Michelle Smith | 2013

Major Case Study Nutrition and Acute Pancreatitis

Table of ContentsIntroduction...................................................................................................................................4

Social History................................................................................................................................. 4

Normal Anatomy and Physiology of Applicable Body Functions....................................................5

Past Medical History......................................................................................................................5

Present Medical Status and Treatment.........................................................................................6

Theoretical Discussion of Disease Condition..............................................................................6

Usual Treatment of the Condition..............................................................................................7

Nutrition Treatment...............................................................................................................7

Medical Treatment.................................................................................................................8

Patient’s Symptoms upon Admission Leading to Present Diagnosis..........................................8

Laboratory Findings and Interpretation.....................................................................................8

Medications............................................................................................................................... 9

Observable Physical and Psychological Changes in Patient........................................................9

Treatment................................................................................................................................ 10

Medical.................................................................................................................................10

Surgical................................................................................................................................. 10

Medical Nutrition Therapy...........................................................................................................11

Nutrition History...................................................................................................................... 11

Analysis of Previous Diet (24 hour recall).................................................................................11

Current Prescribed Diet & Responses......................................................................................11

Nutrition-Related Problems.....................................................................................................12

Evaluation of Present Nutritional Status..................................................................................12

Other Nutrients to Address......................................................................................................12

Patient’s Nutrition Education Process......................................................................................13

General Conditions upon Discharge.........................................................................................13

Emerging Research Relevant to Patient.......................................................................................13

Smoking and Pancreatitis.........................................................................................................13

Prognosis..................................................................................................................................... 14

Summary & Conclusion................................................................................................................14

Appendix A – Lab Values..............................................................................................................16

Appendix B - Medications............................................................................................................18

Bibliography.................................................................................................................................19

Introduction

The patient chosen for this case study, JL, is a 53 year old Caucasian female who has

been diagnosed with acute pancreatitis. The patient also suffers from alcohol abuse and has

gallstones. The height of the patient is 5 feet 4 inches (162.56 cm) and she weighs 103 pounds

(46.95 kg). The patient was chosen for the case study because she had a nutrition-related

diagnosis that often requires enteral or parenteral nutrition support. The patient has been in

and out of the hospital starting back in June of 2011 with initial complaints of nausea, vomiting,

and abdominal pain. She was diagnosed with pancreatitis one year later in June of 2012. She

was recently re-admitted on January 1, 2013 with the same complaints of nausea, vomiting, and

abdominal pain for the past five days and had been unable to eat during that time. The study

ended January 11, 2013, when the patient was discharged.

Social History

The patient is unemployed and relies on social security as her sole source of income. She

is not married but does have a boyfriend that she lives with. When asked if she has any

children, her first response was no. The patient later stated she has two sons, ages 26 and 30,

but they are out of the house and they don’t keep in touch. She has trouble walking and

therefore has few responsibilities at home. The patient has a low standard of living with a

corresponding poor home environment. She admits to drinking 6 or 7 vodka beverages a day

which is down from the half gallon of vodka she used to drink everyday a year ago. She is a

heavy smoker, going through one to two packs a day for the past 30 years. She is does not have

any religious affiliations and therefore has no special religious dietary guidelines to follow.

Normal Anatomy and Physiology of Applicable Body Functions

The pancreas is located in the abdomen behind the stomach and near the duodenum.

There are five main parts to the pancreas, the body, head, neck, tail, and uncinate. The

pancreas is also made up of a system of ducts, the main one called the pancreatic duct. The

pancreas has two functional components. They are called endocrine and exocrine parts. The

exocrine part contains acinar cells that are responsible for secreting enzymes into the

duodenum through the pancreatic duct. These enzymes are called amylase, protease, and

lipase. The pancreatic duct will merge with the bile duct and activate the enzymes, enabling

them to digest food. The endocrine part of pancreas contains the Islets of Langerhan cells that

are responsible for regulating the levels of glucose in the bloodstream by releasing insulin and

glucagon (1-3).

