MEDICAL NUTRITION THERAPY

STATUS-POST WHIPPLE

PROCEDURE

Valerie AgyemanUMD Dietetic InternJune 2016

OUTLINEOVERVIEW OF CONDITION MEET THE PATIENTNUTRITIONAL CONSIDERATIONSNUTRITIONAL DIAGNOSIS AND THERAPYEMERGING RESEARCH AND CONCLUSION

FUNCTION OF THE PANCREASExocrine cells Produce enzymes to help with the digestion of food. Pancreatic enzymes are released in the duodenum.

Endocrine cells Release hormones “insulin and glucagon” into the

bloodstream. Controls blood sugar (glucose) levels.

ANATOMY OF THE PANCREAS

OVERVIEW OF THE CONDITION

PANCREATIC ADENOCARCINOMA•Pancreatic Adenocarcinoma (exocrine tumor) begins in the tissues of the pancreas, specifically the cells that line the ducts of the pancreas. •Associated with a poor prognosis•Hard to detect in early stages•Common symptoms:• upper abdominal pain, jaundice, loss of appetite, nausea, vomiting, & weight loss•Treatment of this cancer depends on the location and cell type of tumor• Patients who develop cancer within the head of pancreas may undergo the Whipple procedure

WHIPPLE PROCEDURE ALSO KNOW AS “PANCREATICODUODENECTOMY”•A procedure that involves removing the head of the pancreas, part

of the small intestine (duodenum), gallbladder and a part of the bile duct.•Remaining parts of the pancreas, stomach and intestines are reconnected to allow the body to digest food.•High risk of infection and bleeding.•Patients may experience nausea and vomiting due to altered stomach emptying delayed gastric emptying or dumping syndrome•Long recovery time.

BEFORE SURGERY VERSUS AFTER SURGERY

MEET THE PATIENT: SG

GENERAL INFORMATIONSG is a 72 year old Caucasian femaleBMI: 24.5 Seen in BWMC Outpatient GI OR (3/11) for Endoscopic Ultrasound Fine Needle Aspiration.Dx: Pancreatic AdenocarcinomaPt had generalized pruritus, jaundice, darkening of urine, clay colored stools, GI upset, URI and a reported weight loss.

SG was admitted 3/14, and was discharged 3/22 after 9 days of hospitalization.

GENERAL INFORMATIONSocial/Family History

Medical History Surgical History

• Patient is divorced. • Patient has 6 children • Retired• Hypertension, Diabetes,

and Cardiovascular disease on the father’s side.

• Denied smoking and drug use.

• Former alcohol drinker.

• Type 2 Diabetes Mellitus

• Hypertension• Dyslipidemia• Hypothyroidism• Congestive Heart

Failure

• Refractive surgery• Dilation and curettage• Blepharoplasty• Orthopedic surgery

(Left knee)• Endoscopic retrograde

cholangiopancreatography (February 2016)

• Esophagoscopy/EGD • Esophageal ultrasound

NUTRITIONAL HISTORYHistory obtained from family: Good appetite prior to dx of pancreatic cancer. Patient lost a significant amount of weight, associated with nausea and smell aversions decreasing intake prior to the pancreatic cancer dx. Chewing difficulties due to a weakened jaw prior to admission, but denied any difficulties swallowing.Patient follows a CHO Controlled diet at home.Supplements:Vitamin B12, folic acid, vitamin C, calcium & vitamin D. ONS: unknown

WEIGHT HISTORYUBW 171#, 152# at admission~20 lbs weight loss in two months (12% weight loss in two months)

DATE WEIGHT (IN POUNDS)

