Pancreas

Question 1

What are the segments of pancreas

Answer 1

head (neck), body and tail

Question 2

what are the 2 main tissues of pancreas and their roles

Answer 2

2 main tissues:

1. acinar (secretive- makes juice that is secreted into the duodenum) and
2. islets of Langerhans (1-2% of all tissues secretes hormones into the blood)

Question 3

What does pancreatitis affect and what are the consequences?

Answer 3

pancreatitis results in inflammation of the ducts-> impairment of exocrine function (mainly, but endocrine sometimes also takes a hit)

Question 4

What are the components of exocrine function

Answer 4

• Digestive enzymes (zymogens)
• Bicarbonate ions

in presence of food, particularly fat, CCK stimulates pancreatic contraction this stimulates the release of precursor digestive enzymes- zymogens Zymogens get activated when they get into the duodenum
Bicarb from increases neutralizes chyme

Question 5

What are the components of endocrine function

Answer 5

• Insulin: beta cells secrete insulin, permitting movement of anabolic nutrients into the cell. hormone
• Glucagon: alpha cells secrete glucagon to stimulate glycogenolysis and gluconeogenesis. Making energy from released fat and AA, triggered by glucagon
• Somatostatin: helps regulate insulin/glucagon e.g., can suppress exocrine function. Can prevent insulin/glucagon secretion

Question 6

What is pancreatitis

Answer 6

inflammation of pancreas and ducts

Question 7

What are the manifestations of pancreatitis

Answer 7

1) Inactive forms of pancreatic enzymes are prematurely activated causing autodigestion of pancreatic cells, and elevated enzymes in blood (e.g., lipase);
2) immune cells and cytokines direct an inflammatory response;
3) Increased vascular permeability, causing edema, hemorrhage and necrosis.

Question 8

What are the potential causes of acute pancreatitis (AP)?

Answer 8

Most common is gallstones, followed by alcohol

High TG can also result in AP

Question 9

What are the symptoms of AP?

Answer 9

• Upper abdominal pain radiating to back; may worsen with food intake
• Nausea, vomiting, abdominal distention, steatorrhea
• Characterized by edema, cellular exudate, fat necrosis
• Elevated blood levels of pancreatic enzymes (e.g., lipase especially)
• Elevated serum TG
• Elevated liver enzymes in biliary cause
• SIRS/shock, fever→may need to be treated in ICU
• Exudate in peritoneal and pleural spaces
(exudate: any fluid that has exuded from a tissue or capillary due to injury/inflammation)

Question 10

how is AP diagnosed

Answer 10

• Imaging studies such as CT that will show the exudate
• Blood work: Lipase and amylase at least three times the normal range.
• Lipase rises for 5-7 days
• Amylase rises for 48-72hrs; levels might be below the baseline after this period

Question 11

why might albumin be low in PA

Answer 11

low albumin is low due to vascular permeability, not nutrition

Question 12

what are very low albumin levels indicative of?

Answer 12

such low albumin is an indicator of high mortality risk

this also an indicator of high probability of hypovolemia - primary treatment goal

Question 13

what is low magnesium a sign of

Answer 13

refeeding syndrome

Question 14

What is the first step in nutritional treatment of AP?

Answer 14

FIRST determine disease severity
• E.g., RANSOM, APACHE II
• Presence of necrotic tissue

Question 15

energy and protein reccs for AP pts (not obese)

Answer 15

Energy: 25-35kcal/kg (Indirect Calorimetry as it is prefered in ICU pts)
Protein: 1.2-1.5g/kg (ASPEN 1.5g/kg)

Question 16

energy and protein reccs for AP pts (obese)

Answer 16

Obese: provide EN regimen should at 65%–70% of target energy requirements as measured by IC.

If IC is unavailable:
BMI 30-50: 11–14 kcal/kg actual body weight per day
BMI>50: 30–50 and 22–25 kcal/kg ideal body weight per day

Protein:
BMI 30-40: 2.0 g/kg ideal body weight per day for patients
BMI ≥40: 2.5 g/kg ideal body weight per day for patients

Question 17

Characteristics of APACHE II <= 9 Ranson’s Criteria <=2

Answer 17

• Degree of Pancreatitis: Mild/moderate
• CT Scan: No necrosis
• Mortality: 0%
• Tolerate PO diet in 7 d: 81%
• Management: supportive

Question 18

Characteristics of APACHE II >= 10 Ranson’s Criteria >=3

Answer 18

• Degree of Pancreatitis: Severe
• CT Scan: Necrosis
• Mortality: 19%-> high
• Tolerate PO diet in 7 d: 0%-> order NPo straight away
• Management: EN/PN & ICU

will stay in hospital for 1 months or more

Question 19

Algorithm for Nutrition Management of Acute Pancreatitis

Answer 19

1. Evaluate disease severity in ED
   a) Mild disease-> admit to ward
   i) Advance to oral diet per patient wishes.
   ii) Only use EN if oral diet fails over 4 d.
   iii) If NG was placed and patient has been tolerating it-> Advance to oral diet per patient wishes.

