cara conti post dietetic internship april 12th,...
TRANSCRIPT
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Cara Conti
Post Dietetic Internship
April 12th, 2012
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Rare tumor that occurs less than 1% compare to other cancers
American Cancer Society estimates for 2012: ◦ About 8,700 people in the US are diagnosed/year
◦ About 1,150 cases will result in death
Generally found in periampullary regions or ampullary regions that are near to the duodenum
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Helicobacter pylori infection (H. Pylori)
Smoking
Bacteria Infection Most common
predisposing factor Common cause of
peptic ulcers ◦ Thrives in an acidic
environment
Commonly live & multiply within the mucous layer that covers and protects tissues that line the stomach & small intestine
Not clear how H. pylori spreads
Can be treated with antibiotics
Interfere with the protective lining of the stomach Making your
stomach more susceptible to the development of an ulcer
Smoking also increases stomach acid
Stress
Promote H. pylori infection
Can cause the production of excess stomach acid
A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer,
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Earlier dx vs. Advanced Stage
Nausea Vomiting Epigastric pain Weight loss Most suffer from poor prognosis that would reduce the survival rates by 5 years that ranges from 20%-40%
Earlier Duodenal Cancer could be easily found by an endoscopy procedure without identifying the symptoms of the disease
The advanced stage of the Duodenal Cancer is found as the ulcerated legins or polyploidy ◦ could only be found due to
the radiography and by endoscopy
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Medical History and Physical Examination
Endoscopy with biopsies
CT scan of abdomen to determine extent of tumor spread
Blood Tests: CBC, electrolyte test and liver function tests ◦ Determine if spread
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Depends on staging and lymph node metastasis
Surgery: Main option and sometimes the only option ◦ Resection
◦ Whipple
Chemotherapy and/or radiation
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Chemotherapy Malnutrition ◦ Obstruction
N/V
Unintended weight loss
Loss of appetite
Diarrhea
Constipation
Acid Reflux
Anemia B12 & Iron
Xerostomia Taste Alterations Mouth Sores Low Blood Counts Fatigue ◦ Unable to perform ADLs
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Depending on individual case and po tolerance/intake
Tube feedings
TPN or PPN
Liberalize diet if diet is restricted
Check Fluids and electrolytes
Small, frequent meals
Consume supplement in between meals
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76 y/o female, JS, admitted to WUH on March 5th, 2012 c/o severe abdominal pain possibly 2˚ previous dx of duodenal CA in May 2011. JS reports N/V, unintentional 31.4% weight loss in 7 months, and unable to tolerate solid foods the past 3 weeks. Could only tolerate liquids in small amounts. Pt. also reports 7 months ago had a good appetite and good po intake.
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Comprehensive Assessment
Diagnosis
Intervention
Monitoring & Evaluation
Follow-ups
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JS
76 y.o. Female
Admitted: 3/05/2012
Discharged: 3/12/2012
This Hospital stay duration: 7 days
Admitting Dx: Abdominal Pain
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Smoked 1 pack/day for 40 years
Strong Family Hx of
GI/Gastric cancer
Middle Class
Caucasian
Occupation: Retired Teacher
Martial Status: Single
Habits: ◦ NO ETOH abuse
◦ Quit tobacco 15 years ago
Family: Lives with sister in Mineola ◦ Other sister flew in from FL
