Gemma Keating Sarah Dann HPB Clinical Nurse Specialist Clinical Lead HPB Dietitian Royal Free London NHS Foundation Trust

HPB CNS Role

Key contact for patients

Liaising with all MDT members

Facilitate the care pathway for patients requiring treatment of HPB cancers (surgical or oncological)

Symptom management, clinical expertise, education

CNS-led follow up clinics

Holistic Needs Assessment

Types of Pancreatic Surgery

Whipple

PPPD

Total Pancreatectomy

Distal Pancreatectomy & Splenectomy

Bypass

Pain Management Paracetamol, Ibuprofen

Tramadol/Co-codamol

Oramorph

Nerve Blocks

Referral to Pain Team if necessary

1. Patient dependant

2. Disease dependant

Follow Up

Telephone Clinic with HPB CNS

MDT meeting

Surgical Clinic

Oncology Clinic

Royal Free or locally

Clinical Trials

Surveillance CT Chest/Abdomen/Pelvis with contrast

3 monthly for 2 years.

6 monthly for the following 3 years.

Annually until 10 years post resection.

Tumour Markers and routine blood tests.

After Surgery Appetite/weight loss

Pain

Nausea

Steatorrhea

Delayed gastric emptying

Constipation

Diet

Diabetes

PERT

Bile/Pancreatic Leak

Wound Care

Thromboprophylaxis

Mobility

Post Chemo Symptoms

Nausea

Vomiting

Diarrhoea

Fatigue

Dry skin/nails

Hair loss

Sore Mouth/Ulcers

Pain

Emotional Support for Patients and Carers

CNS

Counsellors

MacMillan – finance, benefits, children

Charities, e.g. PCUK

GP/District Nurses

Patient Support Groups

Carer/Bereavement Support Groups

Hospice

Recurrence? CT CAP, tumour markers, referral to MDT

MDT

Outpatient clinic – surgery or oncology?

Counselling

Palliative Care – hospital and community

HPB Dietetic Service

Pre-op Referred by a CNS or consultant – we can offer telephone

consultations for these patients

Post op patients are referred if deemed high risk of malnutrition

based on our screening tool

However we aim to review all Whipples/total pancreatectomy patients

Post discharge home We do not have an outpatient clinic however can offer

telephone follow ups/see people in consultant clinics – otherwise they are referred on to local community teams

Dietary problems after surgery

Early problems

Feeling full

Weight loss

Poor appetite

Diarrhoea/steatorrhea

Vomiting/ delayed gastric emptying

Early/late dumping syndrome.

Late problems

Diabetes

Malabsorption

Vitamin/mineral deficiency: B12, Iron, fat soluble vitamins (A,E,D,K).

Dietary management advice Try eating ‘little and often’ - aim for 5-6 small snack-size meals per day

Do not skip meals. Try to eat something even if you are not hungry.

Use food fortification ideas i.e. Adding additional butter, cream, cheese to meals, switching to full fat milk

Eat a protein food with at least 2 main meals (e.g. lean meat, chicken, fish, eggs, lentils)

Do not fill up on low calorie drinks e.g. tea, coffee, Bovril, thin soups, diet drinks which have little nutrition

Keep fruit and vegetables to a minimum initially as they may fill you up

If you suffering from nausea or vomiting

keep away from cooking smells, which may make nausea worse.

Reduce greasy foods as these pass slowly through the gut and can cause ‘reflux’ or heartburn.

Dry foods such as toast or plain biscuits can be easier to take

Dumping Syndrome Early dumping syndrome

Normally, the stomach holds the food before it goes into the small bowel, but if the bottom portion of the stomach has been removed, ‘dumping’ can happen. Food rushes quickly through the gut and ‘dumps’ into the small bowel. It can happen 15-30 minutes after eating a meal. Symptoms include diarrhoea, fullness, stomach cramping and vomiting. You may also experience weakness after eating, redness of the face, dizziness and sweating.

Late dumping syndrome

This is related to blood sugar levels and can happen 2-3 hours after a meal. It happens because of a drop in blood sugar (hypoglycaemia). Symptoms include weakness, sweating, nausea (sickness), hunger and anxiety.

How do I deal with the symptoms of dumping syndrome?

