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Melissa MaskalMedSurg Case StudyNutritional Management of Chronic PancreatitisChronic PancreatitisThe pancreas is an oblong organ that is positioned behind the stomach in the abdominal cavity. The pancreas dually functions as both an endocrine and exocrine organ. The pancreas plays a key role in digestion; the digestive acinar cells produce essential enzymes including trypsin, chymotrypsin, lipase, and amylase. After we eat a meal, these enzymes collect in the pancreatic duct, which combines with the bile duct. Enzymes and bile are released into the duodenum in an effort to digest and absorb food efficiently. Additionally, the pancreas secretes bicarbonate, a substance that neutralizes the acidity of chyme that enters the duodenum from the stomach. The pancreas perhaps is better known for its endocrine role, most notably as the main player in blood glucose control. Pancreatic alpha cells produce glucagon to raise blood sugar in a post-prandial state. On the other hand, pancreatic beta cells produce insulin to lower blood glucose after food intake (Johns Hopkins University, 2016). Chronic pancreatitis is the progressive inflammation of the pancreas, resulting in the irreversible damage to both the anatomy and physiology of the stomach. In pancreatitis, there is a premature activation of trypsin which causes the autodigestion of pancreatic alpha, beta, and digestive acinar cells. Chronic pancreatitis often takes years to develop, with irreversible pancreatic damage preceding the onset of symptoms by several years. Diagnosis is confirmed with pancreatic function tests and imaging techniques. Examples of pancreatic function tests include amylase, lipase, serum trypsinogen, and fecal concentration of elastase and chymotrypsin. Risk factors for the development of chronic pancreatic include alcohol abuse, genetic mutations, malnutrition, hypertriglyceridemia, hypercalcemia related to untreated hyperparathyroidism, autoimmune diseases, and smoking. The main cause of chronic pancreatitis is heavy alcohol intake, which is the cause of 45-85% of cases (Schub, 2017). Other cases may be idiopathic, genetic, autoimmune, obstruction, and recurrent bouts of acute pancreatitis. The most common symptom is abdominal pain radiating to the back, which occurs in about 85% of patients (Schub, 2017). The abdominal pain commonly occurs after a large meal and is worsened by alcohol intake. It often can be relieved by leaning forward. Other symptoms include weight loss, diarrhea, vomiting, anorexia, jaundice, flatulence, constipation, fatty or pale stools, and epigastric tenderness (Bansal, 2017). When pancreatitis progresses to a chronic state, a cure is not likely and the focus shifts to pain and symptom management A. Whipple Procedure The Whipple Procedure, otherwise known as the pancreaticoduodenectomy, has been carried out by surgeons around the world since the 1930s. This complex surgery removes the head of the pancreas, gallbladder, common bile duct, duodenum, pylorus, and surrounding lymph nodes. Remaining organs are attached to the jejunum of the small intestine to maintain gastrointestinal integrity. Following this surgery, pancreatic secretions and bile from the liver directly enter the jejunum. Postprandially, food passes directly from the stomach into the jejunum (Mayo Clinic, 2017). A variant of this surgery, the pylorus-preserving pancreaticoduodenectomy, leaves the pylorus intact. A once very dangerous surgical procedure that yielded a mortality rate of as high as twenty-five percent, the Whipple Procedure is now the most commonly performed surgical treatment to remove pancreatic tumors with a mortality rate of less than 5 percent (University of Southern California, 2002). Other indications for this procedure include the removal of tumors in the duodenum or lower part of the bile duct and as a treatment option for some cases of chronic pancreatitis. My patient had a Whipple Procedure in 2003 because of precancerous duodenal polyps and family history of familial polyposis syndrome and malignant neoplasms. A multitude of nutritional implications comes along with a surgery so complex in nature. The most common complication is delayed gastric emptying, which occurs in 33-50 percent of all patients. Additionally, patients experiences digestive difficulties, dumping syndrome, malabsorption and related micronutrient deficiencies, weight loss, diabetes mellitus, and abnormal blood glucose control (Mayo Clinic, 2017). Both hyperglycemia and hypoglycemia can occur because both alpha and beta pancreatic cells are compromised. Although weight loss is a common complication after surgery, many patients regain the lost weight; one study has determined that patients reach preoperative weight within four to six months (Niedergethmann et al. 2006). This weight loss may be due to altered eating