to move in and help
Family Hx: ◦ Mother died at 83y.o. of
colorectal cancer
◦ Father died in his 70s of GI cancer
◦ Sister died in her 70s from gastric cancer
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Duodenal CA (May 2011) ◦ Received Chemo RT August 2011 s/p attempted Whipple @
North Shore Hospital (January 2012) Found to have nonresectable disease D/C from North Shore
Hospital to Rehab for 2 weeks to regain strength
Breast CA s/p chemo RT and Left Breast lumpectomy ◦ 6 years ago (2006)
DVT ◦ associated c gastric outlet obstruction and MediportHTN
DM NASH HLD
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Exploratory Was found to have a
nonresectable disease
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Ultrasound ◦ Assess fluid-filled abdomen
NGT placement ◦ Suction fluid filled stomach
CT Scan ◦ Showed vascular mass in 3rd portion of
duodenum, causing biliary dilation ◦ Gastric Obstruction ◦ Multiple stones ◦ No evidence of mets
Endoscopy ◦ Stone Extraction ◦ Metal stent placement to correct obstruction
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Height Weight BMI UBW %UBW IBW %IBW
August 2011 (7 Months ago)
5’3” (63”)
210# 37.2 210# 100% 115#±10%
166%
3/7/12 5’3” (63”)
144# 25.5 210# 69% 115#±10%
114%
JS had a 31.4% weight loss in 7 months *Unable to tolerate solid foods, N/V
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HgbA1C: 4.6% WNL
Cholesterol: 127
Amylase: 14 433 144 42 15
Lipase: 38 900 302 96 39
Hgb Hct MCV Glu Na+ K+ BUN Crt Ca++ Adj. Ca++
Alb
3/5 11.9 WNL
36 WNL
98 WNL
105 WNL
141 WNL
4.3 WNL
13 WNL
0.8 WNL
8.8
9.1 WNL
3.6 WNL
3/12 9.9
29.2
96 WNL
96 WNL
138 WNL
3.7 WNL
8 WNL
0.5 WNL
7.8
8.9
2.6
*Requested a Pre-albumin
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Discharged Meds
Lovenox (Anticoagulant)
◦ Prevent DVT
Novolog Correction
◦ For hyperglycemia/DM
Zofran
◦ Prevent N/V caused by CA chemotherapy, RT, and surgery
D5W-1/2NS @50ml/hr
2˚ to weight loss
◦ Metformin
◦ Metoprolol
Home Medications
Warfarin (Anticoagulant)
Zocor o Lowers LDL
Current Medications
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Followed a regular diet, but watched sugar intake at home ◦ Good appetite and good po intake
Decreased po intake past 7 months ◦ 2˚ to abdominal pain, gastric obstruction, and chemo RT
Unable to tolerate solids the past 3 weeks ◦ 2˚ to severe abdominal pain and gastric obstruction
◦ Liquids in small amounts and sips of Ensure
Diet order: NPO ◦ 2˚ to tests, procedures, and stent placement
◦ NG Tube for suctioning of fluid filled stomach
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N/V (duration of 3 weeks) ◦ Unable to tolerate food
Decreased appetite
Unintended weight loss the past 7 months ◦ Type 2 Diabetes
Off medication (Metformin), A1C 4.6%
◦ HTN
Off medication (Metoprolol)
Muscle Loss ◦ Rehab to regain muscle and strength back
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On the Bright Side…
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25-30kcals/KG ◦ For weight
maintenance/deter weight loss
◦ 1640-1965kcals/day
Fat: 35-40gm ◦ 2˚ to fat restriction
Based on current body weight: 65.5kg
1.0-1.2gms/KG ◦ For slightly increased
protein needs
◦ 65.5-79gms/day
CHO: 245Grams
Diet does not meet nutritional needs 2˚ to NPO status
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Patient with unintended weight loss (NC-3.2) related to decreased ability to consume sufficient energy as evidenced by 31.4% weight loss in 7 months, poor po intake, and conditions associated with diagnosis and treatment (Chemo RT 2 to duodenal ca and gastric outlet obstruction)
Patient with altered GI function (NC-1.4) related to duodenal cancer as evidenced by N/V, abdominal distention, and NPOx4.
