patients. If burning occurs, the patient may have discomfort during meals and therefore have a decreased intake. (9, 15, 16, 23)

When a patient is being treated with chemotherapy, targeted therapy, and radiation, it is important to control side effects. If the side effects are not addressed, the patient may decline due to their interrelationship. For example if a patient is experiencing vomiting and diarrhea the patient may subsequently become dehydrated, malnourished, and experience weight loss.

Oral Intake and Aggressive Feeding

Oral feeding is the optimal feeding technique unless contraindicated. The patient should feed orally if possible. If the patient’s intake decreases it is necessary to determine the cause of the decreased intake. Individuals experiencing early satiety, anorexia, and alteration in taste, xerostomia, mucositis, nausea, diarrhea, fatigue, or depression may require eating foods high in energy, protein, and micronutrients to help maintain nutritional status. (4,9,21)

Poor appetite or loss of appetite is a common problem with cancer patients, the cause being multifactorial. Cancer itself, cancer treatment, and psychosocial factors may all effect appetite. Consuming frequent high calorie meals and snacks that are easy to prepare may be helpful in addition to eating in a clam and comfortable environment. Planning a daily menu in advance, arranging for help in preparing meals, and adding extra protein and calories to foods is also helpful. (4,13,23)

Alternations in smell and taste are related to unknown effects of cancer, treatments, mucositis, thrush, or medications. Change in taste, or dysgeusia, can result in food avoidance, including weight loss and anorexia. Changing the types of foods eaten as well as adding additional spices may help improve the taste of food. Rinsing the mouth prior to eating may help improve the taste of foods. If the taste of metal is bothersome using plastic utensils may be helpful. It may also be helpful to have someone else prepare meals to avoid strong scents. In addition if food aroma is a problem consuming cold foods may be helpful. (4, 9, 23)

Xerostomia is a condition of dry mouth and commonly is caused by radiation especially to the head and neck area. Dry mouth may affect taste sensation and ability to swallow. Drinking plenty of liquids and eating moist foods with extra sauces, gravies, butter, or margarine is helpful. Hard candies, frozen desserts, and ice chips can also help. Consuming very sweet or tart foods and beverages may help stimulate saliva. (4, 9, 23)

Sore mouth is caused when rapidly dividing cells inside the mouth are damaged by treatments such as chemotherapy and radiation therapy. Patients may be more susceptible to infection and bleeding in their mouth. It may be easier to eat when carefully choosing foods and taking good care of their mouths. The best foods to choose are foods that are soft, easy to chew and swallow, and nonirritating. Acidic, spicy, salty, and coarse-textured foods are considered irritants. (4,9,23)

Nausea is a very common problem of all cancer patients. Eating before treatments is important, as well as identifying foods that trigger nausea. Nausea is typically caused by spicy, greasy, and strong odor foods. Frequent eating and slowly sipping fluids is helpful. In addition eating bland, soft, and easily digestible foods may help in addition to sitting up or recline with a raised head for one hour after eating. If nausea is persistent, nausea medication may help. (4,9,23)

Diarrhea is caused by radiation, chemotherapy, gastrointestinal surgery, or emotional distress. It is necessary to maintain hydration status and electrolyte balance when having diarrhea to avoid hyponatremia, hypokalemia, and dehydration. Greasy foods, hot or cold liquids, and caffeine may worsen diarrhea. Drinking one cup of liquid following each loose bowel movement will help prevent dehydration. In addition consuming broth, soups, sports drinks, bananas, and canned fruits may help replenish electrolytes. (4,9,23)

At times patient’s may find eating to be exhausting but should be encouraged to try eating; resting before and after meals may help eating be less exhausting. Due to the poor prognosis of pancreatic cancer, many patients may feel depressed and have little desire to eat. Talking about feelings and fears may make emotions more manageable. (4,9,23)