habits prior to and immediately after surgery. The removal of the duodenum results in the loss of a great deal of absorptive surface area, causing diminished absorptive capabilities. The chyme that enters the stomach to aid in digestion is often altered because of the pancreatic insufficiency; this highlights the need for pancreatic enzyme replacement therapy post-Whipple procedure. C. Pancreatic Enzyme Replacement Therapy (PERT)Pancreatic enzyme replacement therapy (PERT) is often needed in cases of the malabsorption of fat-soluble vitamins secondary to pancreatic insufficiency. The article Deficiency of fat-soluble vitamins in chronic pancreatitis: a systematic review and meta-analysis by Martínez-Moneo et al. analyzed 12 studies of over 500 chronic pancreatitis patients to determine and compare the prevalence of these suspected deficiencies. The analysis ultimately determined that 16.8% were Vitamin A deficient, 29.2% were Vitamin E deficient, and 57.6% were Vitamin D deficient. Vitamin E was not analyzed due to a lack of data (Martinez-Moneo et al., 2016). Interestingly, chronic pancreatitis patients were not at increased risk for Vitamin D deficiency; this may indicate that a large portion of the population may have a sub-acute Vitamin D deficiency. The results of this analysis were muddled by the nature of the pathophysiology of the disease; alcohol intake and alcoholism is highly correlated with pancreatitis, perhaps aggravating the deficiencies. It is estimated that 25 percent of all patients who had a Whipple procedure require PERT. Pancreatic enzymes need to be taken with the first bite of food in order to be effective. When initiating PERT, it is important to start low and increase the dosage if signs of malabsorption continue to present; most adults need 10,000-20,000 units of lipase with snacks and 20,000-40,000 units with meals. Often times, pancreatic enzymes are administered with a protein pump inhibitor to maintain enzyme integrity, as the gastric acid in the stomach is known to inactivate the enzymes (Pancreatic Cancer Action Network, 2017). Patient ProfileMy patient, a 56 year old female with the initials LH, was admitted to The Valley Hospital on November 6th for an elective Puestow’s procedure for chronic pancreatitis. Her length of stay was 6 days, as she was discharged on November 12th. Current problems include chronic pancreatitis and associated abdominal pain secondary to a dilated main pancreatic duct with obstruction. Additionally, the patient reports gastrointestinal distress, a diminished appetite, and pneumonia. The patient had a Whipple Procedure in 2003 and stents in 2014. A. Puestow’s Procedure A pancreaticojejunostomy, otherwise known as Puestow’s Procedure, is a surgical procedure that is utilized to alleviate pain associated with chronic pancreatitis. It is performed in the case of pancreatic duct obstruction or a dilated pancreatic duct in an effort to allow for proper drainage. The pancreas and pancreatic duct are attached to the jejunum side-by-side, allowing for pancreatic duct drainage. In this procedure, pancreatic tissue is preserved (Mayo Clinic, 2017). For my patient, this was crucial because of her past medical history in which the pancreatic head was removed as a result of the Whipple Procedure. An alternate to this procedure is a Frey’s procedure in which the pancreatic tissue is not preserved. Nutrition AssessmentA. Client HistoryLH lives with her spouse and 2 adult children. Her chief nutritional complaint is a finished appetite. Past and present illnesses include chronic pancreatitis, pneumonia, hypothyroidism, anemia, Raynaud’s syndrome, asthma, hypertriglyceridemia, hysterectomy, and pyelonephritis with sepsis. A pancreaticoduodenectomy was performed in 2003 secondary to precancerous duodenal polyps. Stents were placed in 2014 due to pancreatic strictures. Familial medical history is pertinent, including familial multiple polyposis syndrome and malignant neoplasm on the maternal side and diabetes mellitus on the paternal side. The patient’s cognitive functions were intact and displayed a broad and appropriate affect. The patient was pale and lacked energy. B. Anthropometric DataLH weighs 52 kilograms (114.64 pounds) and she is 1.65 meters (65 inches) tall. Her BMI of 19.1 is classified as normal. The patient reports a usual body weight of 110-112 pounds and reports no recent weight change, despite a recorded weight of 119 pounds on 10/31. Past visits to The Valley Hospital indicate that her usual body weight may be more near 115-120 pounds. An ideal body weight would be around 125 pounds. The patient did not have any edema or visible muscle or fat wasting.C. Food and Nutrition HistoryThe patient was NPO on the day of her surgery. By postoperative day 3, the patient progressed to a full liquid diet and then a soft diet the day after on postoperative day 4. I did not