Case Report:

Nutrition Support in Pancreatic

Cancer

Neha BhaktaARAMARK Dietetic Internship

St. Luke’s Medical CenterDecember 20,2013

Disease Description

• Pancreatic carcinoma is a highly aggressive type of cancer and is known to be nearly chemotherapy resistant.

• It spreads quickly and is associated with cachexia. Survival rate is less than five percent.

• Patients suffer from abdominal pain, nausea, emesis, taste alterations, early satiety, fatigue, malabsorption, and maldigestion.

• The disease progresses quickly and patients are unable to meet nutrition needs due to symptoms such as nausea, vomiting, abdominal pain, etc.

Disease Description• In 2013, the estimated number of new cases of pancreatic cancer

was 45,220 and 38,460 of those resulted in death.

• The rate of pancreatic cancer has increased over the last 10 years. The cost of cancer care has doubled to $48 billion in the U.S. alone over the past 20 years.

RISK FACTORS:

• The risk of pancreatic cancer increases as one ages, 9 out of 10 pancreatic cancer patients are age 55 or older.

• The male population is 30 percent more likely to develop pancreatic cancer than the female population and is known to be linked to tobacco use as it is more common in men.

• Other risk factors include cigarette smoking, increased BMI, family history, diabetes, chronic pancreatitis, previous history of peptic ulcer surgery, diet high in red meat, cholesterol, fried food and nitrate containing foods.

Evidence-Based Nutrition

Recommendations • Proactive nutrition care can prevent or reduce complications of cancer treatment.

• Problems sometimes stem from effects of the tumor such as tumors in vital organs, which can cause obstruction: • Nausea

• Vomiting

• Impaired digestion

• Malabsorption

• Weight loss, wasting and malnutrition

• Oral nutrition is preferred in patients who are able to eat. • Small, frequent, nutrient dense meals are recommended along with liquid nutrition

supplements.

• In severe pancreatic cancer cases, enteral nutrition by tube is necessary due to the severity of nausea, vomiting, and abdominal pain.

Evidence-Based Nutrition

Recommendations • Pelzer et al, 2010

• Controlled trial• 32 patients• Intervention: Additional parenteral nutrition • Results:

• 27 out of 32 patients showed improvement in nutrition status (gained or maintained weight)

• 15 out of 32 patients had increased BMI

• Limitations: • The study did not allow them to conclude clinical

relevance such as over all survival and quality of life

Evidence-Based Nutrition

Recommendations • Dintinjana et al, 2008

• Controlled, randomized trial• 44 patients (17 of which had liver mets)• Intervention: Nutrition support (enteral) • Results:

• Weight gain and appetite improvement in 32 patients

• 8 patients continued to lose weight in the study

• Limitations: • Degree of disease progression, some patients

had operable tumors, others had inoperable tumors.

Case Presentation

• Case Patient: • 59 year old male • Recently diagnosed with unresectable

pancreatic cancer with metastasis to the liver.• Admitted to the hospital from the oncology

office with complaints of abdominal pain, weight loss and continuous diarrhea. • Other complaints include nausea, vomiting,

and dizziness over the week before admission.

Nutrition Care Process: Assessment

• The Nutrition Care Process was developed for use by medical professionals when implementing medical nutrition therapy to ensure quality individualized care for patients and provide a standardized process for care.

Patient History

• Patient History • Gastroparesis• Gastric outlet obstruction• Biliary obstruction• AKI secondary to dehydration

• His family history includes hypertension and cancer, both mother and father had cancer.

• Social history includes alcohol use, about 9 shots of liquor and 1 can of beer per week prior to cancer diagnosis.

Food/Nutrition-Related History

• Case patient has been in and out of the hospital due to pancreatic cancer that metastasized to the liver.

• At his last visit, he was placed on TPN then transitioned to enteral nutrition.

• Due to severity of cancer, during his past hospital visit he was discharged on a tube feeding regimen: continuous Peptamen AF at 55cc/hr for 24 hours.

• He changed his tube feeding regimen to 16 or 18 hour cyclic feeding to improve quality of life.

Nutrition-Focused Physical Findings

• At admission, the case patient complained of: • Abdominal pain• Continuous diarrhea• Nausea• Vomiting• Weight loss.

• He was not tolerating his home tube feed regimen due to change in rate and time.

• After admission he was also found to be dehydrated. Patient was not able to tolerate any intake by mouth, caused nausea and vomiting. Along with his report of weight loss, loss of muscle mass and loss of subcutaneous fat were noted upon admission. He was also having moderate G-tube output.

Anthropometric Measurements

• Height: 6’ tall

• Weight: 143 pounds.

• BMI: 19.4

• Upon admission, he reported weight loss of approximately ten pounds over last two months.

Biochemical Data, Medical Tests, and

Procedures• The x-ray confirmed pancreatic head and

uncinate process mass. The repeat CT of the abdomen showed pneumatosis.

• Pneumatosis intestinalis is defined as gas in the bowel wall, in this case most likely associated with chemotherapy. Treatment approach that the physicians took was bowel rest, at this point patient was placed on TPN.