SOURCE OF WEIGHT

% UBW % IBW

MARCH 7

150 MEASURED 88% 115%

MARCH 11

152 MEASURED 89% 117%

MARCH 14

152 MEASURED 89% 117%

MARCH 18

160 (?FLUID) MEASURED 94% 123%

HOSPITAL MEDICATIONSSCHEDULED Cipro (Antibiotic) Flagyl (Antibiotic) Heparin (Blood thinner) Lantus/SSI (Insulin) Protonix (proton pump inhibitor) Geodon (anti-psychotic, for anxiety) Lopressor (beta blocker, for HTN) Apresoline (Vasodilator, for HTN) Dilaudid (narcotic)

CONTINUOUS IVF: NS at 100 mL/hr

PRN Dulcolax (laxative) Benadryl (anti-histamine) Zofran (anti-nausea)

LABSLab Referen

ce Range

3/14 3/15 3/16 3/17 3/18 3/19 3/20 3/21 3/22

Na 136-144 mmol/L

132 129 133 133 128 132 133 132 134

K 3.5-5.3 mmol/L

3.2 4.2 3.3 3.2 4.1 3.7 3.2 3.8 3.3

Cl 98-107 mmol/L

102 103 107 106 103 107 103 104 106

CO2 22-32 mmol/L

18 19 19 20 17 18 22 21 22

Creatinine

0.9-1.3 mg/dl

0.85 0.84 1.00 1.00 1.18 0.73 0.81 0.90 0.85

Glucose 75-110 mg/dl

272 267 244 257 269 235 172 163 -

BUN 7-25 mg/dl

10 11 13 12 16 8 7 9 11

Bili Total 0.1-1.3 mg/dl

2.4 - - - - - - - -

Ca 8.6-10.3 mg/dl

6.9 6.6 6.8 7.5 6.7 7.0 7.4 7.8 7.6

Phos 2.5-5 mg/dl

- - 3.0 - 3.0 1.9 2.8 2.6 2.7

Mg 1.8-2.5 mg/dl

1.2 1.9 1.7 - 1.7 1.4 1.3 1.3 1.2

AST 15-41 IU/L

73 - - - - - - - -

ALT 7-52 IU/L

54 - - - - - - - -

WBC 4.8-10.8 k/uL

15.3 19.4 17.2 17.2 17.2 9.8 8.9 14.8 11.2

HIGHLIGHTS FROM HOSPITAL STAYDay 1 (3-14-16) Robotic assisted Whipple procedure, cholecystectomy, wedge liver biopsy, wedge resection of the portal vein and vascular reconstruction. Patient in ICU. Diet: NPO.

Day 2 (3-15-16) POD #1 Nutrition consult received from RN screen for weight loss and poor po. A foley was started to monitor urine output. Hyponatremia. Hypophosphatemia. Hyperglycemia. BS absent, no BM. LBM 3/13. NGT was placed for suction. Patient removed NGT; d/c. 2 JP Abdominal drains. Edema: +2 LUE/RUE. Respiratory: 2L nasal cannula. Diet: NPO.

Day 3 (3-16-16) POD #2 Patient was lethargic. Patient complained of (c/o) nausea. BS absent, no BM. Hyponatremia. Hypophosphatemia. Hyperglycemia. Renal: labs consistent with acute kidney injury (AKI), Nephrology consult ordered. Respiratory 2L nasal cannula. Edema +2 LUE/RUE. Diet: NPO

HIGHLIGHTS FROM HOSPITAL STAY

Day 4 (3-17-16) POD #3 Patient c/o abdominal pain. Delirium, alert not oriented. Hypokalemia and hypomagnesemia. Hyponatremia improving. Hypocalcemia and anemia being monitored. WBC’s elevated. Hyperglycemia. Blood pressure elevated treated with Lopressor. BS absent, no BM. Bowel regimen given (dulcolax). AKI associated labs and urine output being monitored. Respiratory: Room air. Diet: NPO.

Day 5 (3-18-16) POD #4 Mental status slowly improving; Hyponatremia. Hypokalemia. Hyperglycemia continued despite insulin regimen. No BM. Minimal UO. Failed bedside swallow. SLP consult ordered. Surgery approved sips of clears and ice chips. Increased activity, walking with PT. Diet: CLD (sips), ice chips. Intake: n/a.