Nutritional Supplements and Appetite Stimulants

When the patient is not hungry for solid foods, high calorie beverages and supplements can always be consumed. Nutritional supplements such as Ensure, Boost, Carnation Instant Breakfast, and Magic Cup can help increase calories and protein intake. These are especially helpful for patients who do not have an appetite or who cannot consume enough calories in a day. (3, 9)

Appetite stimulants are appropriate for patients with no appetite and who have nausea and vomiting under control. Appetite stimulants include medications such as Dronabinol, Megestrol Acetate, and Anabolic Steroids such as, Oxandrolone, Nandrolone, and Decanoate. Dronabinol is a marijuana derivative, which takes on average four to six weeks to show effects; patients may experience extreme tiredness and impaired memory when taking this drug. Megestrol Acetate, also known as Megace, is useful for stimulating appetite. The dose of Megace needed to stimulate appetite is typically 800mg/day. Anabolic steroids use for appetite stimulation, known as Oxandrin, is a synthetic testosterone that promotes weight gain and increased muscle mass. However, hepatic changes or tumors have been reported. Elevation of low-density lipoprotein can occur with prolonged used causing possible cardiovascular effects. (9, 24, 25)

Enteral and Parenteral Nutrition Support

When adequate oral intake is not possible, supplemental feeds may be initiated through enteral nutrition. If the patient cannot feed orally and their gastrointestinal tract is functional enteral feeds would be initiated at that time as well. When malnutrition is of concern, the patient may require supplemental enteral nutrition feeding. Patients may require either short-term enteral feedings or may require long-term enteral nutrition. Short-tern enteral nutrition would require a nasogastric or a nasojejunal tube. Long-term enteral nutrition is indicated when enteral nutrition is required for three to four weeks, a gastrostomy or jejunostomy feeding tube should place. Contraindications for enteral nutrition include malfunctioning gastrointestinal tract, malabsorptive conditions, mechanical obstructions, severe bleeding, severe diarrhea, intractable vomiting, gastrointestinal fistula in locations difficult to bypass with an enteral tube, inflammatory bowel process, or overall prognosis not consistent with aggressive nutrition support. Enteral nutrition generally has fewer complications than parenteral nutrition and helps maintain the function of the gut. If enteral nutrition is indicated a formula is chosen based on the patients nutritional needs, comorbid conditions, and energy and protein content needs among other factors. (4,9)

However, if the patient does not have a functioning gastrointestinal tract, parenteral nutrition can be initiated. Parenteral nutrition may also be required if the patient requires short-term supplemental nutrition but is experiencing thrush, mucositis, or esophagitis and a temporary tube cannot be replaced. Complications from parenteral nutrition can occur including fluid overload, hyperglycemia, electrolyte imbalance, and infections. If parenteral nutrition is indicated, either a central or peripheral intravenous line must be placed. Central lines can tolerate a higher osmolality solution, allowing for more calories and protein to be administered at one time. (4,9)

Nutrition support is generally indicated when treatment options are aggressive. When patients are considering less aggressive treatments or are looking for comfort measure nutrition support may not be initiated. However, for patients who start with aggressive treatments and nutrition support, nutrition support may be maintained while receiving comfort care. (4)

Palliative Care and Hospice: Nutrition

When a patient and their family decide for palliative care or hospice the focus of nutrition becomes comfort care. Palliative care will provide nutrition for the patient, however the focus is on pleasure and not on providing enough nutrients for the patient. The goal of palliative care is to treat and prevent symptoms, side effects, and psychological, social, and spiritual concerns caused by the cancer or the treatment. However hospice care focuses on providing a high quality of life during the last months of life. The nutrition and hydration of the patient is based on the patient and caregivers wishes. (4,15)

Presentation of the Patient

October 5, 2012 DR was admitted to St. Mary’s Medical Center for nausea, vomiting, abdominal pain and diarrhea. She is a 72 year old Caucasian female, who lives at home with her husband and prepares the meals for her husband. DR’s past medical history includes transient ischemic attack, angina, coronary stent, hypercholesterolemia, hypertension, deep venous thrombosis in her right leg, gastroesophageal reflux disease, renal disease, urinary tract infection, spinal stenosis, spinal fusion, and type 2 diabetes. DR was having nausea, vomiting, abdominal pain, and diarrhea for several months prior to admission and had a thirty-pound weight loss. The CAT scan done on admission revealed multiple liver metastases as well as a mass in the head of the pancreas. Prior to admission the patient underwent an ERCP and biliary stent at Jefferson University Hospital. The ERCP revealed Stage IV pancreatic cancer involving the liver and pancreatic head with obstructive jaundice.