sense any issues with either food procurement or preparation. The patient did not have a large appetite when oral intake was initiated on 11/9 with less than 50 percent of meal tray consumption, but this improved to greater than 75 percent on the following day. The patient reported an allergy to chocolate. At home, the patient reports to trying to follow a low-sugar, low-fat diet in an attempt to manage the gastrointestinal symptoms associated with pancreatitis. During a pancreatitis exacerbation, the patient reports consuming a full liquid diet at home until the symptoms subside. At home, the patient takes a multivitamin and Vitamin D. A typical 24-hour recall includes Greek yogurt, fruit, and coffee for breakfast; a few Ritz crackers as a mid-morning snack; a turkey sandwich on wheat bread and strawberries for lunch; and a veggie taco bowl or cauliflower crust vegetable pizza for dinner. A nutrient analysis determined that this particular day yielded an intake of 1150 calories and 59 grams of protein. She did not meet the DRIs in the fat-soluble vitamins (A, D, E, and K), Vitamin B12, calcium, zinc, and copper. This is concerning because those with pancreatitis often experience maldigestion and malabsorption of these nutrients, placing her at increased risk for deficiency. D. Biochemical DataThe patient saw both an elevated pancreatic lipase and amylase level consistent with pancreatitis. The patient’s fasting glucose levels were within normal limits, but it is important to note that on the day before discharge, her fasting glucose level was near 200 mg/dL. Greater than 80 percent of those with chronic pancreatitis become diabetic within 25 years secondary to pancreatic endocrine insufficiency. The patient also has familial history of diabetes mellitus, making glucose levels something to continuously monitor in the future. The patient had a diminished hematocrit and hemoglobin level, consistent with anemia. The patient’s MCH and MCV levels were both depressed, which points to a microcytic, hypochromic anemia perhaps related to chronic disease or micronutrient deficiencies. The patient reported postoperative diarrhea; the medical team tested for C. difficile; the negative result ruled out infection. Unfortunately, a fecal fat test was never conducted, which would have confirmed steatorrhea related to malabsorption. The elevated white blood cell count is related to the pneumonia; originally, the patient’s medical team thought that the patient may have developed peritonitis, but that was ruled out. A complete summary of the patient’s pertinent biochemical data is provided below.LabReference Range11/711/811/9InterpretationLipase73-393 U/L↑ 1447↑ 443338Pancreatitis Amylase25-115 U/L↑1316550Pancreatitis Glucose74-106 mg/dL9472↑ 115Normal; CP ↑ risk for hyperglycemia & DM Albumin3.4-5 g/dL↓ 2.7↓ 2.4↓ 2.3↓ with infection, hypothyroidism, chronic illness, surgeryHct36-48%↓ 29.6↓ 28.9↓ 24.7Anemia (chronic disease; micronutrient deficiency)Hgb12-16 g/dL↓ 8.7↓ 8.7↓ 8.6Anemia (chronic disease; micronutrient deficiency) C. difficile---NegDiarrhea not associated with C. diff WBC4.5-11 x 109/L↑15.6↑17↑11.6↑ with infection (pneumonia of LLL)E. Medication Use A summary of the patient’s medications, indication for use, and nutritional implications is provided below. It is important to note that both the patient’s magnesium and potassium levels were depressed, which perhaps can be linked to the loop diuretic that is utilized to control blood pressure. It is no surprise that these medications can cause a plethora of nutritional and gastrointestinal side effects, including the nausea, diarrhea, and a loss of appetite that the patient is reporting.MedicationIndicationNutritional ImplicationsHydrochlorothiazideHypertensionhypo-Mg, hypo-K, loss of appetite, diarrheaAmbienInsomniaDiarrhea, nausea, vomiting, abdominal painSynthroidHypothyroidismAbdominal cramps, vomiting, diarrhea, weight lossAlbuterolAsthma, pneumoniaNausea, vomiting, throat irritationOxycodoneAnalgesicNausea, vomiting, diarrhea, constipation, loss of appetite, stomach pain, dry mouthBismatrolDiarrhea, nausea, upset stomachConstipationNaloxoneAnalgesic Abdominal cramps, nausea, vomiting, diarrheaLovenoxAnticoagulant Nausea, diarrhea, anemiaRisaquadProbiotic Difficulty swallowing, swelling of lips/tongueHydromorphoneAnalgesic Dry mouth, abdominal cramping, vomiting Ceftriaxone SodiumAntibioticNausea, vomiting, diarrhea, taste alterationsNutrition Diagnosis Considering all the data and information that was collected on the patient, I determined two nutritional diagnoses, summarized in the following two statements: Inadequate oral intake (NI 2.1) related to diminished appetite secondary to chronic pancreatitis as evidenced by patient reporting a diminished appetite and consumption of 1150 kcal and 59 g PRO compared to estimated needs of 1560 kcal & 62.4 g PRO.Altered GI function (NC-1.4) related to chronic pancreatitis as evidenced by lipase level of 447 U/L and an amylase level of 131 and patient report of abdominal pain and diarrhea. Nutrition Interventions, Monitoring, and EvaluationA. Traditional Medical Nutrition Therapy for Chronic Pancreatitis Traditional medical nutritional therapy for chronic pancreatitis first and foremost begins with NPO for bowel rest. The progression to an oral diet is initiated when symptoms subside and lipase and amylase levels start trending downward. Typically, the diet progresses from NPO to a clear liquid diet to a full liquid diet before solid foods are recommended; this standard is beginning to change with the initiation of fast track protocols in hospitals around the world. Small, frequent feedings are encouraged. A low fat-diet that contains less than 30% of kilocalories from fat is recommended. Protein is suggested at every meal. Pancreatic enzyme replacement therapy and fat-soluble vitamin supplementation should be initiated if malabsorption is present. Alcohol should be avoided, as it can exacerbate both pain and symptoms. Nutrition support is indicated if oral intake cannot result in 5-7 days, with severe malnutrition, and in the cases of severe pancreatitis (Academy of Nutrition and Dietetics, 2017). Enhanced Recovery After Surgery (ERAS), otherwise known as “fast track” protocol, has only recently been indicated for gastrointestinal surgeries like pancreaticoduodenectomies. All ERAS programs have a few main pillars in common, including early ambulation, appropriate analgesic administration, avoidance and early removal of tubes, and perioperative nutrition. Most ERAS programs allow carbohydrate drinks up to 2 hours prior to surgery and the early initiation to a solid diet as tolerated. Recent studies have associated the ERAS protocol with shorter lengths of stay and decreased morbidity. This ultimately enhances quality of life and decreases healthcare costs. Coolsen et al. delved into some of the benefits of ERAS protocols in the article Improving Outcomes after Pancreaticoduodenectomy: Experiences with Implementing an Enhanced Recover After Surgery (ERAS) Program. This study analyzed length of stay (LOS) and delayed gastric emptying (DGE) in 230 patients from 1995 to 2012. These patients were split into three groups based on when their procedure was conducted—Group 1 (no-ERAS) received traditional care from 1995-2005, Group 2 (ERAS-like) were exposed to some ERAS elements from 2006-2009, and Group 3 (ERAS) experienced a full ERAS program from 2009-2012. The LOS decreased from 20 days in the no-ERAS group to 13 days in the ERAS-like group and 14 days in the ERAS-group. These results were consistent when complications were taken into consideration; the average LOS decreased about 6-7 days between the non-ERAS (20 days) and ERAS-like and ERAS groups (13 and 14 days, respectively) when patients experienced complications. Those in the ERAS group were structurally given sips of water in the recovery room and were encouraged to begin their normal diet on post-operative day (POD) 1 as tolerated. An oral solid diet was tolerated in 60 percent of patients on POD 2. This shows that oral intake should not be held if the patient is able to tolerate it. This study did not determine any significant differences between the ERAS and no-ERAS groups in terms of DGE. Although no benefit was discovered in terms of DGE, this research demonstrates the efficiency of ERAS in terms of length of stay which in term lowers healthcare costs. Another less-talked about pillar of ERAS is the avoidance or early removal of tubes. In the article entitled Utility of feeding jejunostomy tubes in pancreaticoduodenectomy, Waliye et al. discussed the routine placement of jejunostomy tubes post-pancreaticoduodenectomy. The authors looked at over 250 patients who had a Whipple procedure done from 2008 to 2014. The authors looked at 90-day morbidity and mortality, length of stay, and rate of delayed gastric emptying. No significant differences were determined between 90-day morbidity and mortality, however those who had jejunostomy tubes placed had a higher rate of delayed gastric emptying, the most common complication following a pancreaticoduodenectomy. The prevalence of delayed gastric emptying for those with a jejunostomy tube was 67 percent compared to 33 percent in those without the tube. Additionally, those with the jejunostomy tubes had a nearly three day increase in length of stay and had a two day delay in the initiation of solid intake. This research highlights the importance of perioperative nutrition and the potential disadvantages of “routine” standard nutritional protocols that are applied to all patients without any individualization. B. Nutrition GoalsI consulted with the Nutrition Care Manual and The Valley Hospital’s RDNs in order to determine appropriate needs. I