Past Medical History

Noted past medical history for the patient includes asthma, chronic obstructive

pulmonary disease (COPD), alcohol abuse, smoking, hypertension (HTN), angina, and a family

history of cancer. It has been documented that she has been admitted to the hospital 12 times

since June of 2011. Each of the 5 admitting diagnoses from June 2011 to May 2012 has included

shortness of breath (SOB) and either alcohol intoxication, syncope, nausea and vomiting with

abdominal pain, lower limb weakness, or right leg swelling. On June 26, 2012 she was again

admitted for abdominal pain and was later diagnosed with pancreatitis. The six admitting

diagnoses since then included chest tenderness, abdominal pain with nausea and vomiting,

dyspnea and falls, or chest pain with palpitations.

Present Medical Status and Treatment

Theoretical Discussion of Disease Condition

Acute pancreatitis is an acute inflammatory condition of the pancreas. Causes of acute

pancreatitis include the presence of gallstones and chronic, heavy alcohol use (3,4). Ethanol and

its metabolites have numerous effects on the pancreas such as inflammation and necrosis from

cell death signaling leading to sensitizing the pancreas to pancreatitis (4). In a person with

normal pancreatic function, the enzymes produced by the pancreas are inactive until they reach

the intestines. In acute pancreatitis, inflammation of the pancreas will cause the enzymes to

activate early thus causing further damage (3). Complications caused by acute pancreatitis

include sepsis, acute renal failure, hypovolemia, circulatory shock, and pancreatic necrosis (2).

There can be varying amounts of injury not only to the pancreas but also to adjacent and

distant organs. It can even cause multisystemic organ failure and, ultimately, death (4,5). Acute

pancreatitis is defined by a discrete episode of abdominal pain and elevations in serum enzyme

levels. Symptoms of include nausea, vomiting, and diarrhea along with sudden and severe

abdominal pain (2) which can decrease or even eliminate oral intake of the patient. Severe

abdominal pain can be so disabling that some patients become addicted to pain medications

(2).

Around 25% of acute pancreatitis patients go on to develop chronic pancreatitis (2). A

patient’s inability to stop drinking alcohol is the leading cause of chronic pancreatitis with

alcohol abuse accounting for 70-90% of the causes of chronic pancreatitis (6).

Usual Treatment of the Condition

Nutrition Treatment

There are many ways to classify acute pancreatitis but from a nutritional standpoint it is

most useful to categorize patients as those with either mild or complicated pancreatitis.

Seventy-five to 85% of pancreatitis diagnoses are considered mild (5). Intervention with

nutritional support is usually not required in mild pancreatitis and patients often recover

without intervention (4,5,7). This is due to the fact that oral intake often restarts within a few

days of hospitalization. It is thought that once oral intake resumes, diet orders should be clear

or full liquid and gradually increased to reduce stimulation of the pancreas (2). A recent gold-

standard (prospective, randomized, controlled, double-blind clinical trial) study showed no

significant differences between symptoms in patient s with mild pancreatitis that progressed to

a solid food diet as opposed to clear liquid diet (8). During this time the patient should avoid

pancreatic irritants, especially alcohol, nicotine, and caffeine (2).

If pancreatitis is severe and oral intake is not expected to resume for greater than three

days after hospitalization, nutrition support will be needed (4). It is widely recognized that the

gut plays a role in maintaining immune system integrity (2) which is why the enteral route for

nutrition support is preferred (9). Research has shown fewer pancreatic problems are seen in

those who are enterally fed versus using total parenteral nutrition (TPN). Patients with acute

pancreatitis receiving TPN have been shown to have statistically more pancreatic infection,

higher mulitsystemic organ failure, and high mortality when compared to patients receiving

enteral feedings (4). Noted benefits of enteral nutrition when compared to parenteral nutrition

include prevention of gut bacteria translocation, alleviating oxidative stress, faster healing, and

fewer complications from infections (5). Using an elemental formula has shown to have more

benefits compared to standard formulas. An elemental formula causes less stimulation to the

pancreas because of their low fat content (5). Enteral nutrition support may not always be

tolerated by patients and parenteral nutrition may be the only recommended route available. If

parenteral nutrition is chosen as the preferred route, it must be monitored to ensure the

patient does not develop the complications associated with it (5).

Medical Treatment

Medical treatment for acute pancreatitis includes surgeries such as necrosectomy,

pancreaticoduodenectomy, or sphincterotomy (2). Surgical treatment is only performed in

patients with severe acute pancreatitis to remove necrotic tissue and is not recommended

within the first two weeks after initial onset of the disease (7).

