Nutrition and Acute Pancreatitis



Michelle Smith | 2013Major Case StudyNutrition and Acute PancreatitisTable of Contents TOC \o "1-3" \h \z \u Introduction PAGEREF _Toc346484530 \h 4Social History PAGEREF _Toc346484531 \h 4Normal Anatomy and Physiology of Applicable Body Functions PAGEREF _Toc346484532 \h 5Past Medical History PAGEREF _Toc346484533 \h 5Present Medical Status and Treatment PAGEREF _Toc346484534 \h 6Theoretical Discussion of Disease Condition PAGEREF _Toc346484535 \h 6Usual Treatment of the Condition PAGEREF _Toc346484536 \h 7Nutrition Treatment PAGEREF _Toc346484537 \h 7Medical Treatment PAGEREF _Toc346484538 \h 8Patient’s Symptoms upon Admission Leading to Present Diagnosis PAGEREF _Toc346484539 \h 8Laboratory Findings and Interpretation PAGEREF _Toc346484540 \h 8Medications PAGEREF _Toc346484541 \h 9Observable Physical and Psychological Changes in Patient PAGEREF _Toc346484542 \h 9Treatment PAGEREF _Toc346484543 \h 10Medical PAGEREF _Toc346484544 \h 10Surgical PAGEREF _Toc346484545 \h 10Medical Nutrition Therapy PAGEREF _Toc346484546 \h 11Nutrition History PAGEREF _Toc346484547 \h 11Analysis of Previous Diet (24 hour recall) PAGEREF _Toc346484548 \h 11Current Prescribed Diet & Responses PAGEREF _Toc346484549 \h 11Nutrition-Related Problems PAGEREF _Toc346484550 \h 12Evaluation of Present Nutritional Status PAGEREF _Toc346484551 \h 12Other Nutrients to Address PAGEREF _Toc346484552 \h 12Patient’s Nutrition Education Process PAGEREF _Toc346484553 \h 13General Conditions upon Discharge PAGEREF _Toc346484554 \h 13Emerging Research Relevant to Patient PAGEREF _Toc346484555 \h 13Smoking and Pancreatitis PAGEREF _Toc346484556 \h 13Prognosis PAGEREF _Toc346484557 \h 14Summary & Conclusion PAGEREF _Toc346484558 \h 14Appendix A – Lab Values PAGEREF _Toc346484559 \h 16Appendix B - Medications PAGEREF _Toc346484560 \h 18Bibliography PAGEREF _Toc346484561 \h 19IntroductionThe patient chosen for this case study, JL, is a 53 year old Caucasian female who has been diagnosed with acute pancreatitis. The patient also suffers from alcohol abuse and has gallstones. The height of the patient is 5 feet 4 inches (162.56 cm) and she weighs 103 pounds (46.95 kg). The patient was chosen for the case study because she had a nutrition-related diagnosis that often requires enteral or parenteral nutrition support. The patient has been in and out of the hospital starting back in June of 2011 with initial complaints of nausea, vomiting, and abdominal pain. She was diagnosed with pancreatitis one year later in June of 2012. She was recently re-admitted on January 1, 2013 with the same complaints of nausea, vomiting, and abdominal pain for the past five days and had been unable to eat during that time. The study ended January 11, 2013, when the patient was discharged.Social History The patient is unemployed and relies on social security as her sole source of income. She is not married but does have a boyfriend that she lives with. When asked if she has any children, her first response was no. The patient later stated she has two sons, ages 26 and 30, but they are out of the house and they don’t keep in touch. She has trouble walking and therefore has few responsibilities at home. The patient has a low standard of living with a corresponding poor home environment. She admits to drinking 6 or 7 vodka beverages a day which is down from the half gallon of vodka she used to drink everyday a year ago. She is a heavy smoker, going through one to two packs a day for the past 30 years. She is does not have any religious affiliations and therefore has no special religious dietary guidelines to follow. Normal Anatomy and Physiology of Applicable Body FunctionsThe pancreas is located in the abdomen behind the stomach and near the duodenum. There are five main parts to the pancreas, the body, head, neck, tail, and uncinate. The pancreas is also made up of a system of ducts, the main one called the pancreatic duct. The pancreas has two functional components. They are called endocrine and exocrine parts. The exocrine part contains acinar cells that are responsible for secreting enzymes into the duodenum through the pancreatic duct. These enzymes are called amylase, protease, and lipase. The pancreatic duct will merge