Download Chronic Pancreatitis - Medical Nutrition Therapy Manual

Patient and Diagnosis
Name: Anna Dough
Sex: Female
DOB: 3/18
Age: 38
Height: 5’ 8”
Weight: 152 lbs
Chief complaint: “I have pain in my lower stomach almost every day. I am so
uncomfortable that I find it hard to eat and have lost 6 pounds in the past two weeks
because of it.”
Patient History:
Anna is a 38-year-old dental assistant who parties and drinks heavily on a regular basis.
She often consumes four beers at a time, three to four nights a week, for the past ten
years. She smokes a pack a day, but has quit three times over the past four years. She
consumes a lot of fast food because she thinks cooking for one is silly.
Nutrition History:
General: Anna has not been eating very much lately due to the pain in the stomach.
Eating is often uncomfortable for her and usually results in diarrhea or vomiting.
Usual diet: Coffee for breakfast, peanut butter and jelly with a pepsi and potato chips for
lunch, a granola bar for a snack, and a McDonald’s cheeseburger and fries for dinner.
Diagnosis:
Chronic pancreatitis due to high alcohol consumption for an extended time.
Treatment Plan:
Ibuprofen for pain management, as needed
Creon 10 Oral, 1 capsule per meal or snack
Smoking cessation
Avoid alcohol
High carbohydrate, low fat diet
Small frequent meals
Multivitamin Supplement
Chronic Pancreatitis
The pancreas produces chemicals (enzymes) needed to digest food and produces the
hormones insulin and glucagon.
Chronic pancreatitis is an inflammation of the pancreas that does not heal or improve,
gets worse over time, and leads to permanent damage. Inflammation and scarring of
the pancreas prevents the pancreas from producing enzymes, insulin and glucagon.
Impairment of the pancreas results in an inability to digest foods, especially fats,
properly.
Etiology
I.
II.
III.
Cause
a. Years of alcohol abuse
b. Repeat episodes of acute pancreatitis
c. Genetics
d. Autoimmune problems
e. Blockage of the pancreatic duct or the common bile duct
f. Cystic Fibrosis complications
g. Hypertriglyceridemia- high levels of triglycerides in blood
h. Hyperparathyroidism- overproduction of parathyroid hormone
Symptoms
a. Abdominal pain
i. Occurs mainly in the upper abdomen
ii. May last hours or days, or be continuous
iii. May be made worse by eating, drinking, and alcohol
iv. May be felt in the back
b. Digestive problems
i. Chronic weight loss with normal eating
ii. Diarrhea
iii. Nausea
iv. Vomiting
v. Fatty or oily stools,
vi. Pale or clay-colored stools
c. Symptoms may mimic pancreatic cancer
d. Symptoms may become more frequent as condition worsens
e. Sitting up and learning forward may relieve symptoms
Tests
a. Fecal fat test
b. Serum amylase
c. Serum amylase
d. Serum lgG4
e. Serum lipase
f. Serum trysinogen
g. Inflammation or calcium deposits of pancreas
i. Abdominal CT scan
ii. Abdominal ultrasound
iii. Endoscopic Retrograde Cholangiopancreatography (ERCP)
iv. Endoscopic Ultrasound (EUS)
v. Magnetic Resonance Cholangiopancreatography (MRCP)
Diagnostic Measures
Biochemical measurements are most useful to determine pancreatic function. The
biochemical levels most useful in diagnosing chronic pancreatitis are isoamylase,
lipase, trysin, and elastase.
I.
II.
III.
Pancreatitis Tests
a. Fecal Fat Test- measures the amount of fat in the stool to determine how
much dietary fat that body is not absorbing
b. Serum Amylase- measures the level of the enzyme (which digests
carbohydrates) in the blood
c. Serum lgG4- determines autoimmune pancreatitis
d. Serum Lipase- measures the amount of the protein enzyme (breaks down
fatty acids) in the blood
e. Serum Trypsinogen- measures the amount of trypsinogen (breaks down
proteins into amino acids) in the blood
Inflammation or Calcium Deposits in Pancreas
(Includes changes in the ducts of the pancreas)
a. Abdominal CT scan- x-ray to create cross-sectional pictures of the belly
area
b. Abdominal Ultrasound- used to examine the internal organs of the
abdomen, including the liver, gallbladder, spleen, pancreas, kidneys, and
some blood vessels
c. Endoscopic Retrograde Cholangiopancreatography (ERCP)- an
endoscope is passed through a catheter into the ducts that lead to the
pancreas and gallbladder to identify stones, tumors, or narrowing bile
ducts
d. Endoscopic Ultrasound (EUS)- an endoscope is inserted into an organ
and combined with an ultrasound to get images of internal organs in the
chest and abdomen
e. Magnetic Resonance Cholangiopancreatography (MRCP)- uses magnetic
resonance imaging to visualize the biliary and pancreatic ducts
Exploratory laparotomy
(May be done to confirm diagnosis, but is usually done for acute pancreatitis)
a. While under general anesthesia, a surgeon makes a cut in the abdomen
and examines that abdominal organs
Treatment
I.
Medical, Surgical, Psychological Treatment
a. Lifestyle
 Consume a diet to maintain a healthy weight
 Low fat
 Eat small, frequent meals
 Drink plenty of liquids
 Consume adequate vitamins and minerals
 May need to add a supplement
 Limit caffeine
 Avoid smoking
 Avoid alcohol
b. Medications
 Pancreatic enzymes to take with each meal
 Helps digest foods better and gain weight
 Pain medications
c. Pancreatic Enzyme Replacement Therapy
 A stent is placed in the biliary duct to facilitate the flow of bile.
