Chapter 20: Pancreatic Flashcards
The pancreas is located in the abdomen, behind the _________
Stomach
Endocrine pancreatic cells produce these 2 hormons
Insulin & glucagon
Exocrine pancreatic cells produce _______ to neutralize stomach acid & ________ enzymes
Bicarbonate
Digestive (lipase, amylase, protease)
What does Trypsin & Chymotrypsin do?
Break down proteins into amino acids
What is the ampulla of vater?
The emptying point of bile& pancreatic juices into the small intestine (duodenum)
The majority of pancreatic cancers arise from the _______ cells, making this called __________
Exocrine cells
Adenocarcinoma
7% of pancreatic cancers arise from the ____________ cells, the most common being ___________
Endocrine
Pancreatic neuroendocrine
Pancreatic adenocarcinoma is AKA
Ductal cell carcinoma or ductal adenocarcinoma
These are nonmalignant tumors of the pancreas that require a similar treatment d/t the location
“Cyst” or “Pseudo” neoplasms
7 risk factors for pancreatic adenocarcinoma
Smoking
Obesity
Family history
Chronic pancreatitis
DM
Heavy drinking (limited evidence)
Poor diet (saturated fat, fructose)
This marker is elevated in most patients with pancreatic cancer
CA 19-9
(Carbohydrate antigen 19-9)
Pancreatic tumors are divided into these 3 categories and this is often the staging method:
- Resectable (potentially curable)
- Bordeline resectable (potentially curable) - requires neoadjuvant chemo
- Unresectable (locally advanced or metastatic)
Why isn’t traditional staging method used for pancreatic tumors?
Requires surgery to determine, thus defining it by resectability is typically used
T/F: Systemic therapy is used with all stages of pancreatic cancer
True
*if radiation is given, it’s typically given with
When might single chemo agents be used with pancreatic cancer? (Rather than combo)
Poor performance status
Combo therapy for pancreatic cancer w/ patients that have good performance status
FOLFIRINOX
fluoroacil, leucovorin, irnotecan, oxaliplatin
A total of ______ months of systemic treatment (for pancreatic cancer- before after or both from surgery) is recommended
6
Adjuvant chemotherapy should commence within ______ weeks post-op, specifically for pancreatic cancer
8-12 weeks
Pancreatic tumors found in the _______ or _____ may require pts may be asked to come to treatment on an empty stomach, then drink a specific volume of fluid to aid in mimicking simulation anatomy
Body
Tail
Concurrent chemoRT typically includes 1 of the following 3 chemo agents
Fluorouracil
Capectiabine
Gemecitabine
3 surgeries for resectable pancreatic cancer
Whipple (pancreaticoduodenectomy (PD),
pylorus preserving pancreaticodueodenectomy (PPPD), distal pancreatectomy
PPDD doesn’t modify any of the _______
stomach
5 organs removed w/ whipple
Head of pancreas
Duodenum
Distal stomach (pylorous)
Bile duct
Gallbladder (sometimes saved)
5 side effects of Whipple
- PEI
- DM
- Lactose intolerence
- Dumping syndrome
- Delayed gastric emptying
What is NOT a side effect or PPPD
Dumping syndrome
These are the 2 main side effects of distal pancreatectomy
PEI, DM
(no GI issues)
Why may you see jaundice w/ pancreatic cancer?
If the head of the pancreas obstructs the bile duct
Why may the hallmark sign of pancreatic insufficiency (loose or frequent BMs) be masked with pancreatic cancer?
Narcotics ghat slow gut motility
Are tests or judgment better indicators of PEI?
Judgement/clinical signs
the tests often underdiagnose and are expensive
What are some tests that may be used to diagnose PEI?
Fecal elastase - most common
Fecal chymotrypsin
Fecal fat excretion
Coefficient of fat absorption
Carbon 13- labeled mixed tryglyceride breath test
Signs of PEI
Excess gas
Abdominal bloating
Cramping after meals
Stool changes (oily/foamy, frequent, floating, clay colored, loose)
Smelly gas
Unexplained wt loss
What are pancreatic enzyme main ingredient
Pancrealipase
The most common dosing of PERT is ________- based
Meal
May dose of pancreatic enzymes (per day and per meal)
2,500 g/kg lipase units per meal (4x/day)
10,000 g/kg lipase units per day
Starting dose for PERT
1-3 capsules with meals and snacks
10,000-15,000 lipase units per capsule
6 steps for optimizing PERT if initial dose doesn’t work
- Acid-reducing therapy (H2 or PPI)
- Educate to space with meals
- Increase dosage
- Open capsules or change to non-enteric coated tablet
- Change brand
- Consider other issues (i.e. lactose intolerence, c diff)
Fat-based dosing for pancreatic enzymes
500-1000 per g fat
No more than 4000 per g fat
Do not sprinkle pancreatic enzymes or acidic or basic foods? What PH?