b) Moderate to Severe Disease: admit to ICU, place NG tube and initiate standard EN if hemodynamically stable
i) If NG was placed and patient has been tolerating it-> Advance to oral diet per patient wishes.
i) If does not tolerate NG EN -> Switch to NJ feeds. Start PN if intolerant > 5d

Question 20

Firs line of treatment: mild vs severe

Answer 20

Mild: try PO, if not tolerating for 4d-> switch to EN
Severe: NG EN with standard formula straight away

Question 21

Why would we use diuretics and fluid resuscitation in AP pts

Answer 21

TO get rid of 3rd space fluid as these patients often have edema and ascites

Question 22

Nutritional Management: Overview for mild acute AP

Answer 22

PO vs EN vs PN depends on severity
• For mild try PO as soon as nausea/vomiting and pain allow- patient lead feeding
• Oral feeds for mild & moderate cases
- Low fat for some, esp biliary issues e.g gallstones
- Aim for SOLID food
• No alcohol
• Frequent small meals (~6/d is commonly tolerated)
• Serum lipase and amylase do not
necessarily correlate with diet
tolerance or AP severity!
• If oral intake fails, initiate EN after 4 days.

Question 23

Nutritional Management: Overview for severe acute AP

Answer 23

NPO vs EN vs PN depends on severity
• EN within first 48-72 hrs = medical tx
- Make sure hemodynamically stable
• NG
• Standard polymeric formula
• Initiate feeding 25 mL/hour, advance to reach goal over 24-48 hrs
• Intolerance COMMON, thus likely not to tolerate
• If not tolerating-> Next: Try elemental, low fat formula or semi- elemental with MCT
• If not tolerating-> Next: Try NJ
• If all fail within 5 days: PN
• Advance to oral diet when no pain or emesis for 24 h

Question 24

Why is EN a part of medical treatment?

Answer 24

• Maintain gut integrity, ↓ septic & metabolic complications, ↓ cost
• Reduces stress response vs PN
• Reduces infection
• Reduces hospital stay
• Reduces surgical intervention
• Reduces organ failure

Question 25

signs of feed intolerance

Answer 25

EN: abdominal signs (distention, tense, discomfort), nausea (check for constipatio, minimize narcotics), emesis (hold feed, check for constipation) PO: similar signs, but they can also be attributed to other thins->less clear

Question 26

when can signs of intolerance be observed

Answer 26

when starting or advancing the feed

Question 27

Additional intolerance signs with AP:

Answer 27

elevated WBC, increased pain, or fever IN ASSOCIATION WITH increases in serum lipase or amylase→ optimize meds → switch to elemental, low fat formula or semi-elemental with MCT If patient has steatorrhea (it is a sign of maldigestion) →optimize meds → switch to semi elemental with MCT

Question 28

when are elevated levels of amylase and lipase ok and not ok?

Answer 28

if lipase and amylase increases but no signs of intolerance-> it ok if levels are elevated + signs of intolerance-> sign of not tolerating and a hint to switch formula/method of administration

Question 29

• Considerations in Nutrition Support with pancreatitis

Answer 29

applicable for acute, mild and severe • Hyperglycemia and insulin resistance common (40-90% of patients) * Hypertriglyceridemia (12-15% of cases) * Electrolyte and micronutrient deficiencies

Question 30

Considerations in Nutrition Support in pancreatitis: Hyperglycemia and insulin resistance

Answer 30

* Cause: Critical illness and residual Islet function * Nutrition: Aim for GIR of 3 mg/kg/min if severe pancreatitis with hyperglycemia (not preferable 3. It HAS to be 3 or lower) * Medical tx: Insulin

Question 31

Considerations in Nutrition Support in pancreatitis: Hypertriglyceridemia

Answer 31

hyper TG definition: when TG <400 mg/dL (i.e., 4.52 mmol/L in Canada) • Cause: Hyperglycemia induced and reduced lipoprotein lipase • Nutrition: Consider GIR of 3 mg/kg/min & <1g fat/kg (HAS to be 1 or lower) • Nutrition: Consider source of ILE (Intralipid <30% total kcal) PO consider low fat and DM diet order (which is already low fat)

Question 32

Considerations in Nutrition Support in pancreatitis: electrolyte and micronutrient deficiencies

Answer 32

Hypocalcemia in up to 25% of cases but doesn't have to be acted upon - no calcium administration is required from you just aim for higher end of the range for calcium administration in PN/EN

Question 33

when might you consider MCT? A. Elevated serum lipase B. Steatorrhea C. All of the above

Answer 33

Answer is B | A. Elevated serum lipase is not not correlated to diet

Question 34

WHy wouldn't NJ be the first choice of EN administration?