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Deter further weight loss ◦ Meet nutritional needs when diet advances to ≥ 75% po
intake of meals
Manage GI side affects
Maintain skin integrity
Attain normalized albumin levels within the next 3 days ◦ Albumin: 3.5-5.0g/dL
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Clears Full liquids Low-fiber
Will follow up after stent placement on po intake ◦ Provide supplements PRN ◦ Encourage mall, more
frequent meals ◦ Provide food preferences as
requested by patient when diet advances
Unintended weight loss ◦ Provide Supplement PRN
depending on po intake ◦ Recommend prostat
depending on po intake and albumin/prealbumin levels
When diet advances Recommend diet
Recommend pre-albumin ◦ further assess
nutritional status
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Pre-albumin requested to assess nutritional status
Request daily weights
Record po intake % when diet advances ◦ Provide supplements PRN
Monitor lab values
N/V
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Follow-Up
3/9/12
NPO x 4 days N/V Stent placed yesterday
(3/8/12) Acute pancreatitis likely from
procedure
Albumin 3.0 ◦ WNL
Skin: Intact Meds: Reviewed Continue with unintended
weight loss (NC-3.2) and altered GI function (NC-1.4)
Plan ◦ Recommend Pre-albumin
◦ Consider TPN/PPN until po tolerance can be established
◦ If diet advanced: clears Low-fat full liquidsLow-fiber, low fat
◦ Follow up with supplement prn when diet advances
◦ Follow up on labs
Amylase & Lipase
Pre-albumin
Amylase: 14 433 144 42 15 Lipase: 38 900 302 96 39
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Diet advanced to Clear liquids last night (3/10/12) ◦ Will advance to low-fat full
liquids tonight for dinner
Albumin 2.4 ◦ Moderate protein depletion
Bloated after clear liquid dinner last night
Continuing clears and will advance to low-fat full liquid diet for dinner tonight ◦ 75% po intake
Continue with unintended weight loss (NC-3.2) and altered GI function (NC-1.4)
Skin: Intact Plan ◦ Provide 6oz. Enlive 2x/day
Provides 200kcal & 7gms. Protein 2x/day
◦ Recommned 30ml Prostat 2x/day
Provides 101kcal & 15gms. Protein 2x/day
◦ Recommend Pre-albumin
Follow-Up
3/11/12
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CHO Protein Fat TOTAL
Total Grams 238 70 38 346
Total Kcals 960 280 342 1582
Total Percent 68.7% 20.2% 11%
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Diet: low fat, low fiber mechanical soft ◦ No green leafy vegetables
◦ Tolerating well
◦ 75% po intake at breakfast
Labs: Albumin 2.6 ◦ Indicates moderate protein
depletion
Skin: Intact
Continue with unintended weight loss (NC-3.2)
Plan: ◦ Continue to encourage po
intake
Small, more frequent meals
◦ Will provide 6 oz Enlive
3x/day which provides 200 kcal and 7 gms protein 3x/day
◦ Recommend Pre-albumin
◦ Recommend MVI
Follow-Up
3/12/12
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Prognosis was fair adequate Follow-up with primary care physician in 1-2
weeks and GI doctors prn Continue low fat, low fiber diet, but add fiber
as tolerated higher fiber intake Avoid Green vegetables until tolerated Education provided ◦ Fluid intake ◦ Diet guidelines
Increase fiber as tolerated
◦ Small, frequent meals
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Prospective cohort study to determine the relationship between intake of dietary fiber/whole grains and the incidence of small intestinal cancer
Methods: analyzed dietary data collected in 1995 and 1996 from 293,703 men and 198,618 women in the National Institutes of Health–AARP Diet and Health Study ◦ used multivariate Cox proportional hazards models to estimate relative
risk (RR) and 2-sided 95% confidence intervals (CIs) for quintiles of dietary fiber and whole grain intake
Results: Through 2003, 165 individuals developed small intestinal cancers. Dietary fiber/whole grain intake was generally associated with a lower risk of small intestinal cancer.
Conclusions: Intake of fiber from grains and whole-grain foods was inversely associated with small intestinal cancer incidence ◦ Grain fiber & whole grain foods seem to protect against lower GI
cancers
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American Cancer Society. Cancer Facts and Figures. Atlanta, Ga.
American Cancer Society, 2012. www.cancer.org Beyer P.L. (2008) In L.K. Mahan & S. Escott-Stump (Eds.), Krause's
Food , Nutrition & Diet Therapy . St. Louis, Missouri: Saunders Beers, M.H. & Porter, R.S. (2006). Small-Bowel Tumors. The Merck
Manual of Diagnosis and Therapy (p. 172-173). Whitestone Station, NJ: Merck & Co., Inc.
Escott-Stump, S. (2012), Nutrition and Diagnosis-Related Care 7th ed. Baltimore, Maryland and Philadelphia, PA: Lippincott Williams & Wilkins.
Litchford, MD. (2008). Assessment: Laboratory Data. In L.K. Mahan & S. Escott-Stump (Eds.), Krause's Food , Nutrition & Diet Therapy 12th ed.(pp. 415-427, 936-939). St. Louis, Missouri: Saunders
Pronsky, ZM & Crowe, JP. (2010). Food/Medication Interactions 16th ed. Birchrunville, PA.
Schatzkin A., & Park, Y (2008). Prospective Study of Dietary Fiber, Whole Grain Foods, and Small Intestinal Cancer. Gastroenterology 4 (p. 1163-1167). Washington, DC: Division of Cancer, Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services.
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Questions??