Patient’s Symptoms upon Admission Leading to Present Diagnosis

According to previous notes, before admission to the hospital in June 2012, the patient

was experiencing abdominal pain with nausea and vomiting. She stated that she would drink

vodka to dull the pain.

Laboratory Findings and Interpretation

There are many clinical indicators for acute pancreatitis. Clinical history that may be

seen in a patient with acute pancreatitis include rapid heart rate, left upper quadrant

abdominal pain, nausea and vomiting, steatorrhea, and results from a CT scan showing

interstitial pancreatic edema. Lab work that may be seen in a patient with acute pancreatitis

include lipase > 110, amylase > 250, glucose > 200 and decreased levels of potassium, sodium,

calcium, and magnesium (2). Labs collected from the patient on the day the diagnosis of

pancreatitis was made can be found in Appendix A. These labs shows decreased sodium and

calcium levels along with increased amylase, lipase, and ethanol levels. Appendix A also

contains labs showing elevated lipase and ethanol levels during previous hospital admissions.

The lipase levels are consistently above 110. The ethanol values show that once the patient was

diagnosed with pancreatitis and informed that alcohol consumption could make it worse, her

intake of alcohol decreased considerably when she was experiencing abdominal pain. Prior to

her diagnosis, she stated she would drink more alcohol to ease the abdominal pain. After her

pancreatitis diagnosis the patient didn’t enter the hospital with ethanol intoxication as often as

she had prior to the diagnosis.

Medications

A list of the medications the patient was on when at the hospital recently in January

2013 is provided in Appendix B. Also listed are the uses, descriptions, and possible side effects

that relate to the patient.

Observable Physical and Psychological Changes in Patient

The major physical change seen in the patient is weight loss. She stated her usual body

weight 6 months ago was 134 pounds. Upon admission she weighed 103 pounds. At a height of

5 feet 4 inches, she is only 86% of her ideal body weight. Psychologically, the patient seems to

be in denial about having any health problems due to drinking or smoking. It has been

explained to her that drinking will worsen the condition but she admits to drink 6 or 7 drinks

per day unless she is experiencing abdominal pain. The patient has also been offered help with

smoking cessation but has declined it.

Treatment

Medical

According to previous notes and documents, on June 25, 2012, a computerized

tomography (CT) scan of the patient’s abdomen was performed. The results showed steatosis,

cholelithiasis with questionable gallbladder wall thickening, mild edema at the head of the

pancreas, diffuse colon bowel wall thickening in primarily the left half of the colon that may

represent colitis. A magnetic resonance cholangiopancreatography (MRCP) of the abdomen

without contrast was also performed that day. It showed increased signal intensity on T2-

weighted images involving the pancreas with slight decreased signal intensity on the T1-

weighted images. There was a mild prominence of the head of the pancreas, edematous

changes in the peripancreatic fat. Edematous changes involved the lateral conal fascia on the

left anterior pararenal fascia. No pancreatic fluid collections were seen. These findings were

consistent with acute pancreatitis.

Surgical

During this most recent admission, an endoscopy was performed on January 3, 2013. It

showed a normal duodenum and normal GE junction. A stomach biopsy was also performed to

rule out H. pylori. There are no plans to remove any part of her pancreas as there is not any

necrotic tissue.

Medical Nutrition Therapy

Nutrition History

The patient does not follow any specific diets at home nor has she in the past. She

usually eats 2 or 3 meals per day, mainly lunch and dinner. Food is purchased by her live-in

boyfriend. She prepares her own lunch at home which is usually a microwaveable frozen

entrée. When her boyfriend gets home from work, he will prepare dinner for the two of them

which is, again, a microwaveable frozen entrée. The patient denies avoiding any particular

types of food unless she is having abdominal pain with nausea and vomiting. In those instances

she will avoid most foods.

Analysis of Previous Diet (24 hour recall)

The patient’s 24-hour recall was performed after admission to the hospital. The previous

afternoon she had undergone a procedure that required her to not consume anything by

mouth that morning. The patient was able to eat dinner and stated she had a chef salad (190

kcals, 21 g protein) and turkey sandwich (375 kcals, 18 g protein). This totals 565 kcals and 67 g

protein. The patient’s needs are between 1410-1645 kcals and 56-66 g protein per day.