Hospital Course

• October 4, 2012: The patient arrived at St. Mary’s Medical Center’s ER complaining of nausea, vomiting, abdominal pain, and diarrhea. She also reports having a thirty-pound weight loss in the past six months. A CAT scan was done and revealed diffuse lobular pancreatic enlargement with diffuse infiltrative masses compatible with neoplasm, presumably adenocarcinoma, which biopsy previously confirmed. Liver metastases and ascites were also noted.

• October 6, 2012: The patient is jaundiced but currently has no further nausea and vomiting. The patient underwent an abdominal ultrasound revealing multiple intrahepatic masses, the 8mm common bile duct stent is in position, and there is no persistent or recurrent bilary ductal dilatation, additional small amounts of ascites are noted. The patient currently taking Omeprazole, Lovenox, Zofran, Morphine, Loperamide, and Sliding Scale Insulin.

• October 8, 2012: A CT scan was done showing stable pancreatic mass with local porta hepatis nodes. New pleural effusions, ascites, and anasarca are also noted.

• October 10, 2012: At this time DR had an access port placed. During the day the patient had significant abdominal pain, discomfort and nausea. At this time the patient’s medications include Bacitracin, Lantus, Omeprazole, Lovenox, Zofran, Morphine, Loperamide, Pancrelipase, and Novolog.

• October 15, 2012: The patient received 250ml packed red blood cell transfusion.

• October 16, 2012: DR continues to have nausea. The physician states the prognosis of the patient is poor. Medications include Promethazine, Procrit, Zofran, Dilaudid, Norvasc, Ativan, Lantus, Omeprazole, Pancrelipase, and Novolog.

• October 17, 2012: The patient received 250ml packed red blood cell transfusion.

• October 18, 2012: The patient received 125ml packed red blood cells and 256ml of platelet cell transfusion.

• October 21, 2012: The physician initiated total parenteral nutrition. DR had tenting of the skin, decreased breathing, abdomen soft and distended with tenderness, as well as +1 pitting edema. The patient looks cachectic and has moderate discomfort. The patient’s blood counts are improving after receiving chemotherapy, cycle 1, with Gemcitabine. The physician plans to wait for the patient’s platelet count to increase over 75,000mcL and may consider 5-FU- oxaliplatin. The physician plans to add insulin to the TPN as well as taper down the TPN.

• October 22, 2012: The physician states the patient has improving appetite and remains on TPN, however plan to discontinue by half. The patient has extremity swelling causing her difficulties to ambulate. The patient also has significant anasarca. The patient is stating she wants to go home, however her husband feels he cannot take care of her. DR does not want to go to a skilled nursing facility and wants to remain a full code. Today patient’s husband toured Chandler Hall, an inpatient hospice center.

• October 23, 2012: TPN is running at half strength.

• October 24, 2012: The patient has a poor prognosis, and is status post one cycle of chemotherapy, has hypoalbuminemia, and anasarca. The patient is discharged to hospice with metastatic pancreatic cancer, +3 pitting edema, diffuse anasarca, malnutrition requiring TPN, thrombocytopenia, anemia, neutropenia, hyperglycemia, hypoglycemia, pancreatic insufficiency, liver failure with elevated bilirubin levels.