Answer 34

``` NJ placement is hard and often gets displayed start with NG first, then switch formula NJ would be the last option as it is so hard to place ```

Question 35

is NJ with standard formula a good first choice for A?

Answer 35

No, polymeric should be the first choice, especially with NJ jejunum, but not many do it going straight to elemental, leaves you with PN only if this approach is not tolerated

Question 36

Feeds were advanced to 35ml/hr but Mr. C experienced abdominal distension and pain. What’s the next step? a. Determine etiology for intolerance b. Determine if NJ is in the correct position c. PN d. All of the above e. A&B only

Answer 36

e. A&B only

Question 37

When should PN be initiated? a. Day 1 b. Day 5 of intolerance to EN c. Day 7 of intolerance to EN

Answer 37

b. Day 5 of intolerance to EN

Question 38

Low fat fluids was an appropriate choice as the first PO option offered A. True B. False

Answer 38

B, false | because we should always aim for solid foods first

Question 39

What is chronic pancreatitis

Answer 39

irreversible loss of exocrine and endocrine mass by replacement with fibrotic tissue

Question 40

Nutritional Management: Chronic Pancreatitis

Answer 40

• Main treatment: Replacement enzymes with meals treatment •Low fat high PRO diet may be indicated - make sure that there are enough enzymes to digest the fat • CHO depends on islet function • MCT oil and EN may be indicated • No alcohol • Vitamin supplements (fat soluble) • may need a diabetic diet if endocrine function has been affected

Question 41

which enzymes are found in PERT pills

Answer 41

lipase, amylase and protease

Question 42

which type of drink should be used with PERT

Answer 42

It is important that you swallow your capsules with a cold drink Hot drinks may damage them and decrease effectiveness

Question 43

What is the goal in pancreatic insufficiency and nutritional recommendations

Answer 43

Goal: Restore and maintain weight, correct malnutrition • Frequent, small meals moderate to low in fat • No research trials of low vs high fat! • Low fat may exacerbate malnutrition–tolerance is the goal • Some research on Mediterranean diet Goal: Improve maldigestion by giving pancreatic enzymes • Treat with insulin if indicated

Question 44

Dose calculation for PERT

Answer 44

Initiate PERT with the lowest dose and increase as needed to control symptoms If not controlled with that dose-> give a higher dose 2 ways of calculations, but usually per meal calculation is used Per meal: 500-2500 U lipase/kg/meal • Do not exceed 2500 U/kg/meal Max: <10,000 U lipase/kg/d Per g of fat: 1000-4000 U lipase/1 g dietary fat per day at meals and snacks

Question 45

PERT instruction for continuous NJ/G

Answer 45

Provide a dose every 3-4 hours

Question 46

consumption instructions for PERT

Answer 46

• Take with cold drinks • Take 30 minutes before or with meals • If pt takes long time to eat-> divide the dose (1/2 in the beginning, 1/2 in the end) • If uncoated, need to suppress stomach acid (meds like proton pump inhibitors prescribed) - Used with J-tubes, but not with G- tubes • Enteric coated (resist degradation by gastric acid) - Do not chew - Requires pH of ~6 to dissolve enteric coat

Question 47

``` If your patient weighs 48kg what is the max dose of lipase units she can take per day? A. 500-2500 B. 480,000 C. 1000-4000 D. 10,000 ```

Answer 47

B. 480,000 Max: <10,000 U lipase/kg/d

Question 48

``` If your patient weighs 48kg how many units should she take per meal? A. 24,000-120,000 B. 500-2500 C. 10,000 D. 480,000 ```

Answer 48

A. 24,000-120,000

Question 49

If your patient weighs 48kg and is taking Creon with 6000 units lipase per capsule. How many capsules does she need to take to cover her meal? A. 10,000 B. 4-20 C. 10-22 D. 3

Answer 49

B. 4-20 48*500/6000 48*2500/6000

Question 50

``` How do you know the lipase dose is sufficient? A. Weight is stable B. Steatorrhea absent C. Bloating, cramping, gas absent D. All of the above ```

Answer 50

D. All of the above note: steatorrhea volume should go down, but it rarely goes away fully

Question 51

WHY do patients need pancreatic surgery?

Answer 51

* Cancer * Necrosis secondary to AP * Assist with control of symptoms associated with CP

Question 52

• Most common pancreatic surgery procedure

Answer 52

= Whipple • AKA pancreaticoduodenectomy

Question 53

HOW do we prepare patients for pancreatic surgery?

