Morgan Overby MAJOR CASE STUDY

Background information PathophysiologyEtiologySigns/symptomsCourse of treatmentMedical nutrition therapyNutrition prescriptionDiet orders LabsMedicationsADIME

OVERVIEW

B.S is a 39 y.o African-American, male B.S admitted to University Mississippi Medical Center

(UMMC) on October 9, 2013 and discharged on October 19, 2013.

Patient diagnosis- Pancreatitis with previous alcohol abuse.

B.S reports and decreased appetite for ~1 month resulting in ~8# weight loss.

Family PMH: Father-T2DMPatient receives support from family.

BACKGROUND INFORMATION

Pancreatitis can occur in two forms, acute pancreatitis or chronic pancreatitis. Pancreatitis is characterized by edema, autodigestion, fat necrosis, and hemorrhage of pancreatic tissue(Nelms, Sucher, Lacey, & Roth,

2011).Chronic pancreatitis is progressive inflammation of

the pancreas and causes irreversible damage to the organ (Vonlaufen et al., 2007).

chronic pancreatitis can lead to serious loss of exocrine and endocrine function of the pancreas and even deterioration of the pancreas (Beers and Berkow, 1999.)

PANCREATITIS

Chronic pancreatitis is caused by alcohol abuse in majority of adult patients (Vonlaufen et al., 2007).

Alcohol consumption aff ects the pancreas by causing the pancreas to produce toxic substances which lead to pancreatitis over time (National Institute of Alcohol Abuse and Alcoholism, n.d).

Puylaert et al., (2007), noted that chronic pancreatitis in 70 to 80 percent of patients is linked with excessive alcohol abuse; although, many alcoholics do not develop pancreatitis.

Puylaert et al., (2007), stated that in 30 percent of those with pancreatitis, alcohol use is not a cause.

PANCREATITIS

Chronic pancreatitis can also be result of genetic mutations (hereditary), autoimmunity, excessive production of the parathyroid hormone, and pancreatitis seen in tropical countries, tropical pancreatitis (Vonlaufen et al., 2007).

Chronic pancreatitis can also be caused by an obstruction of the main pancreatic duct which can be caused by stones, stenosis, or even cancer.

Severe acute pancreatitis can potentially cause suffi cient pancreatic ductal stenosis which alters drainage and can lead to chronic pancreatitis; however, this cause is very rare (Beers and Berkow, 1999).

PANCREATITIS

According to Vonlaufen et al., (2007), symptoms of pancreatitis range from pain, the most common symptom, to maldigestion and diabetes.

Beers and Berkow (1999), state that in chronic pancreatitis sometimes there will be no pain, but severe epigastric pains can last from several hours to several days

If a patient develops lipase and protease secretions that are less than 10 percent of normal, they will begin to develop steatorhea and creatorrhea

PANCREATITIS SYMPTOMS

B.S was treated using Whipple procedure, Peustow procedure, and partial gastrectomy.

A Whipple procedure, or a pancreaticoduodenectomy, is performed to remove the cancerous head of the pancreas or bile ducts. The cancerous tissue, portions of the pancreas, bile duct, small intestine and stomach will be removed and reconstructed (Cancer Treatment Centers of America, 2013).

A partial gastrectomy is performed to resection part of the stomach (Nelms et al., 2011).

A Peustow procedure, or a pancreaticojejunostomy, connects to pancreatic duct and pancreas to the small intestine.

COURSE OF TREATMENT

Nelms et al., (2011), noted that nutritional status of those with chronic pancreatitis depends on the underlying etiology of the disease and the level of endocrine and exocrine function in the patient.

Fat intake should be limited in those with chronic pancreatitis to help prevent steatorrhea (Nelms et al., 2011).

According to the Evidence Analysis Library (2005), there was no research to prove the evidence of a low-residue diet for reducing symptoms linked with pancreatic cancer.

