Download The patient chosen for this case study, JL, is a 53 year old

MAJOR CASE STUDY
NUTRITION AND ACUTE PANCREATITIS
Michelle Smith | 2013
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Table of Contents
Introduction .................................................................................................................................... 4
Social History................................................................................................................................... 4
Normal Anatomy and Physiology of Applicable Body Functions.................................................... 5
Past Medical History ....................................................................................................................... 5
Present Medical Status and Treatment .......................................................................................... 6
Theoretical Discussion of Disease Condition .............................................................................. 6
Usual Treatment of the Condition .............................................................................................. 7
Nutrition Treatment ................................................................................................................ 7
Medical Treatment .................................................................................................................. 8
Patient’s Symptoms upon Admission Leading to Present Diagnosis .......................................... 8
Laboratory Findings and Interpretation ...................................................................................... 9
Medications ................................................................................................................................. 9
Observable Physical and Psychological Changes in Patient ...................................................... 10
Treatment.................................................................................................................................. 10
Medical .................................................................................................................................. 10
Surgical................................................................................................................................... 11
Medical Nutrition Therapy ............................................................................................................ 11
Nutrition History ....................................................................................................................... 11
Analysis of Previous Diet (24 hour recall) ................................................................................. 11
Current Prescribed Diet & Responses ....................................................................................... 12
Nutrition-Related Problems ...................................................................................................... 12
Evaluation of Present Nutritional Status ................................................................................... 12
Other Nutrients to Address ....................................................................................................... 13
Patient’s Nutrition Education Process ...................................................................................... 13
General Conditions upon Discharge.......................................................................................... 14
Emerging Research Relevant to Patient ....................................................................................... 14
Smoking and Pancreatitis .......................................................................................................... 14
Prognosis ....................................................................................................................................... 14
Summary & Conclusion ................................................................................................................. 15
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Appendix A – Lab Values ............................................................................................................... 17
Appendix B - Medications ............................................................................................................. 19
Bibliography .................................................................................................................................. 20
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Introduction
The patient chosen for this case study, JL, is a 53 year old Caucasian female who has
been diagnosed with acute pancreatitis. The patient also suffers from alcohol abuse and has
gallstones. The height of the patient is 5 feet 4 inches (162.56 cm) and she weighs 103 pounds
(46.95 kg). The patient was chosen for the case study because she had a nutrition-related
diagnosis that often requires enteral or parenteral nutrition support. The patient has been in
and out of the hospital starting back in June of 2011 with initial complaints of nausea, vomiting,
and abdominal pain. She was diagnosed with pancreatitis one year later in June of 2012. She
was recently re-admitted on January 1, 2013 with the same complaints of nausea, vomiting,
and abdominal pain for the past five days and had been unable to eat during that time. The
study ended January 11, 2013, when the patient was discharged.
Social History
The patient is unemployed and relies on social security as her sole source of income. She
is not married but does have a boyfriend that she lives with. When asked if she has any
children, her first response was no. The patient later stated she has two sons, ages 26 and 30,
but they are out of the house and they don’t keep in touch. She has trouble walking and
therefore has few responsibilities at home. The patient has a low standard of living with a
corresponding poor home environment. She admits to drinking 6 or 7 vodka beverages a day
which is down from the half gallon of vodka she used to drink everyday a year ago. She is a
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heavy smoker, going through one to two packs a day for the past 30 years. She is does not have
any religious affiliations and therefore has no special religious dietary guidelines to follow.
Normal Anatomy and Physiology of Applicable Body Functions
The pancreas is located in the abdomen behind the stomach and near the duodenum.
There are five main parts to the pancreas, the body, head, neck, tail, and uncinate. The
pancreas is also made up of a system of ducts, the main one called the pancreatic duct. The
pancreas has two functional components. They are called endocrine and exocrine parts. The
exocrine part contains acinar cells that are responsible for secreting enzymes into the
duodenum through the pancreatic duct. These enzymes are called amylase, protease, and
lipase. The pancreatic duct will merge with the bile duct and activate the enzymes, enabling
them to digest food. The endocrine part of pancreas contains the Islets of Langerhan cells that
are responsible for regulating the levels of glucose in the bloodstream by releasing insulin and
glucagon (1-3).
