Pancreaticoduodenectomy

- Treatment of Pancreatitis
Dawn Frick
Sodexo Dietetic Intern
January 30, 2015

Introduction J.S.
Our patient J.S.

52 year old married, Caucasian male

History of chronic pancreatitis and alcoholism

Admitted to St. Joseph Medical Center

12/15/14

Scheduled pancreaticoduodenectomy/
Whipple procedure

Social History
Family Lives with his wife and step-daughter
- Type 1 diabetic
- Wife sole shopper and chef for the family

Education Some college

Profession Unknown probable blue collar
Religion Presumably non-religious
Smoker for 42 years
Alcohol use for many years
- Details uncertain

Objective Data
Initial physical assessment
Thinning, gray hair

An old 52 years wrinkles, puffiness around his

eyes

Cracked skin red, flaky patches

182.9 cm (6 ft)

68.8 kg (152 lbs.)

BMI 21.3 a healthy weight

Objective Data
Initial physical assessment
Blood pressure 157/81

Temperature 36.8 C (98.3 F)

Diet - NPO

Constipation prior to surgery last bowel

movement 12/14/15

History of pancreatic enzyme use

Objective Data Lab Results

Labs

JS

Normal Labs

4 mg/dL

10-20 mg/dL

0.5 mg/dL

0.6-1.2 mg/dL

155, 137, 162, 110 mg/dL

<150 mg/dL

Ca2+

8.0 mg/dL

9.0-10.5 mg/dL

Mg2+

1.5 mEq/L

1.3-2.1 mEq/L

Na

136 mEq/L

136-145 mEq/L

4.0 mEq/L

3.5-5.0 mEq/L

AST

60 U/L

8-48 U/L

ALT

88 U/L

7-55 U/L

Lipase

15 U/L

10-140 U/L

11.6 g/dL

14-18 g/dL

BUN
Creatinine
POC Glucose

Hb

Objective Data - Medications

Medication

Reason

Mechanism of
Action

Nutritional
Impact

Zofran

Antiemetic/Antinause
ant

Serotonin receptor
antagonist

Constipation/Diarrhea

Heparin

Anticoagulant
before and after
surgery

Inactivates
coagulation enzymes

Nausea/vomiting
Vitamin K interaction

Albuterol

Bronchodilator

Binds to beta(2)
receptos in lungs
relaxes bronchial
smooth muscles

Possibility of
increasing appetite.
Limit caffeine

Dilaudid (Morphine)

Analgesic
Management of pain

Binds to opioid
receptors and
provides analgesic
effects

Possible loss of
appetite with nausea
or vomiting

Objective Data - Medications

Medication

Reason

Mechanism of
Action

Nutritional
Impact

Insulin - SSI

Blood sugar control

Provides hormone for

cells to use glucose

Balance with
carbohydrate intake

Pantoprazole

Treatment of GERD

Proton pump inhibitor

May decrease
absorption of iron,
calcium, or vitamin
B12, Ca2+
supplements may be
advised.

Hydralazine

Antihypertensive
Lowers blood
pressure

Vasodilator

Possible increase or
decrease in patient's
body weight. Avoid
natural licorice.

Medical History

Acute Pancreatitis
Type 2 Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Hypertension
Cirrhosis of the Liver
Hepatitis C
Reflux
Anxiety
Depression
Previous cholecystectomy
Family history of diabetes and
liver disease

Initial Consultation December 18, 2014

ICU Day three s/p Whipple

Receiving Dilaudid to manage pain

Diet not yet advanced

A little difficult to understand

Eager to begin a Clear Liquid Diet

15 minute consultation
Obtained social, nutrition, and medical history as
able

Nutrition History

Appetite Poor
Intake Poor

Weight Loss

Less foods he could tolerate

Poor historian on diet prior to surgery
50 lbs in 6 months

Diet

Diabetes vs. Pancreatic

Pancreatic enzymes, diabetes by diet

Quotable Quotes

I've seen a dietitian before,

but I've never talked to one.
J.S. - 12/18/14

The PES Statement

Malnutrition related to poor po intake and
decreased appetite associated with
pancreatitis symptoms as evidenced by
decreased energy intake (<75% of
estimated needs), weight loss (<10% in 6
months), and clavicle muscle wasting.

