Clinical Capstone

1. MEDICAL NUTRITION
THERAPY
STATUS-POST WHIPPLE
Valerie Agyeman
UMD Dietetic
Intern
June 2016

2. OUTLINE
OVERVIEW OF CONDITION
MEET THE PATIENT
NUTRITIONAL CONSIDERATIONS
NUTRITIONAL DIAGNOSIS AND THERAPY
EMERGING RESEARCH AND CONCLUSION

3. FUNCTION OF THE PANCREAS
Exocrine cells
 Produce enzymes to help with the digestion of food.
 Pancreatic enzymes are released in the duodenum.
Endocrine cells
 Release hormones “insulin and glucagon” into the
bloodstream.
 Controls blood sugar (glucose) levels.

4. ANATOMY OF THE PANCREAS

5. OVERVIEW OF THE
CONDITION

6. PANCREATIC ADENOCARCINOMA
•Pancreatic Adenocarcinoma (exocrine tumor) begins in the tissues of
the pancreas, specifically the cells that line the ducts of the pancreas.
•Associated with a poor prognosis
•Hard to detect in early stages
•Common symptoms:
• upper abdominal pain, jaundice, loss of appetite, nausea, vomiting, & weight loss
•Treatment of this cancer depends on the location and cell type of
tumor
• Patients who develop cancer within the head of pancreas may undergo the Whipple
procedure

7. WHIPPLE PROCEDURE ALSO
KNOW AS
“PANCREATICODUODENECTOMY”
•A procedure that involves removing the head of the pancreas, part of
the small intestine (duodenum), gallbladder and a part of the bile
duct.
•Remaining parts of the pancreas, stomach and intestines are
reconnected to allow the body to digest food.
•High risk of infection and bleeding.
•Patients may experience nausea and vomiting due to altered stomach
emptying
delayed gastric emptying or dumping syndrome
•Long recovery time.

8. BEFORE SURGERY VERSUS AFTER
SURGERY

9. MEET THE PATIENT: SG

10. GENERAL INFORMATION
SG is a 72 year old Caucasian female
BMI: 24.5
Seen in BWMC Outpatient GI OR (3/11) for Endoscopic Ultrasound
Fine Needle Aspiration.
Dx: Pancreatic Adenocarcinoma
Pt had generalized pruritus, jaundice, darkening of urine, clay colored stools, GI
upset, URI and a reported weight loss.
SG was admitted 3/14, and was discharged 3/22 after 9 days of
hospitalization.

11. GENERAL INFORMATION
Social/Family
History
Medical History Surgical History
• Patient is divorced.
• Patient has 6 children
• Retired
• Hypertension, Diabetes,
and Cardiovascular
disease on the father’s
side.
• Denied smoking and
drug use.
• Former alcohol drinker.
• Type 2 Diabetes Mellitus
• Hypertension
• Dyslipidemia
• Hypothyroidism
• Congestive Heart Failure
• Refractive surgery
• Dilation and curettage
• Blepharoplasty
• Orthopedic surgery (Left
knee)
• Endoscopic retrograde
cholangiopancreatograp
hy (February 2016)
• Esophagoscopy/EGD
• Esophageal ultrasound

12. NUTRITIONAL HISTORY
History obtained from family:
Good appetite prior to dx of pancreatic cancer.
Patient lost a significant amount of weight, associated with nausea
and smell aversions decreasing intake prior to the pancreatic cancer
dx.
Chewing difficulties due to a weakened jaw prior to admission, but
denied any difficulties swallowing.
Patient follows a CHO Controlled diet at home.
Supplements:
Vitamin B12, folic acid, vitamin C, calcium & vitamin D. ONS: unknown

13. WEIGHT HISTORY
UBW 171#, 152# at admission
~20 lbs weight loss in two months (12% weight loss in two months)
DATE WEIGHT (IN
POUNDS)
SOURCE OF
WEIGHT
% UBW % IBW
MARCH 7 150 MEASURED 88% 115%
MARCH
11
152 MEASURED 89% 117%
MARCH
14
152 MEASURED 89% 117%
MARCH
18
160 (?FLUID) MEASURED 94% 123%