Past Medical History
Noted past medical history for the patient includes asthma, chronic obstructive
pulmonary disease (COPD), alcohol abuse, smoking, hypertension (HTN), angina, and a family
history of cancer. It has been documented that she has been admitted to the hospital 12 times
since June of 2011. Each of the 5 admitting diagnoses from June 2011 to May 2012 has included
shortness of breath (SOB) and either alcohol intoxication, syncope, nausea and vomiting with
abdominal pain, lower limb weakness, or right leg swelling. On June 26, 2012 she was again
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admitted for abdominal pain and was later diagnosed with pancreatitis. The six admitting
diagnoses since then included chest tenderness, abdominal pain with nausea and vomiting,
dyspnea and falls, or chest pain with palpitations.
Present Medical Status and Treatment
Theoretical Discussion of Disease Condition
Acute pancreatitis is an acute inflammatory condition of the pancreas. Causes of acute
pancreatitis include the presence of gallstones and chronic, heavy alcohol use (3,4). Ethanol and
its metabolites have numerous effects on the pancreas such as inflammation and necrosis from
cell death signaling leading to sensitizing the pancreas to pancreatitis (4). In a person with
normal pancreatic function, the enzymes produced by the pancreas are inactive until they
reach the intestines. In acute pancreatitis, inflammation of the pancreas will cause the enzymes
to activate early thus causing further damage (3). Complications caused by acute pancreatitis
include sepsis, acute renal failure, hypovolemia, circulatory shock, and pancreatic necrosis (2).
There can be varying amounts of injury not only to the pancreas but also to adjacent and
distant organs. It can even cause multisystemic organ failure and, ultimately, death (4,5). Acute
pancreatitis is defined by a discrete episode of abdominal pain and elevations in serum enzyme
levels. Symptoms of include nausea, vomiting, and diarrhea along with sudden and severe
abdominal pain (2) which can decrease or even eliminate oral intake of the patient. Severe
abdominal pain can be so disabling that some patients become addicted to pain medications
(2).
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Around 25% of acute pancreatitis patients go on to develop chronic pancreatitis (2). A
patient’s inability to stop drinking alcohol is the leading cause of chronic pancreatitis with
alcohol abuse accounting for 70-90% of the causes of chronic pancreatitis (6).
Usual Treatment of the Condition
Nutrition Treatment
There are many ways to classify acute pancreatitis but from a nutritional standpoint it is
most useful to categorize patients as those with either mild or complicated pancreatitis.
Seventy-five to 85% of pancreatitis diagnoses are considered mild (5). Intervention with
nutritional support is usually not required in mild pancreatitis and patients often recover
without intervention (4,5,7). This is due to the fact that oral intake often restarts within a few
days of hospitalization. It is thought that once oral intake resumes, diet orders should be clear
or full liquid and gradually increased to reduce stimulation of the pancreas (2). A recent goldstandard (prospective, randomized, controlled, double-blind clinical trial) study showed no
significant differences between symptoms in patient s with mild pancreatitis that progressed to
a solid food diet as opposed to clear liquid diet (8). During this time the patient should avoid
pancreatic irritants, especially alcohol, nicotine, and caffeine (2).
If pancreatitis is severe and oral intake is not expected to resume for greater than three
days after hospitalization, nutrition support will be needed (4). It is widely recognized that the
gut plays a role in maintaining immune system integrity (2) which is why the enteral route for
nutrition support is preferred (9). Research has shown fewer pancreatic problems are seen in
those who are enterally fed versus using total parenteral nutrition (TPN). Patients with acute
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pancreatitis receiving TPN have been shown to have statistically more pancreatic infection,
higher mulitsystemic organ failure, and high mortality when compared to patients receiving
enteral feedings (4). Noted benefits of enteral nutrition when compared to parenteral nutrition
include prevention of gut bacteria translocation, alleviating oxidative stress, faster healing, and
fewer complications from infections (5). Using an elemental formula has shown to have more
benefits compared to standard formulas. An elemental formula causes less stimulation to the
pancreas because of their low fat content (5). Enteral nutrition support may not always be
tolerated by patients and parenteral nutrition may be the only recommended route available. If
parenteral nutrition is chosen as the preferred route, it must be monitored to ensure the
patient does not develop the complications associated with it (5).