with the bile duct and activate the enzymes, enabling them to digest food. The endocrine part of pancreas contains the Islets of Langerhan cells that are responsible for regulating the levels of glucose in the bloodstream by releasing insulin and glucagon (1-3). Past Medical HistoryNoted past medical history for the patient includes asthma, chronic obstructive pulmonary disease (COPD), alcohol abuse, smoking, hypertension (HTN), angina, and a family history of cancer. It has been documented that she has been admitted to the hospital 12 times since June of 2011. Each of the 5 admitting diagnoses from June 2011 to May 2012 has included shortness of breath (SOB) and either alcohol intoxication, syncope, nausea and vomiting with abdominal pain, lower limb weakness, or right leg swelling. On June 26, 2012 she was again admitted for abdominal pain and was later diagnosed with pancreatitis. The six admitting diagnoses since then included chest tenderness, abdominal pain with nausea and vomiting, dyspnea and falls, or chest pain with palpitations. Present Medical Status and TreatmentTheoretical Discussion of Disease ConditionAcute pancreatitis is an acute inflammatory condition of the pancreas. Causes of acute pancreatitis include the presence of gallstones and chronic, heavy alcohol use (3,4). Ethanol and its metabolites have numerous effects on the pancreas such as inflammation and necrosis from cell death signaling leading to sensitizing the pancreas to pancreatitis (4). In a person with normal pancreatic function, the enzymes produced by the pancreas are inactive until they reach the intestines. In acute pancreatitis, inflammation of the pancreas will cause the enzymes to activate early thus causing further damage (3). Complications caused by acute pancreatitis include sepsis, acute renal failure, hypovolemia, circulatory shock, and pancreatic necrosis (2). There can be varying amounts of injury not only to the pancreas but also to adjacent and distant organs. It can even cause multisystemic organ failure and, ultimately, death (4,5). Acute pancreatitis is defined by a discrete episode of abdominal pain and elevations in serum enzyme levels. Symptoms of include nausea, vomiting, and diarrhea along with sudden and severe abdominal pain (2) which can decrease or even eliminate oral intake of the patient. Severe abdominal pain can be so disabling that some patients become addicted to pain medications (2). Around 25% of acute pancreatitis patients go on to develop chronic pancreatitis (2). A patient’s inability to stop drinking alcohol is the leading cause of chronic pancreatitis with alcohol abuse accounting for 70-90% of the causes of chronic pancreatitis (6).Usual Treatment of the ConditionNutrition TreatmentThere are many ways to classify acute pancreatitis but from a nutritional standpoint it is most useful to categorize patients as those with either mild or complicated pancreatitis. Seventy-five to 85% of pancreatitis diagnoses are considered mild (5). Intervention with nutritional support is usually not required in mild pancreatitis and patients often recover without intervention (4,5,7). This is due to the fact that oral intake often restarts within a few days of hospitalization. It is thought that once oral intake resumes, diet orders should be clear or full liquid and gradually increased to reduce stimulation of the pancreas (2). A recent gold-standard (prospective, randomized, controlled, double-blind clinical trial) study showed no significant differences between symptoms in patient s with mild pancreatitis that progressed to a solid food diet as opposed to clear liquid diet (8). During this time the patient should avoid pancreatic irritants, especially alcohol, nicotine, and caffeine (2). If pancreatitis is severe and oral intake is not expected to resume for greater than three days after hospitalization, nutrition support will be needed (4). It is widely recognized that the gut plays a role in maintaining immune system integrity (2) which is why the enteral route for nutrition support is preferred (9). Research has shown fewer pancreatic problems are seen in those who are enterally fed versus using total parenteral nutrition (TPN). Patients with acute pancreatitis receiving TPN