Nutrition Recommendations
1.) Recommend advancing diet as medically able to goal of six small meals per
day Low Residue/Consistent CHO (Moderate) Diet with Vital 1.5 BID.
2.) Recommend supplementing with multivitamin with folic acid and thiamine.
3.) Once diet is advanced, will provide diet education on post-Whipple nutrition.
4.) If not able to advance past a Clear Liquid Diet within 48-72 hours,
considering initiating TPN. If within POC, consider to initiate with 550 mL
15% AA, 200 mL D70W, 200 mL 20% lipids; will provide 1,206 calories, 82.5
g protein, 140 g CHO (GIR = 1.4 mL/kg/min). If started, follow electrolytes
(may be refeeding risk monitor K+, Mg, Phos, and replace as needed) and
follow blood glucose levels closely may need insulin added to TPN bag.
Recommend to start slowly and advance toward goal calories as able.
Check triglycerides and prealbumin.

Pancreatitis
Discussion of Disease

The Healthy Pancreas

Role of the Pancreas

1.) Digestion: Exocrine function Acinar Cells
- Pancreatic Juice and Enzymes

Amylase Carbohydrate
Protease Protein
Lipase Lipids
Trypsinogen - INACTIVE

2.) Blood Sugar Maintenance: Endocrine function

Beta Cells
- Insulin and Glucagon

Pancreatitis

Pancreatitis

Acute vs. Chronic Inflammatory

Causes

Gallstones
Alcohol
Medications
Trauma (HIV)
Surgery
Idopathic/Hereditary

Symptoms

Chronic more associated with alcohol abuse and males

Pain (abdominal and possibly back)

Nausea and vomiting
Fever

Possible Consequences

Malnutrition/malabsorption steatorrhea, amylorrhea, and azotorrhea

Weight loss
Diabetes Type 3

Alcohol and Pancreatitis

The Etiology

Trypsinogen Trypsin

Alcohol and Acinar Cells

CCK stimuation

Cell death and cytokine response

Possible sensitization to active form of trypsin

Autodigestion of the pancreas

Role cleaves peptide chains of lysine and arginine

Inflammation

Organ damage

Pancreatic bleeding and possible heart, kidney, or lung damage

Therapies

Previous and currently unpracticed protocol

Gut rest and fasting

TPN

Understanding patient's nutritional status

Malnutrition

Malabsoption

Fat lipase most susceptible to proteolytic degradation

Refeeding syndrome
Alcoholism

Practices of nutrition therapy - as early as possible

Prealbumin, transferring, vitamin and mineral deficiencies

Oral Diet
PERT
Post-pyloric enteral feeding
Last resort TPN (1% of patients)

The Whipple Procedure

The Whipple Procedure

Allen Oldfather Whipple 1935

Pancreaticoduodenectomy (PD) vs. Pyloric

Preserving Pancreaticoduodenectomy (PPPD)

Columbia University

Surgical preference for the PPPD

A 6-10 hour surgery

Removal of the head of the pancreas, the gallbladder, the

distal bile duct, the first few cm of jejunum, and possible
distal stomach.
Remaining section of jejunum resectioned to the pancreas

The Whipple Procedure

The New Pancreas

Complications and Nutrition Plan

Complications

Leakage of pancreatic juice

Surgical site wound infections
Continued malabsorption/malnutrition issues
Abcess formation
Fistulas
Nausea/vomiting
Diabetes

Nutrition Plan

Oral diet when hemodynamically stable

Clear liquid to full liquid to regular diet process
Dietitian consult protein, CHO, and fat requirements
Possible need for PERT