Answer 53

* Screen and assess for malnutrition or other nutrition-related problems * Treat the problems so that patient is prepared to withstand the stress of surgery! * Consider ONS for 7 days before surgery: Not always enough time for food first approach! * CHO loading 2 hours before surgery

Question 54

what do u have to include in the follow up note

Answer 54

Is the previous nutritional diagnosis still relevant, improved, worsened?

Question 55

what does Whipple procedure involve?

Answer 55

Removal of head of pancreas, distal bile duct, gallbladder, duodenum, distal stomach, and first few cm of jejunum

Question 56

what determines the extent of loss of endocrine/exocrine function in whipple?

Answer 56

extent of pancreatic loss determines the extent of loss of endocrine/exocrine function but there always be loss

Question 57

Gastrojejunostomy vs Hepaticojejunostomy vs Pancreaticojejunostomy

Answer 57

A hepaticojejunostomy is the surgical creation of a communication between the hepatic duct and the jejunum; a choledochojejunostomy is the surgical creation of a communication between the common bile duct and the jejunum Gastrojejunostomy is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum • can either have intact or absent pylorus Pancreaticojejunostomy is a surgical formation of an artificial passage connecting the pancreas to the jejunum.

Question 58

after whipple, what flows directly into the jejunum

Answer 58

bile, pancreatic enzymes and stomach contents flow directly into jejunum

Question 59

How should we feed this patient immediately postop?

Answer 59

ERAS-> solid food/regular diet but slow with small amounts Institution specific: NPO → Liquids → Solid food Sometimes surgeon will place J-tube for prolonged EN support; Esp, if malnourished preop. Note: Pancreatic leaks require NPO and PN

Question 60

Whipple: Nutritional implications and treatment

Answer 60

• Surgery alters motility, digestion, and absorption. * 95% will have exocrine pancreatic insufficiency (EPI)-> dietary fat and fat-soluble vitamin malabsorption * Tx: Typically initiate PERT after surgery • If endocrine insufficiency, insulin is the treatment • Motility • Does the patient have pylorus? If not, expect dumping syndrome-> anti-dumping diet • If patient does have pylorus, may experience delayed gastric emptying or gastroparesis

Question 61

What are ERAS reccs after surgery | what are usual approaches in practice?

Answer 61

- pt should be allowed normal diet post surgery with no restrictions - increase intake according to tolerance over 3-4 days In practice, often NPO →CF/FF fluids → solid food by day 4-5. Patients are not discharged from hospital until can tolerate PO.

Question 62

post-discharge diet

Answer 62

- Instruct patient on high kcal, high protein diet divided into frequent small meals - Do not recommend low fat diet => just prescribe PERT - Make sure patient understands how to adjust PERT based on fat intake - May require diabetes education if on insulin tx or high BG. - Tx symptoms that arise, such as dumping or nausea.

Question 63

* Pt is POD 1 of a Whipple procedure. Surgeon surgically placed J-tube during procedure. * Wt: 51kg; BMI: 18 * SGA: C * Energy needs are estimated as 30kcal/kg and 1.2g protein/kg. * 1) Calculate a J-tube feeding for this patient using a semi- elemental formula known as Vital 1 cal. Include, goal, initiation and advancement rate. What is your nutrition prescription statement? * 2) Calculate PERT for this patient.

Answer 63

1530kcal 61.2g of protein required ``` 7 bottles: 1540kcal, 63g fluid: in the formula- 1314, needs 1540 1540-1314=226ml left for flushes 226/6= 38 ml per flush-> 35-40ml per flush give a flush every 4h ``` Continuous feed for max tolerance- good starting point, especially considering that the tube is in the jejunum Statement: initiate a 24h continuous NJ feed with 7 bottles of Vital 1cal. via a pump at 25ml/h and increase by 10ml q 8hours as tolerated until goal rate of 64ml/hr. At goal this will provide 1540kcal (30.2kcal/kg which meets estimated needs), 63g of protein (1.2g/kg). Administer 35ml flushes every 4 hours, providing a total water intake of 1524ml/day, which is 30ml/kg meeting estimated needs lipase prescription: 500*51=25500U/meal total g of fat = 7 bottles *8g per bottle= 56 56*1000=56000, check if lowest dose works with continuous feed, administer every 3-4 hours-> divide this dose 9333U per day every 4 hours- round to practical amount of 10000U every 4 hours

Question 64

when should EN be adminsitered in those, who require it?

Answer 64

within 48-72 hours of admission

Question 65

Enteral Formula Selection in Severe Acute Pancreatitis

Answer 65

- Standard polymeric formula may be used in most patients. - If patient has signs of intolerance (increased pain, fever, or white blood cell count in association with increases in serum amylase and serum lipase), switch to elemental, very low–fat formula or switch to a semi-elemental formula with small peptides and medium-chain triglycerides. - If patient has signs of malassimilation (diarrhea and/or steatorrhea), switch to semi-elemental formula with small peptides and MCT