Eat 6 + small meal per day, instead of 2-3 big meals Eat slowly, chew well and sit up straight when eating Avoid very sweet or sugary food and drink e.g. coke etc., juices, sweets, jellies, cakes,

doughnuts, sweet biscuits, honey, jam - which can all rush through the gut Do not take large amounts of fluid during your meals (take sips only). Eat protein with each meal. Protein will move more slowly through the gut, e.g. eggs,

meat, chicken, fish, milk, yoghurt, cheese

Pancreatic Exocrine Insufficiency

Loose watery stool

Undigested food in the stool

Post-prandial abdominal pain

Nausea / colicky abdominal pain

Gastro-oesophageal reflux symptoms

Bloating / flatulence

Weight loss despite good oral intake

Steatorrhoea (pale, floating, oily stool)

Vitamin deficiencies (especially A,D,E,K,)

Hypoglycaemia in patients with diabetes (Friess & Michalski, 2009)

Steatorrhoea Normal fat losses <7g/day

Severe insufficiency >15g/day.

Visible oil suggests losses 30-40g/day

Up to 55g faecal fat losses may occur with no abdominal symptoms

Low fat diets!

Constipation

How much do we need?

No two patients are the same!

Mean Intra-

digestive

Post Prandial

Peak

Lipase up to 1000u/min 3000 –

6000u/min

Amylase 50 – 250u/min 500 – 1000u/min

Proteases

(Trypsin)

50 – 100u/min 200 – 1000u/min

Enzymes release continues for approximately 2 hours post prandially (360,000 - 720,000u) Keller & Layer, 2005

Why are we all different? Variations in:

Pancreatic function (atrophy / obstruction / resection / disease)

PPI use

Chewing patterns / temperature of meals

Dietary intake / meal patterns / duration of meals

Salivary / gastric / intestinal enzyme secretion

Intestinal transit (opiates / SMA/SMV invasion)

NOT JUST FAT.......

Recommended dose

STARTING DOSE....

44 - 50,000 units with meals

22 - 25,000 units with snacks

25 - 50,000 units with supplements

Will probably need higher dose with larger meals

Increase until symptom control

How should enzymes be taken?

At the beginning of meal

With a cold drink

Split dose if slow eater

If more than one capsule required – take the second half way through the meal

Patient choice on size of capsule vs. number of capsules.

Consider storage – below 25 / 15oC (cars, windowsills, trouser pockets!!)

What if they don’t work? Adequate dose?

Correct timings?

PPI?

Compliance?

Reduce fibre content of diet?

Correct preparation?

Are we missing something?

Lankisch P.G, 1999; 60: 97-104

Bruno M.J, 2001; 1(suppl 1): 55-61

Other conditions to exclude: Bile acid malabsorption (caused by acidic environment

causing bile salt precipitation) most common after cholecystectomy

Bacterial overgrowth

Infective diarrhoea

Other GI disease

Coeliac Disease!

Lactase deficiency

Lankisch P.G, 1999; 60: 97-104

Bruno M.J, 2001; 1(suppl 1): 55-61

Vitamin and mineral deficiencies

Fat soluble vitamins: A, E, D, K. Higher risk of deficiencies if not absorbing fat efficiently.

Bone disease can occur after this surgery due to a decreased intake, and sometimes, poor absorption, of calcium and vitamin D-rich foods (Adcal D).

B12 - stomach makes a special protein (intrinsic factor) which helps the body absorb Vitamin B12.

Iron – deficiency can be common after surgery, this may be because of a reduced intake or poor absorption of iron in the gut

Diabetes

Diabetes secondary to either an inflammation, tumour, trauma or surgery on your pancreas is known as Type 3c diabetes

Can be more brittle diabetes and difficult to control

More research is required as it is not a well understood condition

Can be managed through diet and exercise, oral hypoglycaemics or insulin.

References Bruno MJ (2001) Maldigestion and exocrine pancreatic

insufficiency after pancreatic resection for malignant disease. Pancreatology; Vol 1, issue 1 supp, 55-61

Friess H, Michalski CW (2009) Diagnosing exocrine pancreatic insufficiency after surgery: when and which patients to treat. The official Journal of international Hepato-Pancreato-Biliary Association; 11(Suppl 3): 7-10

Keller J and Layer P (2005) Human pancreatic exocrine response to nutrients in health and disease. Gut;54 (suppl VI):vi1-vi28

Lankisch PG (1999) What to do when a patient with pancreatic exocrine insufficiency does not respond to pancreatic enzyme substitution: a practical guide. 60: 97-104.

Any questions?