Basic, nothing with ph> 4 (like milk)
Regardless of the indication, those with suspected or known PEI on EN should be placed on a ___________ formula, high in _________
Semi-elemental
MCT
*severe PEI may still require PERT
PERT with EN frequency
q3 hours for continuous
with each feeding for gravity/bolus
How to deliver PERT through feeding tube
If you have a large bore feeding tube, put the microspheres in a thickened acidic liquid
For small bore or j tube, crush and dissolve w/ bicarb
Studies in humans with ___________ condition demonstrate that in-line digestive cartridges (like Relizorb) may help enhance lipid absorption
Cystic fibrosis
Fat restriction recommendation for severe steatorrhea
</= 75 g/day
Possible use/benefit of MCT oil?
For those having difficulty consuming adequate kcal d/t fat intolerance. Do not require enzymatic action or bile salts for digestion & absorption. Not very palatable PO, but coconut oil may be a good substitution. MCT shouldnt be the ONLY form of fat though d/t risk for essential FA deficiency
Liberalize A1c goal for those with progressive pancreatic cancer or advanced disease to
</= 8%
CHO control and A1c </= 7% is more appropriate for those post-treatment
What is the ligament of trietz?
separation between the duodenum & jejunum
Gastric outlet obstruction is AKA
Duodenal obstruction
What is gastric outlet obstruction? How is it treated?
When the pancreatic tumor evades the duodenum. Surgery is needed to create a bypass
Other options include a duodenal stent or g tube for drainage. J tube for feeding may be placed at the same time
Difference between gastric outlet obstruction and small bowel obstruction?
Small bowl = beyond ligament of trietz
Gastric outlet = duodenum
MNT for duodenal stent & vented g tube
Liquids then low fiber foods chewed very well. Plenty of liquid with meals
*some institutions will require blended foods before progressing to solids
likely also need laxatives to prevent obstruction
What is serum ascites albumin gradient? (SAAG)
Used to determine the etiology of ascites. If high (>/= 1g/dL), no-salt-added diet may be appropriate
Kcal recommendations for pancreatic cancer pre & post op
25 kcal/kg
30 kcal/kg
EN vs PO post-pancreatic surgery
Really depends on the surgeon but no evidence found to support use of EN - PO is preferred
Immunonutrition w/ pancreatic cancer surgery?
Likely benefit found on outcomes with these products
Diet progression post-whipple
Low fat/fiber ~1-2 weeks post op
Regular ~4-8 weeks, low fat if needed
Should you drink fluid with or without meals for delayed gastric emptying?
With
do the opposite w/ dumpong
MNT for delayed gastric emptying
Low fat, low fiber
liquid with meals
6-8 eating occasions/day
good BG control
potential nutrition support
potential liquid diet
prokiniteic agents (metoclopramide, erythromycin)
Recommendations for absorptive fiber
psyllium or methyllcellulose
take after a meal
avoid drinking fluid x1 hour
start 1x/day and increase to 4 if needed
Pain control using a Celiac Plexus Block may cause _______
diarrhea
If bile acid-related diarrhea is present, _______ medication may be beneficial
Cholestyramine (bile acid sequestrant)
Postoperative pancreatic fistula is the leakage of _______ into the ________
Pancreatic fluid into the abdomen
**oral intake is usually fine, doesn’t increase stimulation of the pancreas
EN > PN
Define chyle leak
Output of milky colored fluid from wound or drain and into the pleural (lung) space
It’s high in trigycerides and requires a diet low fat/fat free, possibly with MCT
Do parenterally administered fats contribute to chyle leak?
No
What are 3 long term side effects of pancreatic cancer survivors?
-Micronutrient deficiencies (pert needs to be optimize to best utilizie micronutrients)
-Decreased bone density
-hepatic steatosis (NAFLD) - unknown etiology. PERT may help treat
Where in the body is calcium absorbed?
Duodenum