Current Prescribed Diet & Responses

The current diet prescribed is a solid regular diet with Ensure Plus ordered twice a day.

Her previous diet orders have been clear liquids when she was preparing for an endoscopy

procedure. She was able to start oral intake soon after admission to the hospital and therefore

was not placed on enteral or parenteral nutrition support. The patient has had a good response

to the diet psychologically. She enjoys the ability to have meals prepared from fresh vegetables

such as salad. Physically she is responding well to the prescribed diet. She is slowly gaining

weight, around 5 pounds in 10 days, which is needed due to unintentional weight loss from

vomiting which also caused decreased oral intake.

Nutrition-Related Problems

Upon admission to the hospital, the patient had inadequate oral intake related to

decreased ability to consume sufficient energy as evidenced by weight loss, nausea, vomiting,

and reports of insufficient intake of energy from the diet when compared with requirements.

Evaluation of Present Nutritional Status

Due to recent unintentional weight loss, it was recommended that the patient

consumes 30-35 kcals/kg body weight and 1.2-1.4 g protein/kg body weight. This is

approximately 1410-1645 kcals and 56-66 g protein per day. This increased intake of kcals and

protein will help replenish lost nutrient stores. Consumption of Ensure Plus supplements twice

a day would also increase kcal and protein intake.

Other Nutrients to Address

Some researchers believe supplementation with antioxidants may shorten the patient’s

length of stay in the hospital and may also decrease complications in patients with acute

pancreatitis but further clinical trials are required (10). Other researchers show no support for

immunonutritional supplements (11). Probiotics have also been suggested to benefit patients

with severe acute pancreatitis but results have not been consistent enough to make

recommendations (11). During her previous admissions, the patient was given thiamine, folic

acid, and a multi-vitamin for alcohol withdrawal.

Goals, Interventions, Monitoring, and Evaluation

The first goal for this patient is to eat more than 50% of meals three times a day. The

next goal is to drink Ensure Plus twice a day. The final goal is to limit pancreatic irritants such as

nicotine and alcohol. Interventions for the patient include a general healthful diet and medical

food supplements. The patient will be monitored and evaluated by checking her food and

beverage intake.

Patient’s Nutrition Education Process

The patient has a few issues that will hinder the process of educating her on nutrition.

She is intelligent but does not seem to understand just how damaging drinking and smoking are

for her health. She seems to be in denial. She also has very little support from her family. She

does have a boyfriend but based on one of my visits, he seems like he needs to be taken care of

by her at times and he may be enabling her. She is a native English speaker which helps but she

seems to have little motivation to change.

General Conditions upon Discharge

Upon discharge, the patient stated she had her appetite back and denied any nausea,

vomiting, or abdominal pain. The importance of decreasing smoking and alcohol consumption

were again emphasized and the patient said she understood, however, lack of motivation was

apparent.

Emerging Research Relevant to Patient

Smoking and Pancreatitis

Chronic tobacco consumption is an independent risk factor of pancreatitis. It increased

the frequency of all major complications of alcoholic chronic pancreatitis in a dose-dependent

fashion apart from alcohol intake (6). This shows that if the patient goes on to develop chronic

pancreatitis, she will really need to consider smoking cessation to avoid major complications.

Prognosis

Unless the patient stops drinking alcohol and quits smoking cigarettes, it is unlikely her

pancreatitis symptoms will completely go away. In the past year the patient has been admitted

to the hospital 10 times. The patient has been diagnosed with pancreatitis for 6 months and

continues to drink heavily every day. Her reported alcohol intake has decreased slightly from a

year ago but is still very high. The patient understands importance of quitting smoking and not

drinking alcohol for improved outcomes but seems unmotivated to do so. She has been offered

smoking cessation help but has declined it. One positive is since being diagnosed with

pancreatitis the patient has learned that drinking will only exacerbate the problem and she

stops drinking when she feels the abdominal pain. In the past, she stated that when she had the

severe abdominal pain she would drink more to dull the sensation. Unfortunately, the patient

continues to drink when she isn’t experiencing abdominal pain.