have been shown to have statistically more pancreatic infection, higher mulitsystemic organ failure, and high mortality when compared to patients receiving enteral feedings (4). Noted benefits of enteral nutrition when compared to parenteral nutrition include prevention of gut bacteria translocation, alleviating oxidative stress, faster healing, and fewer complications from infections (5). Using an elemental formula has shown to have more benefits compared to standard formulas. An elemental formula causes less stimulation to the pancreas because of their low fat content (5). Enteral nutrition support may not always be tolerated by patients and parenteral nutrition may be the only recommended route available. If parenteral nutrition is chosen as the preferred route, it must be monitored to ensure the patient does not develop the complications associated with it (5). Medical TreatmentMedical treatment for acute pancreatitis includes surgeries such as necrosectomy, pancreaticoduodenectomy, or sphincterotomy (2). Surgical treatment is only performed in patients with severe acute pancreatitis to remove necrotic tissue and is not recommended within the first two weeks after initial onset of the disease (7). Patient’s Symptoms upon Admission Leading to Present DiagnosisAccording to previous notes, before admission to the hospital in June 2012, the patient was experiencing abdominal pain with nausea and vomiting. She stated that she would drink vodka to dull the pain.Laboratory Findings and InterpretationThere are many clinical indicators for acute pancreatitis. Clinical history that may be seen in a patient with acute pancreatitis include rapid heart rate, left upper quadrant abdominal pain, nausea and vomiting, steatorrhea, and results from a CT scan showing interstitial pancreatic edema. Lab work that may be seen in a patient with acute pancreatitis include lipase > 110, amylase > 250, glucose > 200 and decreased levels of potassium, sodium, calcium, and magnesium (2). Labs collected from the patient on the day the diagnosis of pancreatitis was made can be found in Appendix A. These labs shows decreased sodium and calcium levels along with increased amylase, lipase, and ethanol levels. Appendix A also contains labs showing elevated lipase and ethanol levels during previous hospital admissions. The lipase levels are consistently above 110. The ethanol values show that once the patient was diagnosed with pancreatitis and informed that alcohol consumption could make it worse, her intake of alcohol decreased considerably when she was experiencing abdominal pain. Prior to her diagnosis, she stated she would drink more alcohol to ease the abdominal pain. After her pancreatitis diagnosis the patient didn’t enter the hospital with ethanol intoxication as often as she had prior to the diagnosis.MedicationsA list of the medications the patient was on when at the hospital recently in January 2013 is provided in Appendix B. Also listed are the uses, descriptions, and possible side effects that relate to the patient. Observable Physical and Psychological Changes in PatientThe major physical change seen in the patient is weight loss. She stated her usual body weight 6 months ago was 134 pounds. Upon admission she weighed 103 pounds. At a height of 5 feet 4 inches, she is only 86% of her ideal body weight. Psychologically, the patient seems to be in denial about having any health problems due to drinking or smoking. It has been explained to her that drinking will worsen the condition but she admits to drink 6 or 7 drinks per day unless she is experiencing abdominal pain. The patient has also been offered help with smoking cessation but has declined it.TreatmentMedicalAccording to previous notes and documents, on June 25, 2012, a computerized tomography (CT) scan of the patient’s abdomen was performed. The results showed steatosis, cholelithiasis with questionable gallbladder wall thickening, mild edema at the head of the pancreas, diffuse colon bowel wall thickening in primarily the left half of the colon that may represent colitis. A magnetic resonance cholangiopancreatography (MRCP) of the abdomen without contrast was also performed that day. It showed increased signal intensity on T2-weighted images