Lab measurement Patients value Normal range

Sodium 123L 135-148 meq/L

Potassium 3.1L 3.6-5.5 meq/L

BUN 58H 10-26 mg/dL

Creatinine 1.22H 0.50-1.20 gm/dL

WBC 16.8H 4.0-10.0 10^3/mL

HGB 12.2L 13.0-16.8 GM/DL

HCT 34.9L 40.0-50.0%

Alk Phos 176H 44-147 IU/L

Total Bilirubin 3.2H 0.3-1.9 mg/dL

ALT 358H 7-55 U/L

AST 91H 8-48 U/L

Nutrient Needs

REE Protein

65 kg x 30 kcal/kg = 1950 kcal

65 kg x 35 kcal/kg = 2275 kcal

1920-2240 kcal/day

65 kg x 1.0 g/kg = 65 g

65 kg x 1.5 g/kg = 97.5 g

64-96 g/day

ARAMARK Nutrition Status

Classification• Based on the ARAMARK Nutrition Status

Classification form, the case patient was classified as severely compromised. He has a score of NSC 4, which means he had greater than or equal to 12 priority points. • Nutrition History: 3 points for diarrhea• Feeding Modality: 4 points for unstable TF• Weight Status: 4 points for weight loss of >5%

usual body weight • Diagnosis: 2 points. • This is a total of 13 points, indicating severely

compromised.

Nutrition Care Process: Nutrition

Diagnosis Domain Problem/

Nutrition Diagnosis

Etiology Signs/Symptoms

Intake

(NI-2.1)

Inadequate oral intake

related to

diarrhea and unintentional weight

as evidenced by

increased energy needs

Nutrition Care Process:

Intervention(s)• Enteral and Parenteral Nutrition: Parenteral

Nutrition/IV Fluids- Formula/Solution (ND-2.2.1). Recommended parenteral nutrition: • For TPN

• Total Volume: 1080 mL • Amino Acid: 70 grams 10%, • Dextrose: 150 grams 70% • Lipids: 15 grams 20%• standard electrolytes/L• Additives: 10 milligrams of zinc sulfate. This TPN regimen

provided 940 kcal and 150 g protein.

• It ran continuously for 6 days before enteral feedings were reintroduced.

• Tube Feeding: Peptamen AF at goal rate of 55cc/hr

Nutrition Care Process: Monitoring

and Evaluation • Food and Nutrient intake: Parenteral nutrition intake-

Formula/solution (FH-1.3.2.1). Parenteral nutrition orders were reviewed to establish calorie and protein intake. • The order met the patient’s estimated energy needs of

about 50% of estimated needs on TPN alone for 6 days.• Once tube feeds of Peptamen AF stated, patient was

meeting closer to 75% estimated nutrition need.• TPN was discontinued once he was tolerating Peptamen

AF at goal rate of 55cc/hr.

• Other discharge recommendations: intermittent clamping, daily IV fluid boluses to replace G-tube output.

Conclusion• Oral nutrition is preferred in patients who are able to eat.

• Small, frequent, nutrient dense meals are recommended along with liquid nutrition supplements.

• Easy to prepare or ready to eat foods, nutrient dense snacks frequently throughout the day, drink plenty of healthy fluids, and be as physically active as possible based on physician recommendations.

• Many cancer patients follow a neutropenic diet, this requires frequent hand washing and keeping kitchen surfaces and utensils clean.

• Research shows enteral/parenteral nutrition for pancreatic cancer helps patients gain weight, improves appetite and increases BMI.

• In severe pancreatic cancer cases, enteral nutrition by tube is necessary due to the severity of nausea, vomiting, and abdominal pain.

• The research shows that majority of pancreatic cancer patients benefit from enteral tube feedings.

References 1. American Cancer Society. Pancreatic Cancer. What are the key statistics about pancreatic

cancer?Web cite. Available from: http://www.cancer.org/cancer/pancreaticcancer/detailedguide/pancreatic-cancer-key-statistics

2. Mahan LK, Escott-Stump S. Krause’s Food & Nutrition Therapy. 12th ed. St. Louis, MO: Saunders Elsevier; 2008:832-859.

3. American Cancer Society. Pancreatic Cancer. What are the risk factors for pancreatic cancer?Web cite. Available from: http://www.cancer.org/cancer/pancreaticcancer/detailedguide/pancreatic-cancer-risk-factors

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5. American Cancer Society. Pancreatic Cancer. What is Cancer? Web cite. Available from: http://www.cancer.org/cancer/cancerbasics/what-is-cancer

6. Hirshberg Foundation for Pancreatic Cancer Research. FREQUENTLY ASKED QUESTIONS ABOUT PANCREATIC CANCER. Web cite. Available from: http://www.pancreatic.org/site/c.htJYJ8MPIwE/b.891925/#q5

7. National Cancer Institute. Web cite. Available from: http://www.cancer.gov/cancertopics/types/pancreatic

8. Pelzer U, Arnold D, Gövercin M, et al. Parenteral nutrition support for patients with pancreatic cancer. Results of a phase II study. BMC Cancer. 2010;10:86.

9. Dobrila dintinjana R, Guina T, Krznarić Z. Nutritional and pharmacologic support in patients with pancreatic cancer. Coll Antropol. 2008;32(2):505-8.

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11. American Dietetic Association. Pocket Guide for International Dietetics & Nutrition Terminology (IDNT) Reference Manual. 3rd ed. Chicago, IL. 2011.

12. Pronsky ZM, Crowe Sr JP. Food Medication Interactions. 17th ed. Birchrunville, PA. 2012.13. Malnutrition Codes and Characteristics/Sentinel Markers. Academy of Nutrition and Dietetics

Web site. Available from: http://www.eatright.org/Members/content.aspx?id=6442451284&terms=DRG+coding.

14. Up To Date. Pneumatosis Intestinalis. Web cite. Available from: http://www.uptodate.com/contents/pneumatosis-intestinalis

Questions