14. HOSPITAL MEDICATIONS
SCHEDULED
 Cipro (Antibiotic)
 Flagyl (Antibiotic)
 Heparin (Blood thinner)
 Lantus/SSI (Insulin)
 Protonix (proton pump inhibitor)
 Geodon (anti-psychotic, for anxiety)
 Lopressor (beta blocker, for HTN)
 Apresoline (Vasodilator, for HTN)
 Dilaudid (narcotic)
CONTINUOUS
 IVF: NS at 100 mL/hr
PRN
 Dulcolax (laxative)
 Benadryl (anti-histamine)
 Zofran (anti-nausea)

15. LABS
Lab Referenc
e Range
3/14 3/15 3/16 3/17 3/18 3/19 3/20 3/21 3/22
Na 136-144
mmol/L
132 129 133 133 128 132 133 132 134
K 3.5-5.3
mmol/L
3.2 4.2 3.3 3.2 4.1 3.7 3.2 3.8 3.3
Cl 98-107
mmol/L
102 103 107 106 103 107 103 104 106
CO2 22-32
mmol/L
18 19 19 20 17 18 22 21 22
Creatinine 0.9-1.3
mg/dl
0.85 0.84 1.00 1.00 1.18 0.73 0.81 0.90 0.85
Glucose 75-110
mg/dl
272 267 244 257 269 235 172 163 -
BUN 7-25
mg/dl
10 11 13 12 16 8 7 9 11
Bili Total 0.1-1.3
mg/dl
2.4 - - - - - - - -
Ca 8.6-10.3
mg/dl
6.9 6.6 6.8 7.5 6.7 7.0 7.4 7.8 7.6
Phos 2.5-5
mg/dl
- - 3.0 - 3.0 1.9 2.8 2.6 2.7
Mg 1.8-2.5
mg/dl
1.2 1.9 1.7 - 1.7 1.4 1.3 1.3 1.2
AST 15-41
IU/L
73 - - - - - - - -
ALT 7-52 54 - - - - - - - -

16. HIGHLIGHTS FROM HOSPITAL STAY
Day 1 (3-14-16) Robotic assisted Whipple procedure, cholecystectomy,
wedge liver biopsy, wedge resection of the portal vein and vascular
reconstruction. Patient in ICU. Diet: NPO.
Day 2 (3-15-16) POD #1 Nutrition consult received from RN screen for
weight loss and poor po. A foley was started to monitor urine output.
Hyponatremia. Hypophosphatemia. Hyperglycemia. BS absent, no BM. LBM
3/13. NGT was placed for suction. Patient removed NGT; d/c. 2 JP Abdominal
drains. Edema: +2 LUE/RUE. Respiratory: 2L nasal cannula. Diet: NPO.
Day 3 (3-16-16) POD #2 Patient was lethargic. Patient complained of (c/o)
nausea. BS absent, no BM. Hyponatremia. Hypophosphatemia.
Hyperglycemia. Renal: labs consistent with acute kidney injury (AKI),
Nephrology consult ordered. Respiratory 2L nasal cannula. Edema +2
LUE/RUE. Diet: NPO

17. HIGHLIGHTS FROM HOSPITAL STAY
Day 4 (3-17-16) POD #3 Patient c/o abdominal pain. Delirium, alert not
oriented. Hypokalemia and hypomagnesemia. Hyponatremia improving.
Hypocalcemia and anemia being monitored. WBC’s elevated. Hyperglycemia.
Blood pressure elevated treated with Lopressor. BS absent, no BM. Bowel
regimen given (dulcolax). AKI associated labs and urine output being
monitored. Respiratory: Room air. Diet: NPO.
Day 5 (3-18-16) POD #4 Mental status slowly improving; Hyponatremia.
Hypokalemia. Hyperglycemia continued despite insulin regimen. No BM.
Minimal UO. Failed bedside swallow. SLP consult ordered. Surgery approved
sips of clears and ice chips. Increased activity, walking with PT. Diet: CLD
(sips), ice chips. Intake: n/a.
Day 6 (3-19-16) POD #5 SLP evaluation completed. Diet advanced to FLD,
nectar thick per SLP. Post-operative anemia improving. Edema: +2
generalized. Stable creatinine, improving urine output. Serum sodium stable,
hyperglycemia improving and hypophosphatemia improving. BM overnight
noted. Diet: FLD, nectar thickened liquids. Intake: n/a.