 Controls diarrhea
 Stabilizes patients weight
 Manage malabsorption
 Decrease pressure in the ductal system
d. Hospitalization
 For people with severe pain or people losing weight may need
hospitalized for:
 Pain medications
 Fluids given through a vein
 Insert a PEG (percutaneous endoscopic gastrostomy)
feeding tube into the stomach to limit the activity of the
pancreas
 Inserting a tube through the nose or mouth to remove
contents of the stomach (nasogastric suctioning)
II.
Medical Nutrition Therapy
a. Dietary Concerns
 Nausea, vomiting, diarrhea which can cause malnutrition because
food intake may be limited
 Loss of appetite
 Steatorrha (fat in the stool) leads to vitamin deficiency
 Poor digestion of proteins, fats, and carbohydrates
 Glucose intolerance
b. Recommendations
 High Carbohydrate
 Low fat
 Six small meals a day
 High fiber
 Maintain a healthy body weight
 Medium-chain triglyceride oils
 Vitamin B12 supplement
 Drink plenty of fluids
c. Foods Recommended
Food Group
Protein
Dairy
Fruit
Vegetable
Grains
Beverages
Other
Foods
Baked, broiled, grilled, or steamed lean meats and poultry
without skin, fish, eggs
Low fat/nonfat dairy including milk, cheese, yogurt, ice cream,
frozen yogurt
All fresh, frozen, canned
All fresh, frozen, cooked
Whole grains including bagels, bread, hot/’cold cereals, pasta,
rice
Water, fruit juice, vegetable juice, hot chocolate, tea
Spices/herbs, applesauce, angel food cake, honey, mustard,
jam, butter
d. Foods to Avoid
Food Group
Protein
Dairy
Fruit
Vegetable
Grains
Beverages
Other
Foods
Fried, fatty, or heavily marbled meats and poultry with skin,
organ meats, duck, fried eggs, processed meats
Cream, fried cheese, whole fat dairy, milkshakes, half and half
Avocado, fried fruits
Fried
Fried grains, biscuits, croissants, fried potatoes, granola, corn
chips
Beverages with cream, eggnog, soda
Lard, seeds, shortening, coconut milk, nuts, nut butters
e. Sample Meal Plan
Meal
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Menu
Omelet with peppers, mushrooms, and kale
2 slices of toast with 2 tsp butter
1 cup Orange Juice
1 cup low fat greek yogurt with ½ cup blueberries
1 cup water
Whole wheat pita with grilled chicken breast, peppers, spinach,
tomatoes, and 2 T hummus
½ sweet potato with 2 tsp butter
1 cup low fat milk
1 cup water
1 cup low fat cottage cheese with ½ cup pineapple
1 cup water
Grilled tuna with lemon butter sauce
Whole wheat roll
1 cup grilled asparagus spears
1 cup low fat milk
Baked apple with honey and cinnamon
1 cup water
III.
Prognosis
a. Chronic pancreatitis cannot be cured
b. Damage to the pancreas is continuous and irreversible
c. Can lead to complications
 Ascites
 Blockage of the small intestine or bile ducts
 Blood clot in a vein of the spleen
 Infections
 Diabetes due to inability of pancreas to produce insulin
 Pseudocysts (fluid-filled sacs in the pancreas)
 Nutrient malabsorption
 Vitamin malabsorption
 Especially fat-soluble vitamins A, D, E, and K
 Breathing problems due to a decrease in the level of oxygen in the
blood
 Pancreas failure
 Pancreatic cancer
d. May lead to death or disability
e. Symptoms and pain can be managed
References
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Cerner Multum, Inc. (2010, December 12). Creon 10 (Pancrelipase Delayed-Released
Capsules) Drug Information: Indications, Dosage and How Supplied - Prescribing
Information at RxList. Retrieved from http://www.rxlist.com/creon-10-drug/indicationsdosage.htm
Chronic Pancreatitis - Symptoms, Diagnosis, Treatment of Chronic Pancreatitis - NY
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Dietary Reference Intakes: Electrolytes and Water. (2005). IOM Home - Institute of
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D083D86164C75B.ashx
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Huffman, MD, J. L. (2012, March 8). Chronic Pancreatitis. Medscape. Retrieved from
http://emedicine.medscape.com/article/181554-overview
Kalloo, MD, A. N. (n.d.). Chronic Pancreatitis: Introduction . Johns Hopkins
Gastroenterology and Hepatology. Retrieved from http://www.hopkinsgi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=024CC2E1-2AEB-4D509E02-C79825C9F9BF&GDL_Disease_ID=0ADCFD83-7DE7-4D53-82F56F0C9BFB7F14
Longstreth, MD, G. F. (2010, January 20). Chronic pancreatitis - PubMed Health.
National Center for Biotechnology Information. Retrieved from
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Meletis, N.D., C. D. (2003). Chloride: The Forgotten Essential Mineral. Elete Water.
Retrieved from http://eletewater.com/uploads/elpdf/chloride_meletis.pdf
Nutrition 411 (2011, October). Eating With Chronic Pancreatitis. Retrieved from
http://www.nutrition411.com/education-materials/allergies-intolerances-and-specialdiets/item/313-eating-with-chronic-pancreatitis
Stanford Hospitals and Clinics (2012, December). Nutrition Guidelines for Chronic
Pancreatitis Patient Education. Retrieved from
http://stanfordhospital.org/digestivehealth/nutrition/DH-Nutrition-Therapy-for-ChronicPancreatitis.pdf