Patient’s Lab Values

Throughout the patient’s hospital course her lab work was monitored. For lab values refer to table 3 in the appendix. Upon admission, the patient’s bilirubin, liver enzymes, and glucose levels were elevated, in addition the patient’s albumin level was low. A few days following DR’s admission, her CA 19-9 Antigen was at 52704units/mL, normal values are less than 34units/mL, this antigen is a marker for pancreatic cancer. The patient’s glucose levels ranged from 378mg/dL to 42mg/dL throughout her hospital course; as DR’s hospital stay progressed her glucose levels remained high until her last glucose level, which was very low. The patient’s bilirubin levels decreased but were still elevated, the decrease may have been due to the stent the patient had placed prior to admission. The patients liver enzymes remained elevated and increased throughout her stay, which may have been due to the metastasis of the cancer to her liver. DR’s albumin levels remained low throughout her stay and the only prealbumin value was also very low at 4.0mg/dL. Lastly DR’s platelet count and white blood cells decreased throughout her stay, this was possibly due to her chemotherapy treatments.

Nutrition Course of the Patient

Assessment: On October 5th, DR was experiencing nausea and vomiting and had lost 30 pounds in six months. DR’s weight loss of 23% in six months is considered significant. When speaking with the patient she states she has had nausea, vomiting, diarrhea, and a decrease in appetite for several months and has been experiencing some pain. DR’s weight at the time of visit was 47kg, height of 157cm, and BMI of 19kg/m2. Due to DR’s low BMI, recent weight loss, and recent nausea, vomiting, and diarrhea, her energy and protein needs were estimated at 30-35kcal/kg and 1.2-1.3gm of protein/kg; DR’s needs were calculated to be 1410-1645kcal and 56-61gm of protein. Diagnosis: Inadequate oral intake related to metastatic pancreatic cancer as evidenced by a significant weight loss of 23% in 6 months. Intervention: Recommend a regular diet with Ensure Plus twice a day and consuming at least 75% of meals. Recommend weighing patient two times per week. Monitor and Evaluate: Monitor meal intake percentages and patient’s intake of Ensure Plus twice daily. Additionally monitor DR’s weight.

Assessment: On October 8th, DR’s appetite had not improved since October 5th. Her meal intakes were fair, consuming about 25-50% of meals. DR is expected to start chemotherapy soon. Her needs were kept the same as her initial assessment. Diagnosis: Inadequate oral intake related to patient with no appetite as evidence by patient consuming 25-50% of meals. Intervention: Encouraged patient to try consuming small frequent meals, recommended to continue drinking Ensure Plus twice daily, and continue with the anti-nausea medication. Recommend weighing patient 2x per week. Megace was recommended if DR’s intake did not improve. Monitor and Evaluate: Monitor tolerance to diet, monitor blood glucose levels. Monitor weights two times per week. The patient was followed up with again on October 11th with no significant changes noted.

Assessment: On October 15th, DR stated she was ordering small amounts of food, and having intermittent nausea and vomiting. The patient received chemotherapy on October 10th. DR is now taking pancreatic enzymes. High calorie supplements were discussed with the patient, who expressed her concern about not consuming enough solid foods and was also concerned about controlling her nausea. Diagnosis: Inadequate oral intake related to chemotherapy and pancreatic cancer as evidence by poor meal intakes, weight loss, and intermittent nausea. Intervention: Encourage small frequent meals and consumption of Ensure Plus twice a day, weigh twice a week, control nausea with medications. Monitor and Evaluate: Monitor patient’s intake and the need for an appetite stimulant, as well as recommend small frequent meals, and control of nausea.