Medical Treatment
Medical treatment for acute pancreatitis includes surgeries such as necrosectomy,
pancreaticoduodenectomy, or sphincterotomy (2). Surgical treatment is only performed in
patients with severe acute pancreatitis to remove necrotic tissue and is not recommended
within the first two weeks after initial onset of the disease (7).
Patient’s Symptoms upon Admission Leading to Present Diagnosis
According to previous notes, before admission to the hospital in June 2012, the patient
was experiencing abdominal pain with nausea and vomiting. She stated that she would drink
vodka to dull the pain.
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Laboratory Findings and Interpretation
There are many clinical indicators for acute pancreatitis. Clinical history that may be
seen in a patient with acute pancreatitis include rapid heart rate, left upper quadrant
abdominal pain, nausea and vomiting, steatorrhea, and results from a CT scan showing
interstitial pancreatic edema. Lab work that may be seen in a patient with acute pancreatitis
include lipase > 110, amylase > 250, glucose > 200 and decreased levels of potassium, sodium,
calcium, and magnesium (2). Labs collected from the patient on the day the diagnosis of
pancreatitis was made can be found in Appendix A. These labs shows decreased sodium and
calcium levels along with increased amylase, lipase, and ethanol levels. Appendix A also
contains labs showing elevated lipase and ethanol levels during previous hospital admissions.
The lipase levels are consistently above 110. The ethanol values show that once the patient was
diagnosed with pancreatitis and informed that alcohol consumption could make it worse, her
intake of alcohol decreased considerably when she was experiencing abdominal pain. Prior to
her diagnosis, she stated she would drink more alcohol to ease the abdominal pain. After her
pancreatitis diagnosis the patient didn’t enter the hospital with ethanol intoxication as often as
she had prior to the diagnosis.
Medications
A list of the medications the patient was on when at the hospital recently in January
2013 is provided in Appendix B. Also listed are the uses, descriptions, and possible side effects
that relate to the patient.
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Observable Physical and Psychological Changes in Patient
The major physical change seen in the patient is weight loss. She stated her usual body
weight 6 months ago was 134 pounds. Upon admission she weighed 103 pounds. At a height of
5 feet 4 inches, she is only 86% of her ideal body weight. Psychologically, the patient seems to
be in denial about having any health problems due to drinking or smoking. It has been
explained to her that drinking will worsen the condition but she admits to drink 6 or 7 drinks
per day unless she is experiencing abdominal pain. The patient has also been offered help with
smoking cessation but has declined it.
Treatment
Medical
According to previous notes and documents, on June 25, 2012, a computerized
tomography (CT) scan of the patient’s abdomen was performed. The results showed steatosis,
cholelithiasis with questionable gallbladder wall thickening, mild edema at the head of the
pancreas, diffuse colon bowel wall thickening in primarily the left half of the colon that may
represent colitis. A magnetic resonance cholangiopancreatography (MRCP) of the abdomen
without contrast was also performed that day. It showed increased signal intensity on T2weighted images involving the pancreas with slight decreased signal intensity on the T1weighted images. There was a mild prominence of the head of the pancreas, edematous
changes in the peripancreatic fat. Edematous changes involved the lateral conal fascia on the
left anterior pararenal fascia. No pancreatic fluid collections were seen. These findings were
consistent with acute pancreatitis.
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Surgical
During this most recent admission, an endoscopy was performed on January 3, 2013. It
showed a normal duodenum and normal GE junction. A stomach biopsy was also performed to
rule out H. pylori. There are no plans to remove any part of her pancreas as there is not any
necrotic tissue.
