Clinical Case Study:

Advocate Sherman Hospital

Presented by: Lexi Brand, ISU Dietetic Intern, 2022
Presentation Outline
➢ Overview of patient
➢ Medical history/prior hospitalizations
➢ Present admission
➢ Physical examination/data/imaging
➢ Etiology, signs/symptoms, risk factors
➢ Types of treatments, whipple
➢ Prognosis & statistics
➢ Nutrition Care Process
➢ Reflection
➢ Questions?
General Patient Information
Patients Initials: ER
Age, Height, Weight, BMI: 68 y/o, 5’5”, 72.6 kg (160 lb), 26.63 kg/m2
Occupation: Retired
Family Responsibility: Married
Dates of Current Admission: 4/14/22 - 4/20/22
Attending Physician: Asad Shah
Whipple Surgeon: John Brems
Unit: Oncology
Medical History
Past Medical History:
➢ Type 2 Diabetes Mellitus
➢ Barrett’s Esophagus
➢ Hypertension
➢ Hyperlipidemia
➢ Cerebral infarction
➢ Colonic polyps
➢ High cholesterol
➢ GERD
Surgical History:
➢ Endoscopic retrograde
cholangiopancreatography
procedure (ERCP)
➢ Stent placement
➢ EUS/FNA
➢ Back surgery
➢ Left knee replacement
Admission of Case Study - 4/14/22
ER was admitted to Advocate Sherman Hospital because of persistent
nausea, vomiting, abdominal pain and dehydration for several days.
Additional notes of constipation and diarrhea switching and forth, as well
as burning with urination. Pt had not eaten for 3 days upon admission. Pt
has been receiving chemotherapy for Stage 3 pancreatic cancer, with her
third cycle being last week. The patient was found to be Afebrile once
admitted. Leukopenia and Thrombocytopenia were also identified. ER
also underwent a whipple procedure just a few short months ago and is
experiencing post surgery effects.
Timeline
12/23/21: CT scan reveals pancreatic cancer.
1/10/22: Pt admitted for worsening abdominal pain to left upper and lower
quadrant x 10 days. ERCP, Sphincterotomy, stent placement, and EUS/FNA.
1/28/22: Pt has whipple procedure, insertion of gastrostomy tube, and
abdominal lymphadenectomy.
2/3/22: Pt was found to have postoperative diabetic gastroparesis.
4/14/22: Pt admitted for persistent nausea and vomiting from chemo, and
post-whipple effects.
5/2/22: Pt admitted for swelling of her right arm. Identified thrombosis, Pt has
two blood clots currently being treated.
Endoscopic Ultrasound (EUS)
➢ EUS is one of the most common imaging procedures used to diagnose
pancreatic cancer
Etiology of Pancreatic Cancer
➢ The etiology or cause of pancreatic cancer is still poorly understood.
➢ Cancer tends to spread quickly through the pancreas before causing
symptoms.
➢ Pancreatic cancer typically arises in the head of the pancreas.

Types of pancreatic cancer:

➢ Pancreatic exocrine cancer (adenocarcinoma)
➢ Exocrine cells secrete digestive enzymes into pancreatic duct
➢ Most common - 93% of tumors
➢ Pancreatic endocrine cancer (neuroendocrine tumors or Islet cells)
➢ Neuroendocrine cells produce hormones in the pancreas
➢ Less common - 7% of tumors
 Signs/Symptoms
➢ Jaundice
➢ Weight loss
➢ Loss of appetite
➢ Nausea/Vomiting
➢ Recent-onset diabetes
➢ Changes in the stool
➢ Dark-colored urine
➢ Abdominal pain radiating
towards the back
Risk Factors
➢ Cigarette smoking
➢ Obesity
➢ Diabetes
➢ Chronic Pancreatitis
➢ Inherited gene mutations:
➢ BRCA2
➢ Lynch Syndrome
➢ FAMMM Syndrome
Treatment of Pancreatic Cancer
➢ Radiation therapy
➢ Chemotherapy
➢ Immunotherapy
➢ Surgery
➢ Whipple (Pancreaticoduodenectomy)
➢ Distal Pancreatectomy
➢ Total Pancreatectomy
➢ Combination of surgery and radiation/chemotherapy
Whipple Procedure:
What the procedure involves:
➢ Removal of the head of the pancreas, first part of the intestine (duodenum),
gallbladder, lymph nodes near the pancreas, stomach, and bile duct.
➢ In some cases this surgery only a portion of the stomach is removed
➢ Reconnection of the remaining organs.