determined LH’s fluid needs to be 30 mL/kg for a total of 1560 mL of fluid. I used a factor of 1.2 g PRO/kg to calculate her total protein needs at 62.4 grams. Lastly, I determined an energy intake of 1560 kcal using the factor of 30 kcal/kg. Taking the patient’s case into consideration, I determined the following six nutrition goals:Advance diet as tolerated by the patientEncourage the consumption of >75% of meal traysWeight maintenancePrevent/manage exacerbations of GI symptomsCorrect fluid/electrolyte abnormalitiesFollow up with outpatient RDNC. Nutrition InterventionsBased on the standard medical nutrition therapy and nutrition goals for this patient, I determined the following nutrition interventions detailed below: Recommend a low-fat diet—a low fat diet is often better tolerated by the pancreatitis patient. High-fat foods may also aggravate delayed gastric emptying. Recommend a high-protein diet—chronic pancreatitis is an inflammatory disease that requires extra protein to prevent malnutrition. Recommend the avoidance of alcohol—alcohol can further damage the pancreas and can exacerbate symptoms related to pancreatitis. Encourage small, frequent feedings—because the patient reports a diminished appetite, I believe the initiation of small, frequent feedings will allow her to meet her energy and protein needs. Furthermore, many patients report better tolerance to small, frequent meals. Additionally, large meals may cause an exacerbation in abdominal pain. Suggest fecal fat test to determine extent of steatorrhea— the fecal fat test is the gold standard for measuring malabsorption in chronic pancreatitis patients. Because the patient tested negative for C. diff, I would have liked to rule out steatorrhea and malabsorption as a source of the diarrhea. The patient was previously taking pancreatic enzymes, but has discontinued them because she stated that they did not work. Determining if malabsorption is present would determine the need for potentially reintroducing pancreatic enzymes in this patient.Recommend a multivitamin supplement— the patient reports to taking a multivitamin at home, but was not given one in the hospital. Because she is at risk for a multitude of micronutrient deficiencies, I believe micronutrient supplementation will prevent any subacute deficiencies. D. Monitoring and Evaluation It is important to monitor pancreatic enzyme levels in a pancreatitis patient. The enzyme levels were trending down in LH, but they did not rebound to normal levels. Additionally, I continued to monitor and evaluate steatorrhea relating to malabsorption and diet tolerance and the need for pancreatic enzyme replacement therapy. Monitoring symptoms associated with the exacerbating of pancreatitis is key because dietary modifications may be needed for comfort of the patient. Lastly, it is important to monitor changes in weight because her BMI is on the lower spectrum of the normal range and she may be at risk for deficiencies or malnutrition if she is not consuming adequate nutrients. BibliographyAcademy of Nutrition and Dietetics. (2017). Pancreatitis. Retrieved November 17, 2017, from Bansal, R. (2017).?Chronic Pancreatitis. The Merck Manual. Retrieved November 20, 2017, from . Coolsen, M.M.E., van Dam R.M., Chigharoe, A., Olde Damink, S.W.M., Dejong C.H.C. (2014). Improving Outcome after Pancreaticoduodenectomy: Experiences with Implementing an Enhanced Recovery After Surgery (ERAS) Program. Dig Surg, 31, 177-184. Johns Hopkins University (2016). The Pancreas. Retrieved November 21, 2017, from . Martínez-Moneo, E., Stigliano, S., Hedstr?m, A., Kaczka, A., Malvik, M., Waldthaler, A., Maisonneuve, P., Simon, P., Capurso, G. (2016). Deficiency of fat-soluble vitamins in chronic pancreatitis: A systematic review and meta-analysis. Pancreatology, 16(6), 988-994. . Mayo Clinic. (2017, May 24). Whipple procedure. Retrieved November 15, 2017, from . Medical University of South Carolina. (n.d.). Puestow Procedure. Retrieved November 15, 2017, from Niedergethmann, M., Shang, E., Soliman, M.F., Saar, J., Berisha, S., Willeke, F., Post, S. (2006). Early and enduring nutritional and functional results of pylorus preservation vs classic Whipple procedure for pancreatic cancer. Lagenbeck’s Archives of Surgery, 391(3), 195-202. . Pancreatic Cancer Action Network (2017). Pancreatic Enzyme. Retrieved November 21, 2017, from . Schub, T. (2017). Pancreatitis, Chronic. Mosby’s Nursing Skills Manual. The National Pancreas Foundation. (2017). Whipple Procedure. Retrieved November 15, 2017, from . University of Southern California (2002). Whipple operation/surgery. [online] Available at: Waliye, H.E., Wright, G.P., McCarthy, C., Johnson, J., Scales, A., Wolf, A., Chung, M. (2017). Utility of feeding jejunostomy tubes in pancreaticoduodenectomy. Am J Surg, 213(3), 530-533. ................
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