Case 13 Medical Nutrition Therapy

 April 6, 2015 Unit Five – Nutrition Therapy for Hepatobiliary and Pancreatic Disorders Case 13 – Acute Pancreatitis

1. Describe the normal exocrine and endocrine functions of the pancreas. The pancreas is a large digestive gland located behind the stomach. The pancreas has to ma!or functions " endocrine and exocrine functions. The pancreas is the onl# organ that has both exocrine and endocrine functions. The exocrine functions produce en$#mes necessar# for digestion hile the endocrine functions produces hormones to regulate the use of bod# fuel, mainl# glucose. 2. Determine the potential etiolog# of both acute and chronic pancreatitis. %hat information provided in the ph#sical assessment supports the diagnosis of acute pancreatitis&  Acute pancreatitis has some persisting s#mptoms. These s#mptoms include upper upp er abdominal abdominal pain that normall# normall# orsens orsens ith ingestio ingestion n of foo food. d. The mechanism that leads to pancreatic in!ur# is not 'non, hoever there are common characteristics li'e the premature activation of tr#psin ithin the pancreas, resulting in auto digestion of the pancreatic cells. The en$#mes released b# destro#ing b# destro#ed pancreatic cells eventuall# reach the bloodstream, hich causes elevated serum am#lase and lipase levels. A diagnosis of acute pancreatitis is based on clinical s#mptoms and abnormal serum am#lase and lipase levels. (hronic pancreatitis is an irreversible inflammation, hich leads to fibrosis ith tissue calcification. )igns and s#mptoms are chronic abdominal pain and elevated pancreatic en$#me levels. The patient described having increasing abdominal pain, hich is a t#pical s#mpt s# mptom. om. *e als also o co compl mplain ained ed of fre fre+ue +uent nt na naus usea ea an and d h hich ich ar are e bot both h associated ith acute pancreatitis as ell. . %hat laborator# values or other tests support this diagnosis& -ist all abnormal values and explain the li'el# cause for each abnormal value. The pa The patie tient nt has sev severa erall la lab b va value lues s th that at su suppo pport rt the dia diagn gnosi osis s of ac acut ute e pancreatitis. pancreat itis. *is -D* levels, A)T levels, / levels, )erum cholesterol and trigl#ceride trigl#cer ide levels, ( levels, levels, and %( count count are all elevated. The most telling lab values are the extremel# elevated -ipase and Am#lase levels. The high levels of bilirubin are common among pancreatitis patients. These are hat helped diagnose acute pancreatitis. The patient has several other abnormal laborator# values. *is high serum osmolalit#, /, and creatinine all indicate that the patient is deh#drated. Ther Th ere e is an el elev evat ated ed le leve vell of al al'a 'ali line ne ph phos osph phat atas ase e co coul uld d be du due e to inflammation in the liver. 3f there is inflammation, gallstones can form and then bloc' bile ducts, this then causes bile to collect and bac' up. This bac'up causes damage to liver hich in turn causes an increase in A- levels. leve ls. AA-T T is alan alanine ine amin aminotra otransfe nsferas rase. e. Th The e AA-T T leve levels ls are a biol biologic ogical al mar'er mar' er of gal gallsto lstone ne panc pancrea reatiti titis. s. (re (reatin atine e pho phosph spho'in o'inase ase or (4 leve levels ls

could be elevated because of the inflammation in the patients muscle. (4 is an en$#me found in muscles and (4 levels become elevated hen there is an# 'ind of muscle damage or inflammation. )egs  and ands  are t#pes of neutrophils. The neutrophils are elevated because the# are a t#pe of  hite blood cells and elevated hite blood cell count is t#pical among acute pancreatitis patients. *e also tested positive for ilirubin and /robilinogen, in his urine. These all indicate that there is a problem in the in the some t#pe of  biliar# obstruction. rotein and rotein ch' ere both positive and this could be seen in the urine of some patients ith pancreatitis. The presence of  'etones is also a possible sign of pancreatic problems. 7. The ph#sician lists an AA(*8 score in his note. %hat factors are used to determine this score& %hat does this mean&  AA(*8 means Acute h#siolog# and (hronic *ealth 8valuation 33 and it is a classification s#stem in hich the severit# of the disease is calculated. 9alues of 12 clinical measures are used from the first tent#:four hours after  admission. The patients age, chronic health conditions and ph#siological variables are all ta'en into account hen determining a score. The higher the  AA(*8 score, the more severe the disease and also the higher the ris' of  death. The criteria used to get a score are; the age, i?2 levels, a?2 levels,  Arterial p*, )odium levels, otassium levels, (reatinine levels, hether or  not the patient had acute renal failure, hematocrit levels, and %(. The patients AA(*8 score as 7, this indicates that his severit# of disease is lo and also that his mortalit# rate is lo. 5. %hat are the potential complications of acute pancreatitis& otential complications of acute pancreatitis include shoc', pulmonar# failure, renal failure, gastrointestinal bleeding, and multiorgan s#stem failure. 6. *istoricall#, the patient ith acute pancreatitis as made ?. %h#& This patient has an < tube placed@h#&