Reason for a whipple:

➢ Used to treat pancreatic cancer that is confined to the head of the pancreas.
➢ Remove the tumor and prevent it from growing and spreading to other
organs.
➢ Prolong survival or fully cure the cancer.
Post-Whipple Complications
➢ Gastroparesis
➢ Pancreatic insufficiency
➢ Development of Diabetes Mellitus
➢ Dumping syndrome
➢ Gastric obstruction
➢ Weight loss
➢ Renal failure
➢ Nutrient deficiencies:
➢ Those of concern: iron, calcium, zinc, copper, selenium, Vitamins A,
E, D, & K
Prognosis of Post-Whipple
➢ The 5 year survival rate after Whipple surgery is estimated
to be 20-25%
➢ About 15-20% of all pancreatic tumors are resectable.
➢ Despite successfully removing tumor:
➢ Cancer cells could have already spread
➢ New tumors may still form later
➢ Recovery and side effects from the surgery can be very
difficult.
Prognosis of Pancreatic Cancer
➢ The 5-year survival rate after diagnosis is only 5-10%.
➢ Survival is impacted by how far cancer has spread past the
pancreas at the time of diagnosis and treatment.
➢ Total cure is only possible when cancers are localized in the
pancreas (< 20% of cases).
➢ Stage IV prognosis has a 5-year survival rate of 1 %.
➢ Almost 80% of cases are diagnosed at very difficult to treat
stages.
Pancreatic Cancer Statistics
The American Cancer Society Estimates for
Pancreatic Cancer in 2022:

Number of people Number of people

who will be 1,918,030 who will die from
pancreatic cancer:
609,360
diagnosed with
pancreatic cancer:

Percentage of all
Percentage of all
cancers in the US:
3% cancer deaths in the 7%
US:

Average risk of pancreatic cancer: 1 in 64

Hospital Medications List
➢ Zofran ➢ Lopressor:
➢ Nausea treatment ➢ High blood pressure treatment
➢ Compazine ➢ Protonix:
➢ Nausea treatment ➢ Proton pump inhibitor
➢ Morphine: ➢ Glucagon Injections:
➢ Pain relief ➢ Treat low blood sugars
➢ Tramadol: ➢ Humalog
➢ Pain relief ➢ Insulin for diabetes
➢ Lipitor: ➢ Dextrose (glutose)
➢ Treat high ➢ Rocephin:
cholesterol/triglycerides ➢ Antibiotics
Initial Nutrition Assessment 4/14
Nutritional Risk Factors:
➢ Clear liquid diet
➢ Unintentional weight loss
➢ Poor intake prior to admission
➢ Poor appetite since admission
➢ High risk pancreatic cancer diagnosis

Diet Recall:
➢ Pt reports usually eating a healthy balanced diabetic diet
➢ 3 days prior to admission - small amounts of broth & bites of jello

* Pt notes side effects from chemo such as taste aversion, texture aversion, and
sensitivity to cold foods,
Physical Examination
➢ Patient was alert, oriented, and able to answer questions
➢ Pale skin
➢ No edema
➢ No jaundice

Nutrition Focused Physical Findings:

➢ Muscle Loss: no depletion of muscle stores.
➢ Fat Loss: no depletion of fat stores.
➢ Fluid Status: no fluid accumulation noted.
Patient’s Weight Data
Lab Data
Date Sodium Potassium Calcium BUN Creatinine Magnesium Glucose
(mEq/L) (mEq/L) (mg/dL) (mq/dL) (mq/dL) (mEq/L) (mq/dL)
(135-145) (3.4-5.1) (8.4-10.2) (6-20) (0.6-1.17) (1.6-2.6) (65-99)

19-Apr 136 4.0 6.8 ↓ 12 0.61 1.9 125 ↑

Findings: 18-Apr 135 4.0 6.8 ↓ 13 0.58 2.2 142 ↑

Following the whipple procedure 17-Apr 134 ↓ 3.1 ↓ 6.6 ↓ 13 0.61 1.8 130 ↑
on 1/28 Pt has had:
➢ Hypomagnesemia 16-Apr 138 3.1 ↓ 7.1 ↓ 12 0.61 1.6 ↓ 98

➢ Hypokalemia 15-Apr 133 ↓ 3.4 6.7 ↓ 12 0.62 1.4 ↓ 145 ↑

➢ Hypocalcemia
➢ Hyperglycemia 14-Apr 133 ↓ 3.7 7.5 ↓ 14 0.73 1.7 210 ↑

3-Feb 144 3.7 8.0 ↓ 4 ↓ 0.65 1.6 ↓ 95

Labs were overall concerning for
renal function. 2-Feb 142 3.9 7.6 ↓ 3 ↓ 0.62 1.9 162 ↑

1-Feb 142 3.2 ↓ 7.7 ↓ 5 ↓ 0.63 1.6 ↓ 134 ↑

* Calcium deficiency can be very
common after surgery because of 29-Jan 141 4.2 7.8 ↓ 16 0.63 2.0 159 ↑

the nutrient malabsorption that 28-Jan 143 3.5 7.4 ↓ 8 0.58 1.2 ↓ 117 ↑
may result.
NCP: Nutrition Diagnosis
Inadequate protein and energy intake and unintentional weight loss
related to altered GI function/GI disorder, decreased intake, nausea,
vomiting and taste change as evidenced by calculated needs, consuming
<50% estimated needs, diet history/recall, documented/reported intake
and weight loss over time.