Summary & Conclusion

From this case study I learned not to judge a person before seeing them, even when you

hear things about them that make you think you know them. After reading the notes from

doctors about the patient’s high alcohol consumption and seeing that she has been in the

hospital 6 times in the past year, I thought I would be walking in on a grumpy woman who

wouldn’t be willing to answer my questions. When I entered her room, she was on the phone.

By the way she was talking I could tell it was her boyfriend and she was consoling him. Once she

saw me walk in, she told him she had to go and hung up. That alone impressed me as I have had

some patients keep talking on the phone and ignore me altogether or wave me away. I

explained to her that I would be asking a lot of questions, some of which might be personal and

she did not have to answer any that made her uncomfortable. Once I started my inquiries she

really opened up to me. She is actually a very nice woman and was willing to answer anything I

asked. She is going through tough times right now but I am hoping that someday soon she will

realize she needs to make some big changes for her health.

As for pancreatitis, I learned a lot of new things about the disease that I didn’t know

before. I didn’t realize how gallstones will irritate the duct and cause the pancreas to become

inflamed. I knew that chronic alcohol abuse would make the situation worse but I didn’t know

that 70-90% of alcohol abusers would go on to develop chronic pancreatitis. I also wasn’t aware

that so many studies need to be done to fully determine many aspects related to nutrition and

pancreatitis.

Appendix A – Lab Values

Labs outside normal limits from day of diagnosis: June 25, 2012

Lab Value Normal Value RangeSodium 132 135-145Calcium 8.1 8.5-10.2AST 81 10-40Amylase 140 23-85Lipase 298 10-60Ethanol 87 <10

Labs showing elevated lipase levels during previous hospital admissions

Date Lab Value6/26/12 (day after diagnosis) 4767/15/12 1199/4/12 1141/1/13 2131/2/13 1721/11/13 117

Labs showing ethanol levels during previous hospital admissions

Date Lab Value6/4/11 3976/7/11 1294/26/12 995/3/12 2285/22/12 2036/25/12 877/15/12 (after diagnosis) < 109/14/12 < 1011/16/12 9312/21/12 < 10

Drug Use Description Side EffectsAlbuterol for asthma

and COPDBronchodilator that relaxes muscles in the airways and increases air flow to the lungs. Used to treat or prevent bronchospasm in people with reversible obstructive airway disease.

Uncontrollable shaking of a part of the body, nervousness, headache, nausea, vomiting, cough, throat irritation, and muscle, bone, or back pain. Serious side effects include fast, pounding, or irregular heartbeat, chest pain, increased difficulty breathing, difficulty swallowing.

Cymbalta (duloxetine)

for depression

Selective serotonin and norepinephrine reuptake inhibitor for oral administration as antidepressant.

Nausea, dry mouth, constipation, loss of appetite, tiredness, drowsiness, or increased sweating. Drug can cause drowsiness or dizziness, avoid alcoholic beverages. Duloxetine may affect blood sugar levels.

Advair for asthma and COPD

Prevents the release of substances in the body that cause inflammation. It contains fluticasone, a steroid, and salmeterol, a bronchodilator, which works by relaxing muscles in the airways to improve breathing.

Chest tightness, fast or uneven heart beats, stabbing chest pain, nausea, vomiting, diarrhea, dry mouth, nose, or throat. Long-term use of steroids may lead to bone loss, especially if you smoke.

Zestril (lisinopril)

for HTN Angiotensin converting enzyme (ACE) inhibitor.

Vomiting, diarrhea, heavy sweating, very low blood pressure, electrolyte disorder, kidney failure. Drinking alcohol could further lower blood pressure and increase side effects. Do not use salt substitutes or potassium supplements while taking medication unless doctor has approved.

Miralax for occasional constipation

Works by holding water in the stool to soften the stool and increases the number of bowel movements.

Nausea, abdominal cramping, or gas.

Dulcolax (bisacodyl)

for cleaning out the intestines before a bowel examination/surgery

Works by increasing the movement of the intestines, helping the stool to come out.

Stomach/abdominal pain or cramping, nausea, diarrhea, and weakness.

Appendix B - Medications

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