Assessment: At DR’s next follow up on October 18th, it was noted the physician initiated TPN. Through a central line, the patient was receiving a TPN solution containing 70% carbohydrates, 30% lipids, and 1.2gm of protein/kg. DR’s oral intake decreased to poor intake, consuming less than 25% of meals. At this time DR’s albumin was 1.1gm/dL and glucose of 169mg/dL. DR at the time of the visit had inadequate meal intakes, had initiated TPN, and decreased serum protein. DR was experiencing excessive fluid overload, edema, and elevated blood glucose levels. Recommended to consider a nasojejunal tube for nutrition support rather than TPN. Diagnosis: Inadequate oral intake related to patient has nausea, vomiting, and no appetite as evidence by patient consuming less than 25% of meals and initiated on TPN. Intervention: Continue to encourage small frequent meals, continue consume Ensure Plus twice daily, and weigh patient 2x per week. Monitor and Evaluate: Monitor patient’s weight and continue to monitor meal intakes. Monitor tolerance to TPN, may want to consider discontinuing TPN and initiating nasojejunal feeds.

October 22nd was DR’s final follow up assessment. Assessment: DR was still consuming only fair intake, albumin of 1.2mg/dL and prealbumin of 4mg/dL. The patient was still receiving TPN at this time. She expressed concern that she was not receiving enough oral nutrition. The physician at this time is noting the patient to have a poor prognosis and plans to wean DR from TPN. The TPN is contributing to fluid retention and weight gain. The patient is currently receiving Lasix and Aldactone. The patient and patient’s family are thinking of hospice. Diagnosis: Inadequate oral intake, related to poor appetite, nausea, and vomiting, as evidence by patient consuming less than 25% of meals. Interventions: Recommend discontinuing TPN and providing a regular house diet. Monitor and Evaluation: Will monitor meal intakes, watch for weaning of TPN, and will monitor for the plan of care.

Critical Comments

After researching the topic of pancreatic cancer and learning all of the nutritional implications, there are several things I would change about her nutritional care. It would have been beneficial to speak with the nurses and physicians at further lengths to discuss the patient’s nutrition and plan of care. Making sure the patient was receiving Zofran as needed, as well as explain different techniques to the patient regarding reducing nausea. Additionally ensuring the patient was receiving the pancreatic enzymes at the appropriate time may have helped the patient with digestion of food. Talking with the attending physician may have prevented the initiation of TPN, which was not appropriate for this patient. Speaking with the physician at further lengths may have encouraged the use of a tube feeding for supplemental feedings, which may have improved outcome or quality of life. A multidisciplinary care approach as well as acting as a patient advocate could have contributed to an optimal outcome.

Monitoring DR’s labs more closely may have been beneficial, the patient’s albumin and prealbumin remained very low, and liver enzymes increased over her time of stay. Additionally checking the C-reactive protein and transferrin saturation may have provided additional information on the patient’s nutritional status. Although DR was not consuming sufficient nutrition, regardless it may have been more appropriate when calculating the patients needs to adjust the patient’s body weight for ascites, which the patient presented with on admission.

Additionally I would have reassessed the patient’s needs and would have recommended additional nutritional supplements and oral intake before initiating TPN. After the initiation of TPN the patients triglycerides were elevated, glucose was high, as well as increased liver enzymes. The patient also had fluid overload while on TPN. When TPN was initiated and throughout the time she was receiving TPN, DR’s white blood cells were low, which increased her risk of infection with TPN. Expressing these concerns with the physician would have been appropriate.

After researching pancreatic cancer, it is necessary to consider that the patient had Stage IV pancreatic cancer. This cancer was unresectable, and chemotherapy was her only option. Comfort measures were possibly all that could have been done in this case. Helping the patient overcome pain, nausea, vomiting and diarrhea through comfort measures may have improved DR’s meal intake as well as improve her quality of life.

Summary

Many nutrition implications of pancreatic cancer can arise depending on the type of pancreatic cancer, stage of cancer, and the treatments that may be provided. An individualized plan of care is needed for patients because no two patients are the same. The nutritional status of an individual throughout their course of treatment is important for recovery and quality of life. It is necessary to also inquire as to why a patient is having nutritional problems and find ways to help the patient achieve a solution. Always remembering to have a multidisciplinary approach and patient centered care is key for optimal outcomes.

Glossary of Pertinent Medical Terms

Antigen: Antigens cause the immune system to make antibodies against the antigen.