Day 6 (3-19-16) POD #5 SLP evaluation completed. Diet advanced to FLD, nectar thick per SLP. Post-operative anemia improving. Edema: +2 generalized. Stable creatinine, improving urine output. Serum sodium stable, hyperglycemia improving and hypophosphatemia improving. BM overnight noted. Diet: FLD, nectar thickened liquids. Intake: n/a.

HIGHLIGHTS FROM HOSPITAL STAYDay 7 (3-20-16) POD #6 Overall condition stable. Tolerating diet. Pain controlled with po pain medication. Hypophosphatemia improving. Hyponatremia stable. Stable renal function. Foley d/c. No BM. Diet: FLD, nectar thickened liquids. Intake: n/a.

Day 8 (3-21-16) POD #7 Alert and oriented, ambulating with PT. Patient reported a good appetite. Overall condition stable. Denied pain. BM today. Low magnesium. Nutrition Education: Whipple Nutrition therapy. Transferred from ICU to step down unit. Diet: Diet advanced to CHO controlled, nectar thickened liquids, 6 small meals. Intake: PO intake is “fair” per EPIC chart documentation.

Day 9 (3-22-16) POD #8 Discharged and transferred to a sub-acute rehabilitation facility (Genesis Corsica Hills) for PT. Next appointment scheduled for 3/29/16 with physician.

DIET AND PO INTAKE DATE DIET MODIFICATIONS INTAKEMARCH 14 NPO X 1 DAY NONE 0%MARCH 15 NPO X 2 DAYS

(NUTRITION CONSULT RECEIVED)

NONE 0%

MARCH 16 NPO X 3 DAYS NONE 0%MARCH 17 NPO X 4 DAYS NONE 0%MARCH 18 Clear Liquid (sips), ice

chips.NONE FEW SIPS OF

ICE CHIPS AND ENSURE

CLEARMARCH 19 Full Liquid Diet Nectar thickened liquids NOT

DOCUMENTED

MARCH 20 FULL LIQUID DIET NECTAR THICKENED LIQUIDS NOT DOCUMENTE

D MARCH 21 CHO controlled

standard, 6 small meals

NECTAR THICKENED LIQUIDS 50% X 2 MEALS

MARCH 22 CHO Controlled standard, 6 small meals

NECTAR THICKENED LIQUID DISCHARGED IN THE EARLY

MORNING, NOT

DOCUMENTED.

NUTRITIONAL CONSIDERATIONS Alteration of GI tract post Whipple procedure can result in multiple long term nutritional complications:

GastroparesisDumping SyndromeExocrine pancreatic insufficiency: Fat maldigestionDiabetesNutrient deficiencies

NUTRITION DIAGNOSIS AND THERAPY

NUTRITION DIAGNOSESMalnutrition (NI 5.2) related to pancreatic head adenocarcinoma, decreased appetite as evidenced by ~20 lbs weight loss in two months, 12% weight loss in two months, family reports of poor po and 2+ edema in lower and upper extremities.

Unintentional weight loss (NC 3.2) related to pancreatic head adenocarcinoma and decreased appetite as evidenced by ~20 lbs weight loss in two months, 12% weight loss in two months.

Altered GI function (NC 1.4) related to GI surgery status post Whipple and cholecystectomy as evidenced by potential for fat and carbohydrate malabsorption.

NUTRITION PRESCRIPTIONNPO until cleared by surgery. Advanced from CLD to FLD, to CHO Controlled Diet. CHO Controlled Standard (1600-2000 kcals) diet, 6 small meals, Nectar thick liquids.