/suall# a patient ith acute pancreatitis is made ? because it is assuming that not having the patient consume foods b# mouth ould stimulate the pancreas and aggravate it causing even more inflammation of the pancreas. This patient has an < tube placed because he needs nutrients to his bod# as soon as possible, but he also needs the food to be partiall# digested in order for his bod# to be able to brea' them don. *e stated that he has eaten ver# little over the past three da#s because of pain, nausea, and vomiting, so it is important that he gets some nutrients into him through enteral feeding immediatel#. . The ph#sician has ritten an order for a nutrition consult to start enteral feedings. /sing the most current literature and A)8 guidelines, explain the role of enteral feeding in acute pancreatitis. Do #ou agree ith the initiation of enteral feeding& %h# or h# not&

3n past #ears, it as thought that pancreatic neglect as the best a# to treat pancreatitis, but no ne research has been done ith shos that stimulating the gut ith enteral nutrition is beneficial to the patient. Also, parenteral nutrition is used as a last resort for patients, if the# can process food even a little bit then having them still use their digestive tract is important to 'eep it functioning. 3 agree ith the initiation of enteral feeding in this patient, because it is important he get nutrients using his digestive tract. 8nteral feeding ould have the food alread# partiall# bro'en don so it ould be easier for the stomach to brea' don, hich ould reduce the pain. Also, if the digestive tract is not used, then the patient could be at ris' for the digestive tract to stop or'ing. Also,recent studies have shon that enteral nutrition helps patients to recover faster over parenteral nutrition. B. Does this patients case indicate the use of an immune:modulating formula&  According to current evidence, enteral feeding is prefered over parenteral feeding. 3t is recommended that the tube feeding consists of supplements such as omega: fatt# acids, and other necessar# vitamins. 3mmune: modulating formula is not recommended because extra supplementation is not needed. The patient shos signs of elevated %(, hich indicates an immune response. This is probabl# due to the pancreatitis. 3mmune modulating formula formula is not needed. C. %hat research supports the use of probiotics in acute pancreatitis& 3s there an# evidence supporting the use of supplemental glutamine& There is conflicting evidence hen it comes to the use of probiotics and its effects in acute pancreatitis. )ome studies have shon that there are positive effects of using probiotics, but more recent studies have found opposite results. There is evidence supporting the use of supplemental glutamine in acute pancreatitis patients. )tudies sho that glutamine supplementation reduced the mortalit# rate of patients. 10. Assess =r. =ahons height and eight. (alculate his =3 and  usual bod# eight. =3; =3  E %eight in ounds F E *eight in inches x *eight in inches G G x 0 E275 lbs F E1 inGH2G x 0  7 =3 (lassified as obese /%; 1C5 lbs /%  E100 x Actual %eightGF/sual bod# eight  E100 x 275 lbsGF1C5 lbs  126

11. 8valuate =r. =ahons initial nursing assessment. %hat important factors noted in his nutrition assessment ill affect #our nutrition recommendations& *is excessive inta'e of alcohol, constant vomiting and nausea, and a stead# eight gain over the past 5 #ears ould affect m# nutrition recommendations to him. *is excessive amounts of alcohol inta'e puts more strain on his pancreas because of the need to process the high amounts of alcohol, causing oxidative stress to the gland. *e ould need to cut don on the alcohol consumption or remove alcohol from his diet to allo his pancreas to recover. *is constant nausea and vomiting ould affect m# nutrition recommendations because 3 ould need to 'eep in mind that it is hard for him to eat and 'eep food don. )upplements of vitamins and minerals ma# need to be given to ma'e sure he receives the appropriate amount of nutrients to 'eep him health# and in safe ranges of nutrient inta'e. *is constant eight gain over the past five #ears could ma'e me recommend for him to decrease his his caloric inta'e once he is able to 'eep food don again. 3 believe his decrease in alcohol consumption ould help ith this issue, but counseling him on a general health# diet could help him decrease his eight to a health# =3. 12. Determine =r. =ahons energ# and protein re+uirements. 8xplain the rational method #ou used to calculate these re+uirements. 8nerg# eeds *arris:enedict 8+uation *eight; 511 1 in  1B0.7cm %eight; 275lb  111.1'g Age; 2C =ales; 88 66.5 I 1.B Eeight in 'gG I 5.0 Eheight in cmG: 6.B E#ear oldG 66.5 I E1.B x 111.1'gG I E5 x 1B0.7G : E6.B x 2CG 66.5 I 1,5.6 I C01. : 1C.2  2,05 'cal -ight activit# ; 2,05 J 1.  !""# $cal per da# : to maintain eight rotein 3nta'e; *igh levels of distress from abdomen pain 2 gF'g  2g x 111.1'g   % of protein dail# 1. Determine =r. =ahons fluid re+uirements. (ompare this ith the information on the inta'eFoutput record. 0:70 ccF'g avg si$e adult and 1B:57 #rs old 5cc  5cc x 111.1'g  ,BC0 cc or ,BC0 ml The information on the inta'eFoutput record sa#s he is inta'ing 7,500m- and he is output is 7,BCm- per da#. This information tells me that he needs more fluid than his recommended fluid re+uirements and more fluid than his nutrition chart suggests because he is losing more fluid than he is ta'ing in. This could lead to deh#dration and cause other health complications.