Medical Nutrition Therapy
Nutrition History
The patient does not follow any specific diets at home nor has she in the past. She
usually eats 2 or 3 meals per day, mainly lunch and dinner. Food is purchased by her live-in
boyfriend. She prepares her own lunch at home which is usually a microwaveable frozen
entrée. When her boyfriend gets home from work, he will prepare dinner for the two of them
which is, again, a microwaveable frozen entrée. The patient denies avoiding any particular
types of food unless she is having abdominal pain with nausea and vomiting. In those instances
she will avoid most foods.
Analysis of Previous Diet (24 hour recall)
The patient’s 24-hour recall was performed after admission to the hospital. The previous
afternoon she had undergone a procedure that required her to not consume anything by
mouth that morning. The patient was able to eat dinner and stated she had a chef salad (190
kcals, 21 g protein) and turkey sandwich (375 kcals, 18 g protein). This totals 565 kcals and 67 g
protein. The patient’s needs are between 1410-1645 kcals and 56-66 g protein per day.
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Current Prescribed Diet & Responses
The current diet prescribed is a solid regular diet with Ensure Plus ordered twice a day.
Her previous diet orders have been clear liquids when she was preparing for an endoscopy
procedure. She was able to start oral intake soon after admission to the hospital and therefore
was not placed on enteral or parenteral nutrition support. The patient has had a good response
to the diet psychologically. She enjoys the ability to have meals prepared from fresh vegetables
such as salad. Physically she is responding well to the prescribed diet. She is slowly gaining
weight, around 5 pounds in 10 days, which is needed due to unintentional weight loss from
vomiting which also caused decreased oral intake.
Nutrition-Related Problems
Upon admission to the hospital, the patient had 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.
Evaluation of Present Nutritional Status
Due to recent unintentional weight loss, it was recommended that the patient
consumes 30-35 kcals/kg body weight and 1.2-1.4 g protein/kg body weight. This is
approximately 1410-1645 kcals and 56-66 g protein per day. This increased intake of kcals and
protein will help replenish lost nutrient stores. Consumption of Ensure Plus supplements twice
a day would also increase kcal and protein intake.
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Other Nutrients to Address
Some researchers believe supplementation with antioxidants may shorten the patient’s
length of stay in the hospital and may also decrease complications in patients with acute
pancreatitis but further clinical trials are required (10). Other researchers show no support for
immunonutritional supplements (11). Probiotics have also been suggested to benefit patients
with severe acute pancreatitis but results have not been consistent enough to make
recommendations (11). During her previous admissions, the patient was given thiamine, folic
acid, and a multi-vitamin for alcohol withdrawal.
Goals, Interventions, Monitoring, and Evaluation
The first goal for this patient is to eat more than 50% of meals three times a day. The
next goal is to drink Ensure Plus twice a day. The final goal is to limit pancreatic irritants such as
nicotine and alcohol. Interventions for the patient include a general healthful diet and medical
food supplements. The patient will be monitored and evaluated by checking her food and
beverage intake.
Patient’s Nutrition Education Process
The patient has a few issues that will hinder the process of educating her on nutrition.
She is intelligent but does not seem to understand just how damaging drinking and smoking are
for her health. She seems to be in denial. She also has very little support from her family. She
does have a boyfriend but based on one of my visits, he seems like he needs to be taken care of
by her at times and he may be enabling her. She is a native English speaker which helps but she
seems to have little motivation to change.
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General Conditions upon Discharge
Upon discharge, the patient stated she had her appetite back and denied any nausea,
vomiting, or abdominal pain. The importance of decreasing smoking and alcohol consumption
were again emphasized and the patient said she understood, however, lack of motivation was
apparent.
Emerging Research Relevant to Patient
Smoking and Pancreatitis
Chronic tobacco consumption is an independent risk factor of pancreatitis. It increased
the frequency of all major complications of alcoholic chronic pancreatitis in a dose-dependent
fashion apart from alcohol intake (6). This shows that if the patient goes on to develop chronic
pancreatitis, she will really need to consider smoking cessation to avoid major complications.