18. HIGHLIGHTS FROM HOSPITAL STAY
Day 7 (3-20-16) POD #6 Overall condition stable. Tolerating diet. Pain
controlled with po pain medication. Hypophosphatemia improving.
Hyponatremia stable. Stable renal function. Foley d/c. No BM. Diet:
FLD, nectar thickened liquids. Intake: n/a.
Day 8 (3-21-16) POD #7 Alert and oriented, ambulating with PT.
Patient reported a good appetite. Overall condition stable. Denied
pain. BM today. Low magnesium. Nutrition Education: Whipple
Nutrition therapy. Transferred from ICU to step down unit. Diet: Diet
advanced to CHO controlled, nectar thickened liquids, 6 small meals.
Intake: PO intake is “fair” per EPIC chart documentation.
Day 9 (3-22-16) POD #8 Discharged and transferred to a sub-acute
rehabilitation facility (Genesis Corsica Hills) for PT. Next appointment
scheduled for 3/29/16 with physician.

19. DIET AND PO INTAKE
DATE DIET MODIFICATIONS INTAKE
MARCH 14 NPO X 1 DAY NONE 0%
MARCH 15 NPO X 2 DAYS
(NUTRITION CONSULT
RECEIVED)
NONE 0%
MARCH 16 NPO X 3 DAYS NONE 0%
MARCH 17 NPO X 4 DAYS NONE 0%
MARCH 18 Clear Liquid (sips), ice
chips.
NONE FEW SIPS OF
ICE CHIPS
AND ENSURE
CLEAR
MARCH 19 Full Liquid Diet Nectar thickened liquids NOT
DOCUMENTED
MARCH 20 FULL LIQUID DIET NECTAR THICKENED LIQUIDS NOT
DOCUMENTED
MARCH 21 CHO controlled
standard, 6 small meals
NECTAR THICKENED LIQUIDS 50% X 2
MEALS
MARCH 22 CHO Controlled
standard, 6 small meals
NECTAR THICKENED LIQUID DISCHARGED
IN THE EARLY

20. NUTRITIONAL CONSIDERATIONS
Alteration of GI tract post Whipple procedure can result in multiple
long term nutritional complications:
Gastroparesis
Dumping Syndrome
Exocrine pancreatic insufficiency: Fat maldigestion
Diabetes
Nutrient deficiencies

21. NUTRITION DIAGNOSIS
AND THERAPY

22. NUTRITION DIAGNOSES
Malnutrition (NI 5.2) related to pancreatic head adenocarcinoma,
decreased appetite as evidenced by ~20 lbs weight loss in two
months, 12% weight loss in two months, family reports of poor po
and 2+ edema in lower and upper extremities.
Unintentional weight loss (NC 3.2) related to pancreatic head
adenocarcinoma and decreased appetite as evidenced by ~20 lbs
weight loss in two months, 12% weight loss in two months.
Altered GI function (NC 1.4) related to GI surgery status post Whipple
and cholecystectomy as evidenced by potential for fat and
carbohydrate malabsorption.

