MAJOR CASE STUDY ACUTE PANCREATITIS Michelle Smith OUTLINE

MAJOR CASE STUDY: ACUTE PANCREATITIS Michelle Smith

OUTLINE Introduction Social & Past Medical History Normal Anatomy & Physiology Disease Condition Lab Findings & Medications Treatment Past & Current Nutrition of Patient Prognosis

INTRODUCTION JL - 53 yowf Dx: Acute pancreatitis � Alcohol abuse & gallstones Ht: 5’ 4” Wt: � UBW: 134# � Admission: 103# � % wt change: 23% � % IBW: 86%

HISTORY OF THE PATIENT Social History Unemployed Social Security Lives with boyfriend 26 and 30 year old sons Drinks 6 -7 vodka beverages a day � Down from ½ gallon of vodka per day Smokes 1 -2 packs per day Past Medical History Asthma COPD Alcohol abuse HTN Angina

NORMAL ANATOMY & PHYSIOLOGY OF PANCREAS Exocrine � Acinar cells � Enzymes to digest food Endocrine � Islets of Langerhan cells � Regulate glucose

ACUTE PANCREATITIS DISEASE CONDITION Causes � Presence of gallstones � Chronic, heavy alcohol abuse Complications � Sepsis, acute renal failure, hypovolemia, circulatory shock, pancreatic necrosis Symptoms � Nausea, vomiting, and diarrhea, with sudden & severe abdominal pain

LAB FINDINGS Increased lipase, amylase, glucose Decreased K+, Na, Ca, Mg Lab Value Normal Value Range Sodium 132 135 -145 Calcium 8. 1 8. 5 -10. 2 Amylase 140 23 -85 Lipase 298 10 -60 Ethanol 87 <10

LAB FINDINGS - ETHANOL Date Lab Value 6/4/11 397 6/7/11 129 4/26/12 99 5/3/12 228 5/22/12 203 6/25/12 87 7/15/12 (after diagnosis) < 10 9/14/12 < 10 11/16/12 93 12/21/12 < 10

Drug Albuterol Use for asthma and COPD Cymbalta for depression (duloxetine) Advair for asthma and COPD Zestril (lisinopril) for HTN Miralax for occasional constipation Dulcolax (bisacodyl) Description Bronchodilator 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. Selective serotonin and norepinephrine reuptake inhibitor for oral administration as antidepressant. Prevents 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. Angiotensin converting (ACE) inhibitor. Side Effects 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. 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. 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. enzyme 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. Works by holding water in the stool Nausea, abdominal cramping, or gas. to soften the stool and increases the number of bowel movements. for cleaning out the Works by increasing the movement Stomach/abdominal pain or cramping, nausea, diarrhea, and intestines before a of the intestines, helping the stool weakness. bowel to come out. examination/surgery

NUTRITION TREATMENT Oral vs EN vs TPN Oral � Clear liquids vs solid foods EN � Elemental vs standard formula

MEDICAL TREATMENT Surgeries � Necrosectomy � Pancreaticoduodenectomy � Sphincterectomy Remove necrotic tissue

MEDICAL AND SURGICAL PROCEDURES ON PATIENT CT scan and MRCP � Cholelithiasis � Mild edema at the head of the pancreas Surgical � No necrotic tissue

NUTRITION HISTORY No specific diets 24 hour recall � Turkey 2 to 3 meals per day � Lunch & dinner Microwaveable frozen entrees sandwich & chef salad � 565 kcals, 39 g pro � 40% kcals, 70% pro

PRESCRIBED DIET & RESPONSE Solid regular & Ensure Plus BID Enjoys fresh fruits & vegetables Gaining weight

NUTRITION-RELATED PROBLEM 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 Problem Etiology Signs & Symptoms

NUTRITION PRESCRIPTION 30 -35 kcals/kg body weight � 1410 -1645 1. 2 -1. 4 g pro/kg body weight � 56 -66 kcals per day g pro per day Ensure Plus BID provides 700 kcals and 26 g pro

OTHER NUTRIENTS TO ADDRESS Pancreatitis � Antioxidants � Probiotics � Immunonutritional Alcohol withdrawal � Thiamine � Folic acid � Multi-vitamin supplements

Goals �> 50% of meals � Ensure Plus BID � Limit pancreatic irritants Interventions � General healthful diet � Medical food supplements Monitoring & Evaluation � Food intake 3 meals per day � Beverage intake Ensure Plus BID

PATIENT’S NUTRITION EDUCATION PROCESS Pros Cons � Intelligent � Denial � Native � Limited English speaker family support � Enabling boyfriend � Lack of motivation

GENERAL CONDITIONS UPON DISCHARGE Denied N/V or abdominal pain Appetite had returned Emphasized limiting smoking and alcohol consumption

PROGNOSIS Around 25% of acute pancreatitis patients go on to develop chronic pancreatitis Alcohol abuse accounts for 70 -90% of the causes of chronic pancreatitis

REFERENCES Johns Hopkins Medicine. The Sol Goldman Pancreatic Cancer Research Center page. Available at: http: //pathology. jhu. edu/pc/Basic. Overview 3. php? area=ba. Accessed January 5, 2013. Escott-Stump S. Nutrition and Diagnosis-Related Care. 7 th 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: http: //digestive. niddk. nih. gov/ddiseases/pubs/pancreatitis/. 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 -8 Rebours, 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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