Malnutrition Status:
Pt with acute severe protein calorie malnutrition as evidenced by <50% of
estimated requirements for >/= 5 days, and wt loss > 7.5%/3 months.
ER’s Nutritional Needs
Patient’s current weight: 160# (72.6 kg)
IBW: 125# +/- 10%
% IBW: 128%
Adjusted BW: 134# (61 kg)

Estimated needs based on adjusted weight of 61 kg:

➢ Energy: 1830 - 2135 kcal/day (30 - 35 kcal/kg)
➢ Protein: 61 - 91 g/day (1.0 - 1.5 g/kg)
➢ Fluid: 1 mL/kcal

Calculations based on AAH Oncology Nutrition Assessment Guidelines for

patients in need of repletion/weight gain.
NCP: MNT/Intervention
Nutrition Education:
➢ Management of chemo side effects
➢ Gastroparesis

Nutrition Supplements:
➢ ProSource Gelatein

Quease Ease:
➢ Aromatherapy
MNT Post-Whipple Diet
Based on Nutrition Care Manual Guidelines:
➢ Eat small, frequent meals (5-6 meals per day)
➢ Eat slowly and chew foods very well
➢ Low fat, low fiber foods
➢ Avoid food/drinks high in sugar
➢ Eat foods high protein for healing
➢ Drink most fluid 30 minutes before and after meals
➢ Limit fluid intake (48-64 oz per day)
NCP: Monitoring/Evaluation
Goals:
➢ Increase oral intake to >/= 50% of meals and supplements
➢ Maintain or improve weight
➢ Meet >/= 75% of estimated needs
➢ Advance diet past clear liquids

Monitoring:
➢ Symptoms of nausea/vomiting, BM’s, weight, labs, toleration
and advancement of diet, overall intake, ONS.
Progression During Visit
4/14/22: Clear liquids, persistent nausea, bouts of vomiting, abdominal discomfort, initiate
anti-emetics, IV fluids.

4/15/22: Clear liquids, IV fluids, receiving aggressive anti-emetic regimen medications.

4/16/22: Clear liquids, ProSource Gelatein TID, sepsis, tachycardia, antibiotics, complaints of
diarrhea/frequent stools, continued nausea, IV fluids, still receiving anti-emetics,
replacement of potassium & magnesium.

4/17/22: Clear liquids, ProSource Gelatein TID, Pt in A-fib now, Continue with magnesium
and potassium replacement, nausea improving.

4/18/22: Full liquids, Potassium replacement, ProSource Gelatein TID going well, Quese Ease
implemented, nausea continues to improve.

4/19/22: Low fiber diet, remains afebrile, nausea subsided, continue potassium replacement

4/20/22: Low fiber diet, potassium back in normal limits, nausea resolved, Discharge.
Discharge
Care plans discussed with with patient and her husband:
➢ Discussed importance of high protein and high calorie intake at
home.
➢ Encouraged daily use of nutrition supplemtns at home
➢ Pt to continue with lower fiber/fiber restricted diet at home
following discharge
➢ No additional education necessary at discharge

No concerns regarding compliance - Pt was attentive during nutrition

education and agreeable to all interventions implemented.
What Would I Do Different?
➢ Something I learned about while doing research and learning
more about post op for whipple surgery was the use of
pancreatic enzyme replacements. These are made to take the
place of enzymes that the pancreas would normally produce to
digest protein, carbohydrates, and fat. I was not familiar with
these before and wonder if it would have been helpful for my
patient and her issues with managing post op side effects.
Questions?
References
1. Nutrition Care Manual 2022. Oncology>Cancer Sites>Disease Process [online] Available at:
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=22938&lv2=145158&lv
3=145168&ncm_toc_id=270223&ncm_heading=Nutrition%20Care
2. National Cancer Institute. Cancer types>Pancreatic Cancer [online] Available at:
https://www.cancer.gov/types/pancreatic
3. Pancreatic Cancer Action Network. 2022. Types of Pancreatic Cancer. [online] Available at:
<https://www.pancan.org/facing-pancreatic-cancer/about-pancreatic-cancer/types-of-pancrea
tic-cancer/#exocrine>[Accessed 24 April 2022].
4. “Whipple Procedure - Mayo Clinic.” Mayo Clinic, 3 June 2020,
www.mayoclinic.org/tests-procedures/whipple-procedure/about/pac-20385054#:%7E:text=A%
20Whipple%20procedure%20%E2%80%94%20also%20known,pancreas%2C%20intestine%20
and%20bile%20duct.
5. “Exocrine Pancreatic Insufficiency In | VCA Animal Hospitals.” Vcahospitals,
vcahospitals.com/know-your-pet/exocrine-pancreatic-insufficiency-in-. Accessed 27 Apr. 2022.
6. Nutrition Care Manual 2022. Gastrointestinal>Whipple Surgery Nutrition Therapy [online]
Available at: https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=354
7. Mayoclinic.org. 2022. Endoscopic ultrasound - Mayo Clinic. [online] Available at :
https://www.mayoclinic.org/tests-procedures/endoscopic-ultrasound/about/pac-20385171
[Accessed 4 May 2022].