involving the pancreas with slight decreased signal intensity on the T1-weighted images. There was a mild prominence of the head of the pancreas, edematous changes in the peripancreatic fat. Edematous changes involved the lateral conal fascia on the left anterior pararenal fascia. No pancreatic fluid collections were seen. These findings were consistent with acute pancreatitis.SurgicalDuring this most recent admission, an endoscopy was performed on January 3, 2013. It showed a normal duodenum and normal GE junction. A stomach biopsy was also performed to rule out H. pylori. There are no plans to remove any part of her pancreas as there is not any necrotic tissue.Medical Nutrition TherapyNutrition HistoryThe patient does not follow any specific diets at home nor has she in the past. She usually eats 2 or 3 meals per day, mainly lunch and dinner. Food is purchased by her live-in boyfriend. She prepares her own lunch at home which is usually a microwaveable frozen entrée. When her boyfriend gets home from work, he will prepare dinner for the two of them which is, again, a microwaveable frozen entrée. The patient denies avoiding any particular types of food unless she is having abdominal pain with nausea and vomiting. In those instances she will avoid most foods.Analysis of Previous Diet (24 hour recall)The patient’s 24-hour recall was performed after admission to the hospital. The previous afternoon she had undergone a procedure that required her to not consume anything by mouth that morning. The patient was able to eat dinner and stated she had a chef salad (190 kcals, 21 g protein) and turkey sandwich (375 kcals, 18 g protein). This totals 565 kcals and 67 g protein. The patient’s needs are between 1410-1645 kcals and 56-66 g protein per day. Current Prescribed Diet & ResponsesThe current diet prescribed is a solid regular diet with Ensure Plus ordered twice a day. Her previous diet orders have been clear liquids when she was preparing for an endoscopy procedure. She was able to start oral intake soon after admission to the hospital and therefore was not placed on enteral or parenteral nutrition support. The patient has had a good response to the diet psychologically. She enjoys the ability to have meals prepared from fresh vegetables such as salad. Physically she is responding well to the prescribed diet. She is slowly gaining weight, around 5 pounds in 10 days, which is needed due to unintentional weight loss from vomiting which also caused decreased oral intake.Nutrition-Related ProblemsUpon admission to the hospital, the patient had inadequate oral intake related to decreased ability to consume sufficient energy as evidenced by weight loss, nausea, vomiting, and reports of insufficient intake of energy from the diet when compared with requirements.Evaluation of Present Nutritional StatusDue to recent unintentional weight loss, it was recommended that the patient consumes 30-35 kcals/kg body weight and 1.2-1.4 g protein/kg body weight. This is approximately 1410-1645 kcals and 56-66 g protein per day. This increased intake of kcals and protein will help replenish lost nutrient stores. Consumption of Ensure Plus supplements twice a day would also increase kcal and protein intake.Other Nutrients to AddressSome researchers believe supplementation with antioxidants may shorten the patient’s length of stay in the hospital and may also decrease complications in patients with acute pancreatitis but further clinical trials are required (10). Other researchers show no support for immunonutritional supplements (11). Probiotics have also been suggested to benefit patients with severe acute pancreatitis but results have not been consistent enough to make recommendations (11). During her previous admissions, the patient was given thiamine, folic acid, and a multi-vitamin for alcohol withdrawal.Goals, Interventions, Monitoring, and EvaluationThe first goal for this patient is to eat more than 50% of meals three times a day. The next goal is to drink Ensure Plus twice a day. The final goal is to limit pancreatic irritants such as nicotine and alcohol. Interventions for the patient include a general healthful diet and medical food supplements. The patient will be monitored and evaluated by checking her