Major case study

1. Major case study Morgan Overby

2. Overview • Background information • Pathophysiology • Etiology • Signs/symptoms • Course of treatment • Medical nutrition therapy • Nutrition prescription • Diet orders • Labs • Medications • ADIME

3. Background information • 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-T2DM • Patient receives support from family.

4. Pancreatitis • 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.)

5. Pancreatitis • Chronic pancreatitis is caused by alcohol abuse in majority of adult patients (Vonlaufen et al., 2007). • Alcohol consumption affects 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. • Puylaertet al., (2007), stated that in 30 percent of those with pancreatitis, alcohol use is not a cause.

6. 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 sufficient pancreatic ductal stenosis which alters drainage and can lead to chronic pancreatitis; however, this cause is very rare (Beers and Berkow, 1999).

7. Pancreatitis Symptoms • 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

8. Course of treatment • 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 apancreaticojejunostomy, connects to pancreatic duct and pancreas to the small intestine.

9. Medical nutrition therapy • 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.

10. 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 affected by fatty acids (Evidence Analysis Library, 2006).

11. Nutrition prescription • 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.

12. Diet orders throughout stay • 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 19B.S discharged w/ reports of eating ~50% of meals.

13. 24 hour recall • A 24 hour recall was completed on October 18 with results of B.S consuming 681 kcal and 61 g protein,

14. Nutritional intake

15. Anthropometrics • 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).

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

17. Laboratory data

18. 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.

19. 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.

20. 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.

21. 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 109 (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).

22. Medications • 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. • Cefoxitinhas 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).

23. 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).

24. 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).

25. 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).

26. ADIME

27. Adime

28. Summary • 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.

29. Questions