MEDICAL NUTRITION THERAPY

In another conclusion statement by the Evidence Analysis Library (2005), there was limited research for proving the relationship between the use of EPA as a fish oil supplement for reducing weight loss in those with pancreatic cancer.

There is also limited evidence to prove that the acute phase response in cancer patients can be aff ected by fatty acids (Evidence Analysis Library, 2006).

MEDICAL NUTRITION THERAPY

1,815 to 2,178 kcal which was based on providing 25 to 30 kcal/kg. However, Alexander (2005), states that calorie needs for those with chronic pancreatitis may be as high as 30 to 35 kcal/kg.

87 to 109 g protein which was calculated using 1.2 to 1.5 g/kg.

1,815 to 2,178 ml based on the calculation of 1 ml/kcal fluid.

NUTRITION PRESCRIPTION

October 9-14 B.S was NPO.October 15 B.S was advanced to a mechanical soft

diet. Reports of minimal intake, but tolerating foods

October 15 diet was advanced again to a low-fat diet.October 17, still on low- fat diet. B.S stated that his

appetite was not great and he reports eating approximately 50 percent of his breakfast but says he is not hungry again throughout the day.

October 18 diet advanced to a regular diet.October 19 B.S discharged w/ reports of eating ~50%

of meals.

DIET ORDERS THROUGHOUT STAY

A 24 hour recall was completed on October 18 with results of B.S consuming 681 kcal and 61 g protein,

24 HOUR RECALL

Date Diet Order Estimated Needs

Breakfast % Intake Lunch % Intake Supper % Intake

10/10/13 NPO 1,815-2,178 Kcal (25-30 kcal.kg)87-109 g protein (1.2-1.5 g/kg)

0 0 0

10/15/13 Low Fat/Mechanical Soft

1,815-2,178 Kcal (25-30 kcal.kg)87-109 g protein (1.2-1.5 g/kg)

50% 0% 10%

10/18/13 Regular 1,815-2,178 Kcal (25-30 kcal.kg)87-109 g protein (1.2-1.5 g/kg)

75% 25% 25%

10/19/13 Regular 1,815-2,178 Kcal (25-30 kcal.kg)87-109 g protein (1.2-1.5 g/kg)

75% 50% 50%

NUTRITIONAL INTAKE

160 pounds (72.6 kg) 6’1” IBW 184 pounds (83.63 kg) 87%IBW. BMI 21 which is classified as normal according to the

Centers for Disease Control and Prevention (2011).

ANTHROPOMETRICS

According to Nelms et al., (2011) it is important to monitor laboratory data of blood glucose, triglycerides, hemoglobin, hematocrit, and white blood cells.

Nelms et al. (2011) also states that because pancreatitis is an inflammatory state, laboratory values of albumin, prealbumin, and transferrin may not be good indicators of nutritional status in these patients.

LABORATORY DATA

Lab 10/9 10/10 10/11 10/12 10/13 10/14 10/15 10/16 10/17 10/18

Blood Glucose

179 118 N/A 86 81 68 79 93 92 85

Hemoglobin 12.9 11.8 N/A 9.8 9.8 9.9 9.8 8.6 9.7 9.5

Hematocrit 39.1 36.9 N/A 29.4 30.1 30.9 29.5 26.3 29 28.2

WBC 7.2 8.3 N/A 6.7 5.4 5.5 7.3 6.3 5.7 N/A

LABORATORY DATA

Throughout B.S’s course of stay his blood glucose levels were consistently normal.

Blood glucose measures the level of glucose, a specific sugar, in the blood stream (WebMD, 2011).

The normal blood glucose level is 65-99 ml/dl (American Dietetic Association, 2009).

B.S did have an elevated blood glucose level on the day of admission but this is likely due to the fact that he was eating more before admission to the hospital.

LABORATORY DATA

Hemoglobin is a specific protein found in erythrocytes which works to deliver oxygen to cells and picks up carbon dioxide for expiration by the lungs (Nemls et al., 2011).