17. >rom the nutrition histor#, assess =r. =ahons alcohol inta'e. %hat is his average caloric inta'e from alcohol each da# using the information that he provided to #ou& *is average caloric inta'e from alcohol ould be about 1,100 'cals or more from consuming about 11 alcoholic servings dail# and more on ee'ends. ?ne serving of alcohol averages at about 100 'cals. *e consumes 6 beers and 7.5 shots dail#, and more than that on ee'ends. 15. -ist all medication that =r. =ahon is receiving. Determine the action of each medication and identif# an# drug:nutrient interactions that #ou should monitor. Drug

Mechanism of Action

Drug-nutrient interactions

3mipenen

inhibits bacterial cell:all s#nthesisK binds to penicillin:binding proteins

 Alcohol should not be consumed. Ta'ing ith meals or on an empt# stomach ma# affect results : should be ta'en in beteen meals.

epcid

*:2 histamine bloc'er. educes the amount of acid in the stomach. *elps to heal and prevent stomach ulcers, and prevents s#mptoms li'e heartburn.

*:2 bloc'ers inhibit 12 absorption, and are associated ith decreased iron absorption.

=eperidine

AnalgesicK acts as an agonist at the L: opioid receptor 

 Alcohol should not be consumed or else dangerous side effects or death can occur.

?ndansteron

Antiemetic through inhibition of 5:*TK selective serotonin 5: *T receptor antagonist.

-o levels of potassium or magnesium in the blood ma# also increase #our ris' of MT prolongation Edela#ed repolari$ation of the heartG.

=il' of =agnesia

Dras fluid from the bod# and retains fluid thats in the lumen of the intestine, thus stimulating nerves ithin the colon all, inducing peristalsis and resulting in successful release of colonic content

3nterferes ith absorption of man# nutrients, such as thiamine.

(olace EdocusateG

)oftens stool b# alloing incorporation of ater and fat, b# the reduction of surface tension of the oil:ater interface of the stool.

3mpacts magnesium levels and increases amount of potassium excreted in the stool.

 Ativan

() depressant.

Alcohol and other () depressants should not be consumed, as consumption could lead to fatal respirator# depression.

16. 3dentif# the pertinent nutrition problems and the corresponding nutrition diagnoses. The patient has not been able to eat due to pain : inade+uate oralFfood inta'e The patient drin's 7:5 shots and 6 beers dail# : excessive alcohol inta'e atient is diagnosed ith acute pancreatitis, hich compromises the function of his pancreas : impaired nutrient utili$ation 1. %rite #ou 8) statement for each nutrition problem. 3nade+uate oral inta'e, T patient feeling pain resulting in loss of appetite,  A8 diagnosed acute pancreatitis secondar# to F9. 3mpaired nutrient utili$ation, T compromised pancreatic function A8 excessive vomiting and diarrhea and significantl# elevated liver en$#mes -ipase ECB0 /F-G and am#lase E57 /F-G. 8xcessive alcohol inta'e, T lac' of nutrition education andFor unillingness to stop drin'ing, A8 27:hour recall E7:5 shots of bourbonFda# and 6 beersFda#G. 21. 3f this patients acute pancreatitis resolves, hat ill be the recommendation for him regarding nutrition and his alcohol inta'e hen he is discharged&  Alcohol should be avoided, even ell after he is recovered. )upplementation of thiamin and folate, as ell as a general multivitamin ould be ise due to ta'e care of an# deficiencies resulting from his alcoholism. ?nce a li+uid or solid diet is reached, the diet should consist of  high:protein, lo:fat, easil# digestible foods over 5:6 small meals. &eferences  Asrani, 9, et al. N