1380-1932 calories/day (20-28 kcal/kg, using act wt. 69 kg).82.8-103.5 gm protein/day (1.2-1.5 g/kg for post op recovery)1725-2070 ml fluid/day (25-30 ml/kg, using act wt. 69 kg)

NUTRITION INTERVENTIONNutrition Education (NE 1.4) Whipple Nutrition therapy education to family and patient. Provide handouts as a reference. GOAL: Patient will tolerate diet after discharge.Referral to other providers (RC-1.5): Refer to SLP. GOAL: Evaluate need for modified consistency diet/risk of aspiration based on diet advancement post Whipple.Referral to other providers (RC-1.5): Refer to outpatient GI RD. GOAL: Patient receives more information regarding altered GI and nutrition, and nutritional status is monitored after discharge.Prescription medication (ND-6.1): Recommend bowel regimen. GOAL: Patient’s bowel function improves.Collaboration with other providers (RC-1.4): Collaborate with medical team to provide the best nutrition care for patient (bowel function, diet tolerance, SLP for texture modification, repletion of electrolytes, blood glucose management). GOAL: Patient is nutritionally stable for discharge to rehab.

MONITORING AND EVALUATIONIndicator Criteria

Total energy intake (FH-1.1.1.1)

Food and nutrition knowledge (FH-3.1)

Adherence (FH-4.1)

Labs (BD 1.2)

Weight (AD-1.1.2)

GI function (PD 1.1.5)

Patient consumes >75% of meals.

Patient is able to describe the importance of optimal nutrition during post op recovery.

Patient visits outpatient gastrointestinal RD and continues to follow diet recommendations after discharge.

Patient’s labs remain stable and within normal range.

Patient’s weight trends stabilize.

Patient will have no complaints of abdominal pain, nausea/vomiting, diarrhea (symptoms of malabsorption/maldigestion), bowel movement will be regular.

EMERGING RESEARCH Recent research suggests that there may be an inflammatory component that is:

Predictive of Pancreatic Cancer survival in advanced disease

An inflammatory process associated with periodontal disease may occur before the development of the cancer.

CONCLUSIONS

KEY POINTS RD’s should provide an Individualized nutrition therapy based on each patient’s preferences and ability to handle certain foods.RD’s play a crucial role in counseling this patient population to: avoid unnecessary dietary restrictions to increase variety in the diet to improve the patient’s quality of life through close monitoring and attention to signs and symptoms

to help optimize nutritional status and help prevent complication exacerbation

QUESTIONS?

REFERENCES •Decher N, Berry Amy. Post-Whipple: A Practical Approach to Nutrition Management. Nutrition Issues in Gastroenterology. 2012: 108: 30-42.•Berry, Amy. Pancreatic Surgery: Indications, Complications, and Implications for Nutrition Intervention. Nutrition in Clinical Practice. 2013: 28(3): 330-357.•Nutrition Therapy for Pancreatic Cancer. Cancer Treatment Centers of Americans. www.cancercenter.com/pancreatic-cancer/nutrition-therapy/. Accessed June 2, 2016. •Understanding Pancreatic Cancer. National Pancreatic Cancer Foundation. www.npcf.us. Accessed May 25, 2016. •Pancreatic Cancer. American Cancer Society. www.cancer.org/pancreatic-cancer-pdf. Accessed June 8th, 2016.•Academy of Nutrition and Dietetics (n.d.). Pancreatic Cancer. https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=145168. Accessed May 2, 2016.•Evidence Analysis Library. Oncology: Pancreatic Cancer. http://www.andeal.org/topic.cfm?menu=5291&cat=3201. Accessed June 2, 2016.• Julie, A. Jacob M.A. Study Links Periodontal Disease Bacteria to Pancreatic Cancer Risk. American Medical Association. 2016. pp. E1-E2. •Hutchinson, L. Pancreatic Cancer: Inflammatory Index to Predict Survival. Nature Reviews Clinical Oncology. 2016 (89). • Image from slide 4: http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/image_article_collections/anatomy_pages/Pancreas2.jpg• Image from slide 8: http://www.arizonatransplant.com/images/pancreas_large_5.JPG