Carcinoma in situ: A group of abnormal cells that remain in the place where they first formed. They have not spread. These abnormal cells may become cancerous and spread into nearby normal tissue. Also called stage 0 disease.

Computed Tomography Scan: Also known as a CT scan. This is a technique that combines a series of x-rays to create cross-sectional images of the bones and soft tissues within the body.

C-Reactive Protein: Abbreviated CRP is a protein produced by the liver and found in the blood. CRP increases after an injury, infection, or inflammation and decreases when the injury heals or infection or inflammation clears.

DNA: Deoxyribonucleic acid is the heredity material within cells; DNA provides the instructions for development and function of cells.

Eicosapentaenoic Acid: Abbreviated EPA, a type of Omega-3 fatty acid with 20 carbon atoms, commonly found in fish.

Endoscopic Retrograde Cholangiopancreatography: Also known as an ERCP, this test combines the use of an endoscope with an x-ray to examine the tubes that drain the liver, gallbladder, and pancreas.

Endoscopic Ultrasound: Also known as EUS, this procedure combines an endoscopy and an ultrasound to obtain images of the digestive tract and surrounding organs.

Eosinophils: Type of white blood cell produced in the bone marrow and migrates to tissues. Different types of white blood cells release substances when foreign substances enter the body; the substances released from the other white blood cells attract eosinophils, which release toxic substances to kill invading substances.

Esophageal Varices: These are abnormally enlarged and extremely dilated veins in the lower esophagus.

Fistula: An abnormal or surgically made passage between a hollow organ and the body surface, or between two hollow organs.

Fluorouracil: Also known as 5-FU, is an antimetabolite used as an Antineoplastic agent.

Gastric Varices: These are abnormally enlarged and extremely dilated veins in the stomach, typically in the fundus and cardia, which are located at the top portion of the stomach below the esophagus.

Laparotomy: A laparotomy is a procedure to explore the organs within the abdomen. A surgical incision is made into the abdomen wall.

Magnetic Resonance Cholangiopancreatography: Also known as a MRCP, this is an imaging technique using magnetic resonance imaging to visualize the biliary and pancreatic ducts.

Magnetic Resonance Imaging: Also known as an MRI, this test using a magnetic field and pulses of radio wave energy to produce pictures of organs and structures inside the body.

Mucin: This is a glycoprotein component of mucus.

Non-Steroidal Anti-Inflammatory Drugs: Abbreviated NSAIDs, these are medicines that relieve pain, swelling, stiffness, and inflammation.

Oxaliplatin: An Antineoplastic agent used to treat metastatic carcinoma with 5-FU.

Portal Vein: This is a large vein that brings blood from the digestive organs, spleen, pancreas, and gallbladder to the liver.

Pylorus: This is the lower part of the stomach that connects the stomach to the duodenum.

Splenomegaly: Is an enlargement of the spleen, an organ, which is involved in the production and removal of blood cells, also forming part of the immune system.

Tumor Necrosis Factor: Abbreviated TNF, is a proinflammatory cytokine that is produced by white blood cells; has an antineoplastic effect; one of multiple proteins capable of inducing necrosis of tumor cells that possess a wide range of proinflammatory actions.

Xerostomia: Abnormal dryness of the mouth resulting from decreased secretion of saliva.

Medication Bibliography

|Medications |Indication |Contraindication |Food-Drug Interaction |

|Aldactone (Spironolactone) |Ascites from cirrhosis |Anuria. Caution with renal impairment,|Take with meals or milk to decrease GI|

| | |hyponatremia, diabetes mellitus, and |irritation and increase absorption. |

| | |elderly patients. |Avoid natural licorice. May cause dry |

| | | |mouth, nausea, vomiting, gastritis, |

| | | |cramps, and diarrhea. |

|Ativan |Anxiety with depression |Caution with respiratory impairment, |May take with food if GI distress |

|(Lorazepam) | |central nervous system depression, |occurs. Limit caffeine to |

| | |seizure history, renal impairment, | ................
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