The normal range for hemoglobin in men is 13.6-18 g/dl (American Dietetic Association, 2009).

During B.S’s hospital stay, his hemoglobin never reached the normal ranges.

His hemoglobin was low likely due to iron-deficiency anemia or protein-energy malnutrition.

LABORATORY DATA

Hematocrit is the percentage of blood which is actually made of red blood cells.

Hematocrit is much like hemoglobin and will be low likely to iron deficiency anemia.

The normal range for hematocrit in males is 40-54 percent (American Dietetic Association).

B.S’s hematocrit level was decreased during his entire course of stay likely to anemia.

LABORATORY DATA

White blood cells function to fight off infection, protect to body from invasion by foreign organisms, produce, and transport and distribute antibodies throughout the body.

The normal range for white blood cells is 5-10 x 10 9 (SI units).

B.S’s white blood cell count was normal throughout his length of stay.

The white blood cell count has the potential of being decreased in infection, anemia, alcoholism, shock, sepsis, and hematopoietic disease (American Dietetic Association, 2009).

LABORATORY DATA

Cefoxitin is used as an antibiotic. The drug helps to fight various bacterial infections in

the body, including those infections that are severe or life-threatening.

Cefoxitin has a food/drug interaction with sodium. There are approximately 53 mg of sodium per gram of Cefoxitin. The drug should be used cautiously in those with hypertension, fluid restrictions, sodium restrictions, or congestive heart failure (CHF) (Drug Information Online, n.d).

MEDICATIONS

Famotidine is used as a histamine 2-blocker which helps to reduce the amount of acid produced by the stomach.

The drug can be used to prevent or treat stomach or intestine ulcers, gastroesophageal reflux, and conditions in which to stomach produces too much acid.

There are no known food/drug interactions for Famotidine (Drug Information Online, n.d).

MEDICATIONS

Heparin is an anticoagulant and is used as a blood thinner to prevent to formation of blood clots.

Heparin will often times be used before surgery to decrease the risk of blood clot formation.

There are no known food/drug interactions for Heparin (Drug Information Online, n.d).

MEDICATIONS

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) used to reduce inflammation in the body (Drug Information Online, n.d).

B.S was likely prescribed this drug to aid in pain for his pancreatitis and the inflammation caused by the disease. Ketorolac should be used cautiously in those with hypertension and should not be used by those using alcohol (Drug Information Online).

MEDICATIONS

Diagnose Intervention Monitor Evaluate

Inadequate energy intake related to patient being NPO status for seven days 2/2 to pancreatitis surgery, decreased appetite as evidenced by 5.5% weigh loss during hospital stay and calorie intake 10/18 of 681 and protein intake of 61 grams.

-When medically appropriate, advance diet as tolerated.

-If unable to advance PO consider alternate methods of nutrition.

-weight

-labs

-weight does not further decrease.

-labs WNL

ADIME

Diagnose Intervention Monitor Evaluation

Impaired nutrient utilization related to compromised endocrine function of the pancreas related (pancreatitis) as evidenced by 5.5% weight loss in seven days, hypoglycemia, decreased appetite, and reports of ~8 pound weight loss in ~ one month.

-If PO intake remains decreased, consider alternate methods of nutrition.

-Boost Plus TID.

-Appetite stimulant.

-weight

-labs

-weight does not further decrease

-labs WNL

ADIME

B.S was discharged from UMMC on October 19, 2013. When he was discharged it was recorded that he was

eating ~50 percent of all his meals. For a patient with severe weight loss it would be ideal that the patient be discharged after eating for than 50 percent of each meal.

The patient was stable when he was discharged and at discharge his prognosis looked good.

Patient was discharged home with mother who supports the patient.

The patient was scheduled for a follow up with the doctor two weeks after discharge.

SUMMARY

QUESTIONS