food and beverage intake.Patient’s Nutrition Education ProcessThe patient has a few issues that will hinder the process of educating her on nutrition. She is intelligent but does not seem to understand just how damaging drinking and smoking are for her health. She seems to be in denial. She also has very little support from her family. She does have a boyfriend but based on one of my visits, he seems like he needs to be taken care of by her at times and he may be enabling her. She is a native English speaker which helps but she seems to have little motivation to change. General Conditions upon DischargeUpon discharge, the patient stated she had her appetite back and denied any nausea, vomiting, or abdominal pain. The importance of decreasing smoking and alcohol consumption were again emphasized and the patient said she understood, however, lack of motivation was apparent.Emerging Research Relevant to PatientSmoking and PancreatitisChronic tobacco consumption is an independent risk factor of pancreatitis. It increased the frequency of all major complications of alcoholic chronic pancreatitis in a dose-dependent fashion apart from alcohol intake (6). This shows that if the patient goes on to develop chronic pancreatitis, she will really need to consider smoking cessation to avoid major complications.PrognosisUnless the patient stops drinking alcohol and quits smoking cigarettes, it is unlikely her pancreatitis symptoms will completely go away. In the past year the patient has been admitted to the hospital 10 times. The patient has been diagnosed with pancreatitis for 6 months and continues to drink heavily every day. Her reported alcohol intake has decreased slightly from a year ago but is still very high. The patient understands importance of quitting smoking and not drinking alcohol for improved outcomes but seems unmotivated to do so. She has been offered smoking cessation help but has declined it. One positive is since being diagnosed with pancreatitis the patient has learned that drinking will only exacerbate the problem and she stops drinking when she feels the abdominal pain. In the past, she stated that when she had the severe abdominal pain she would drink more to dull the sensation. Unfortunately, the patient continues to drink when she isn’t experiencing abdominal pain.Summary & Conclusion From this case study I learned not to judge a person before seeing them, even when you hear things about them that make you think you know them. After reading the notes from doctors about the patient’s high alcohol consumption and seeing that she has been in the hospital 6 times in the past year, I thought I would be walking in on a grumpy woman who wouldn’t be willing to answer my questions. When I entered her room, she was on the phone. By the way she was talking I could tell it was her boyfriend and she was consoling him. Once she saw me walk in, she told him she had to go and hung up. That alone impressed me as I have had some patients keep talking on the phone and ignore me altogether or wave me away. I explained to her that I would be asking a lot of questions, some of which might be personal and she did not have to answer any that made her uncomfortable. Once I started my inquiries she really opened up to me. She is actually a very nice woman and was willing to answer anything I asked. She is going through tough times right now but I am hoping that someday soon she will realize she needs to make some big changes for her health. As for pancreatitis, I learned a lot of new things about the disease that I didn’t know before. I didn’t realize how gallstones will irritate the duct and cause the pancreas to become inflamed. I knew that chronic alcohol abuse would make the situation worse but I didn’t know that 70-90% of alcohol abusers would go on to develop chronic pancreatitis. I also wasn’t aware that so many studies need to be done to fully determine many aspects related to nutrition and pancreatitis. Appendix A – Lab ValuesLabs outside normal limits from day of diagnosis: June 25, 2012Lab ValueNormal Value RangeSodium132135-145Calcium8.18.5-10.2AST8110-40Amylase 14023-85Lipase29810-60Ethanol87<10Labs showing elevated lipase levels during previous hospital admissionsDateLab Value6/26/12 (day after diagnosis)4767/15/121199/4/121141/1/132131/2/131721/11/13117Labs showing ethanol levels during previous hospital admissionsDateLab Value6/4/113976/7/111294/26/12995/3/122285/22/122036/25/12 877/15/12 (after diagnosis)< 109/14/12 < 1011/16/129312/21/12< 10DrugUseDescriptionSide EffectsAlbuterolfor asthma and COPDBronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Used to treat or prevent bronchospasm in people with reversible obstructive airway disease.Uncontrollable shaking of a part of the body, nervousness, headache, nausea, vomiting, cough, throat irritation, and muscle, bone, or back pain. Serious side effects include fast, pounding, or irregular heartbeat, chest pain, increased difficulty breathing, difficulty swallowing.Cymbalta (duloxetine)for depressionSelective serotonin and norepinephrine reuptake inhibitor for oral administration as antidepressant.Nausea, dry mouth, constipation, loss of appetite, tiredness, drowsiness, or increased sweating. Drug can cause drowsiness or dizziness, avoid alcoholic beverages. Duloxetine may affect blood sugar levels.Advairfor asthma and COPDPrevents the release of substances in the body that cause inflammation. It contains fluticasone, a steroid, and salmeterol, a bronchodilator, which works by relaxing muscles in the airways to improve breathing.Chest tightness, fast or uneven heart beats, stabbing chest pain, nausea, vomiting, diarrhea, dry mouth, nose, or throat. Long-term use of steroids may lead to bone loss, especially if you smoke. Zestril (lisinopril)for HTNAngiotensin converting enzyme (ACE) inhibitor.Vomiting, diarrhea, heavy sweating, very low blood pressure, electrolyte disorder, kidney failure. Drinking alcohol could further lower blood pressure and increase side effects. Do not use salt substitutes or potassium supplements while taking medication unless doctor has approved.Miralaxfor occasional constipationWorks by holding water in the stool to soften the stool and increases the number of bowel movements.Nausea, abdominal cramping, or gas.Dulcolax (bisacodyl)for cleaning out the intestines before a bowel examination/surgeryWorks by increasing the movement of the intestines, helping the stool to come out.Stomach/abdominal pain or cramping, nausea, diarrhea, and weakness.Appendix B - MedicationsBibliographyJohns Hopkins Medicine. The Sol Goldman Pancreatic Cancer Research Center page. Available at: . Accessed January 5, 2013.Escott-Stump S. Nutrition and Diagnosis-Related Care. 7th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2012.U.S. Department of Health and Human Services. The National Digestive Diseases Information Clearinghouse (NDDIC) page. Available at: . Accessed January 5, 2013. Pandol SJ, Saluja AK, Imrie CW, Banks PA. Acute pancreatitis: bench to the bedside. Gastroenterology. 2007; 132(3):1127-51.Gramlich L and Taft K. Acute pancreatitis: practical considerations in nutrition support. Curr Gastroenterol Rep. 2007; 9(4):323-8Rebours, V, Vullierme MP, Hentic O, Maire F, Hammel P, Rusniewski P, Levy P. Smoking and the course of recurrent acute and alcoholic pancreatitis: a dose-dependent relationship. Pancreas. 2012; 41(8): 1219-24.Kylanpaa L, Rakonczay Z, O’Reilly DA. The clinical course of acute pancreatitis and the inflammatory mediators that drive it. Int J Inflam. 2012; 2012, article ID 360685, 10 pages.Moraes JMM, Felga GEG, Chebli LA, Franco MB, Gomes CA, Gaburri PD, Zanini A, Chebli JMF. A full solid diet as the initial meal in mild acute pancreatitis is safe and result in a shorter length of hospitalization: results from a prospective, randomized, controlled, double-blind clinical trial. J Clin Gastroenterol. 2010; 44(7): 517-22.Cao Y, Xu Y, Lu T, Gao F, Mo Z. Meta-analysis of enteral nutrition versus total parenteral nutrition in patients with severe acute pancreatitis. Ann Nutr Metab. 2008; 53(3-4):268-75.Sateesh J, Bhardwaj P, Singh N, Saraya A. Effect of antioxidant therapy on hospital stay and complications in patients with early acute pancreatitis: a randomized controlled trial. Trop Gasteroenterol. 2009; 30(4):201-6.Andersson R, Sward A, Tingstedt B, Akerberg D. Treat of Acute Pancreatitis. Drugs. 2009; 69(5):505-14. ................
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