Major Case Study: Acute Pancreatitis - PowerPoint Presentation

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Major Case Study: Acute Pancreatitis

Michelle Smith

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Outline

Introduction

Social & P

ast Medical History

Normal Anatomy & Physiology

Disease Condition

Lab Findings & Medications

Treatment

Past & Current Nutrition of Patient

Prognosis

Slide3

Introduction

JL

- 53

yowf

Dx

: Acute pancreatitisAlcohol abuse & gallstonesHt: 5’4”Wt:UBW: 134# Admission: 103# % wt change: 23%% IBW: 86%

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History of the Patient

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 daySmokes 1-2 packs per dayAsthmaCOPDAlcohol abuseHTN

AnginaSocial History

Past Medical History

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Normal Anatomy & Physiology of Pancreas

Exocrine

Acinar cells

Enzymes to digest food

Endocrine

Islets of Langerhan cellsRegulate glucose

Slide6

Acute Pancreatitis Disease Condition

Causes

Presence of gallstones

Chronic, heavy alcohol abuse

Complications

Sepsis, acute renal failure, hypovolemia, circulatory shock, pancreatic necrosisSymptomsNausea, vomiting, and diarrhea, with sudden & severe abdominal pain

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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

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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

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Drug

Use

Description

Side Effects

Albuterol

for asthma and

COPD

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.

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 depression

Selective 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.

Advair

for asthma and COPD

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.

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 HTN

Angiotensin

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.

Miralax

for occasional constipation

Works 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/surgery

Works by increasing the movement of the intestines, helping the stool to come out.

Stomach/abdominal pain or cramping, nausea, diarrhea, and weakness.

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Nutrition Treatment

Oral

vs

EN

vs

TPNOralClear liquids vs solid foodsENElemental vs standard formula

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Medical Treatment

Surgeries

Necrosectomy

Pancreaticoduodenectomy

Sphincterectomy

Remove necrotic tissue

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Medical and Surgical Procedures on Patient

CT scan and

MRCP

Cholelithiasis

Mild edema at the head of the pancreasSurgicalNo necrotic tissue

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Nutrition History

No specific diets

2 to 3 meals per day

Lunch & dinner

Microwaveable frozen entrees

24 hour recallTurkey sandwich & chef salad565 kcals, 39 g pro

40% kcals, 70% pro

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Prescribed Diet & Response

Solid regular & Ensure Plus BID

Enjoys fresh fruits & vegetables

Gaining weight

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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

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Nutrition Prescription

30-35

kcals

/kg body weight

1410-1645

kcals per day1.2-1.4 g pro/kg body weight56-66 g pro per dayEnsure Plus BID provides 700 kcals and 26 g pro

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Other Nutrients to Address

Pancreatitis

Antioxidants

Probiotics

Immunonutritional

supplementsAlcohol withdrawalThiamineFolic acidMulti-vitamin

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Goals> 50% of meals

Ensure Plus BID

Limit pancreatic irritants

Interventions

General healthful

dietMedical food supplementsMonitoring & EvaluationFood intake 3 meals per day Beverage intakeEnsure Plus BID

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Patient’s Nutrition Education Process

Pros

Intelligent

Native English speaker

Cons

DenialLimited family supportEnabling boyfriendLack of motivation

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General Conditions upon Discharge

Denied N/V or abdominal pain

Appetite had returned

Emphasized limiting smoking and alcohol consumption

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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

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References

Johns Hopkins Medicine. The Sol Goldman Pancreatic Cancer Research Center page. Available at: http://pathology.jhu.edu/pc/BasicOverview3.php?area=ba. 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: 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.

 

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L and Taft K. Acute pancreatitis: practical considerations in nutrition support.

Curr

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Rebours

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Vullierme

MP,

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F,

Hammel

P,

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P, Levy P. Smoking and the course of recurrent acute and alcoholic pancreatitis: a dose-dependent relationship.

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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.

 

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Xu

Y, Lu T,

Gao

F, Mo Z. Meta-analysis of enteral nutrition versus total parenteral nutrition in patients with severe acute pancreatitis.

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. 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

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Akerberg

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Drugs

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Questions??