Long-Term Post Whipple Nutrition

Individualized

Weight management
Supplements

Prior malnutrition state

Tolerance of fat (high vs. low fat diets)
Motility

MV, calcium, vitamin D, zinc

PERT
Small, frequent meals, separate liquids, low fiber, high protein
Education - dumping syndrome, weight loss, early satiety, bloating, lactose
intolerance, SIBO
Early foods to avoid raw vegetables, fried foods, tough meat

PERT

Pancreatic Enzyme Replacement Therapy

Enteric Coated
30,000-50,000 IU of lipse

Timing

With meals goal of meeting in the SI

FDA approved

Upper limit of 10,000 IU lipase per kg of body weight

Creon, Zenpep

Goal correcting steatorrhea

Current Research Summary

For patients with
pancreatitis/Whipple
procedure:

For patients who cannot

tolerate an oral diet (for
approximately 5% of
patients):

For patients who were

unsuccessful with enteral
nutrition (for
approximately 1% of
patients):

An early, oral feeding which provides an

increased energy intake of 30-35 kcal/kg
(due to the patients current
hypermetabolic state), moderate fat intake
(25-30%) supplemented with PERT,
protein intake of 1.0-1.5 g/kg/day, low
fiber (due to its interaction with the
pancreatic enzyme), small but frequent
meals, and supplementing with a multivitamin. Oral supplements are advised
for patients who are unable to consume
the necessary calories/protein from their
meals.

Indications: Patients who are unable to

consume/digest their oral diet (nausea,
vomiting), weight loss in spite of
appropriate intake, or other acute
complications that make an oral diet
improbable.

Indications: Patients who have a gastric

outlet obstruction, jejunal access is
unsuccessful, there is a pancreatic fistula,
of if the patient is severely malnourished
and will be undergoing surgery.

EN should be initiated early once the

decision has been made. Post-pyloric
enteral feedings with a peptide-based,
calorically dense, elemental formula with
PERT. Studies have been done on
immune enhancing and polymeric
formulas without definite evidence that
indicates one would be preferred over the
other.

PPN should be initiated early once the

decision has been made.

The Nutrition Follow-Up

with JS

Treatment for JS
PPPD
Dynamically stable
Pressors and Insulin d/c'd
Weaning from Dilaudid
On 12/18/15 Clear Liquid

Advanced to Full and a Regular Diet

PERT
POC Glucose Levels
130 190 mg/dL

Appetite GOOD!
Moved off of ICU floor

Our Follow-Up Consultation

Labs trending normal

Bowel movements

12/21/14

PO intake

ALT, AST

50/100/25/75% over previous 24 hours

Meal prior to RD visit Hamburger and FF

Estimated needs

1,720-2,064 kcal (25-30 kcal/kg)

103-138 g protein (1.5-2.0 kcal/kg)
20-25% kcal from fat

JS's Meal Choice

Super Tracker Statistics

RD Recommendations
1.) Please change diet to Low Fat, GI Soft, Consistent CHO
(moderate) Diet no concentrated sweets, 6 small meals per
day. Pt expressing discomfort after eating on liberalized
Regular Diet. Will order snacks per pt preferences.
2.) Supplement Prosource Gelatein BID to help pt meet
increased protein needs.
3.) Supplement MIV with minerals, folic acid.
4.) Continue with pancreatic enzymes prn.
5.) Diet education and handouts provided on post-Whipple
nutrition.

Treatment Discussion

Prosource Gelatein/Vital 1.5 not ordered

COPD/Cirrhosis of Liver never addressed

Probiotics

Cirrhosis

BCAA

Vitamin C and Smokers - American Journal of Clinical Nutrition

Pulmonary function

Cirrhosis

Increased REE

COPD

Patient Discharge

December 24, 2014

Improved mobility
Pain managed
Nutrition education provided

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Questions?