23. NUTRITION PRESCRIPTION
NPO until cleared by surgery. Advanced from CLD to FLD, to CHO
Controlled Diet.
CHO Controlled Standard (1600-2000 kcals) diet, 6 small meals,
Nectar thick liquids.
1380-1932 calories/day (20-28 kcal/kg, using act wt. 69 kg).
82.8-103.5 gm protein/day (1.2-1.5 g/kg for post op recovery)
1725-2070 ml fluid/day (25-30 ml/kg, using act wt. 69 kg)

24. NUTRITION INTERVENTION
Nutrition Education (NE 1.4) Whipple Nutrition therapy education to family
and patient. Provide handouts as a reference. GOAL: Patient will tolerate diet
after discharge.
Referral to other providers (RC-1.5): Refer to SLP. GOAL: Evaluate need for
modified consistency diet/risk of aspiration based on diet advancement post
Whipple.
Referral to other providers (RC-1.5): Refer to outpatient GI RD. GOAL: Patient
receives more information regarding altered GI and nutrition, and nutritional
status is monitored after discharge.
Prescription medication (ND-6.1): Recommend bowel regimen. GOAL:
Patient’s bowel function improves.
Collaboration with other providers (RC-1.4): Collaborate with medical team
to provide the best nutrition care for patient (bowel function, diet tolerance,
SLP for texture modification, repletion of electrolytes, blood glucose
management). GOAL: Patient is nutritionally stable for discharge to rehab.

25. MONITORING AND EVALUATION
Indicator Criteria
Total energy intake (FH-1.1.1.1)
Food and nutrition knowledge (FH-3.1)
Adherence (FH-4.1)
Labs (BD 1.2)
Weight (AD-1.1.2)
GI function (PD 1.1.5)
Patient consumes >75% of meals.
Patient is able to describe the importance of
optimal nutrition during post op recovery.
Patient visits outpatient gastrointestinal RD
and continues to follow diet
recommendations after discharge.
Patient’s labs remain stable and within
normal range.
Patient’s weight trends stabilize.
Patient will have no complaints of
abdominal pain, nausea/vomiting, diarrhea
(symptoms of malabsorption/maldigestion),
bowel movement will be regular.

26. EMERGING RESEARCH
Recent research suggests that there may be an inflammatory
component that is:
 Predictive of Pancreatic Cancer survival in advanced
disease
 An inflammatory process associated with periodontal
disease may occur before the development of the cancer.

27. CONCLUSIONS

28. KEY POINTS
RD’s should provide an Individualized nutrition therapy based on
each patient’s preferences and ability to handle certain foods.
RD’s play a crucial role in counseling this patient population to:
 avoid unnecessary dietary restrictions
to increase variety in the diet
to improve the patient’s quality of life through close monitoring and attention to
signs and symptoms
to help optimize nutritional status and help prevent complication exacerbation

29. QUESTIONS?

31. REFERENCES
•Decher N, Berry Amy. Post-Whipple: A Practical Approach to Nutrition Management. Nutrition Issues in
Gastroenterology. 2012: 108: 30-42.
•Berry, Amy. Pancreatic Surgery: Indications, Complications, and Implications for Nutrition Intervention.
Nutrition in Clinical Practice. 2013: 28(3): 330-357.
•Nutrition Therapy for Pancreatic Cancer. Cancer Treatment Centers of Americans.
www.cancercenter.com/pancreatic-cancer/nutrition-therapy/. Accessed June 2, 2016.
•Understanding Pancreatic Cancer. National Pancreatic Cancer Foundation. www.npcf.us. Accessed May
25, 2016.
•Pancreatic Cancer. American Cancer Society. www.cancer.org/pancreatic-cancer-pdf. Accessed June
8th, 2016.
•Academy of Nutrition and Dietetics (n.d.). Pancreatic Cancer.
https://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&ncm_toc_id=145168. Accessed
May 2, 2016.
•Evidence Analysis Library. Oncology: Pancreatic Cancer.
http://www.andeal.org/topic.cfm?menu=5291&cat=3201. Accessed June 2, 2016.
•Julie, A. Jacob M.A. Study Links Periodontal Disease Bacteria to Pancreatic Cancer Risk. American
Medical Association. 2016. pp. E1-E2.
•Hutchinson, L. Pancreatic Cancer: Inflammatory Index to Predict Survival. Nature Reviews Clinical
Oncology. 2016 (89).
•Image from slide 4:
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/image_article_col