Prognosis
Unless the patient stops drinking alcohol and quits smoking cigarettes, it is unlikely her
pancreatitis symptoms will completely go away. In the past year the patient has been admitted
to the hospital 10 times. The patient has been diagnosed with pancreatitis for 6 months and
continues to drink heavily every day. Her reported alcohol intake has decreased slightly from a
year ago but is still very high. The patient understands importance of quitting smoking and not
drinking alcohol for improved outcomes but seems unmotivated to do so. She has been offered
smoking cessation help but has declined it. One positive is since being diagnosed with
pancreatitis the patient has learned that drinking will only exacerbate the problem and she
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stops drinking when she feels the abdominal pain. In the past, she stated that when she had the
severe abdominal pain she would drink more to dull the sensation. Unfortunately, the patient
continues to drink when she isn’t experiencing abdominal pain.
Summary & Conclusion
From this case study I learned not to judge a person before seeing them, even when you
hear things about them that make you think you know them. After reading the notes from
doctors about the patient’s high alcohol consumption and seeing that she has been in the
hospital 6 times in the past year, I thought I would be walking in on a grumpy woman who
wouldn’t be willing to answer my questions. When I entered her room, she was on the phone.
By the way she was talking I could tell it was her boyfriend and she was consoling him. Once she
saw me walk in, she told him she had to go and hung up. That alone impressed me as I have had
some patients keep talking on the phone and ignore me altogether or wave me away. I
explained to her that I would be asking a lot of questions, some of which might be personal and
she did not have to answer any that made her uncomfortable. Once I started my inquiries she
really opened up to me. She is actually a very nice woman and was willing to answer anything I
asked. She is going through tough times right now but I am hoping that someday soon she will
realize she needs to make some big changes for her health.
As for pancreatitis, I learned a lot of new things about the disease that I didn’t know
before. I didn’t realize how gallstones will irritate the duct and cause the pancreas to become
inflamed. I knew that chronic alcohol abuse would make the situation worse but I didn’t know
that 70-90% of alcohol abusers would go on to develop chronic pancreatitis. I also wasn’t aware
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that so many studies need to be done to fully determine many aspects related to nutrition and
pancreatitis.
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Appendix A – Lab Values
Labs outside normal limits from day of diagnosis: June 25, 2012
Sodium
Calcium
AST
Amylase
Lipase
Ethanol
Lab Value
132
8.1
81
140
298
87
Normal Value Range
135-145
8.5-10.2
10-40
23-85
10-60
<10
Labs showing elevated lipase levels during previous hospital admissions
Date
6/26/12 (day after diagnosis)
7/15/12
9/4/12
1/1/13
1/2/13
1/11/13
Lab Value
476
119
114
213
172
117
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Labs showing ethanol levels during previous hospital admissions
Date
6/4/11
6/7/11
4/26/12
5/3/12
5/22/12
6/25/12
7/15/12 (after diagnosis)
9/14/12
11/16/12
12/21/12
Lab Value
397
129
99
228
203
87
< 10
< 10
93
< 10
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Appendix B - Medications
Drug
Albuterol
Use
for asthma
and COPD
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.
Cymbalta
(duloxetine)
for
depression
Selective
serotonin
and
norepinephrine
reuptake
inhibitor for oral administration
as antidepressant.
Advair
for asthma
and COPD
Zestril
(lisinopril)
for HTN
Miralax
for
occasional
constipation
Dulcolax
(bisacodyl)
for cleaning
out the
intestines
before a
bowel
examination
/surgery
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 enzyme Vomiting, diarrhea, heavy sweating,
(ACE) inhibitor.
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 Nausea, abdominal cramping, or gas.
stool to soften the stool and
increases the number of bowel
movements.
Works by increasing the Stomach/abdominal pain or cramping,
movement of the intestines, nausea, diarrhea, and weakness.
helping the stool to come out.
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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.
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