Pancreatic Disease (Cystic Fibrosis, Acute and Chronic Pancreatitis, Gallbladder Disease)

Question 1

What are the most common causes of pancreatitis?

Answer 1

Alcoholism
Biliary tract disease
Cystic Fibrosis
Cancer
Surgical procedures
Trauma

Question 2

What are the mechanisms of Pancreatitis?

Answer 2

Pancreatic duct that is completely or partially blocked can lead to gallstones and edema

Pancreatic flow continues and enzymes are released

Enzymes (trypsin) become activated and high levels overwhelm trypsin inhibitor

Trypsin begin “Autodigestion” of pancreas which initaes inflammation

Question 3

What route of feeding is recommended for pancreatitis?

Answer 3

If it is moderate pancreatitis, can use EN in the small bowel and use an elemental tube feed (past ligament of trietz)

If Acute severe, NPO + TPN

Question 4

what are the stress factors for acute severe pancreatits?

Answer 4

1.3-1.5

Question 5

What are the symptoms of pancreatitis?

Answer 5

Severe abdominal pain that worsens with eating
nausea
vomiting
edema
shock
elevated serum amylase, lipase (enzymes diffuse into the blood and are 100-200x normal)
Can be radiologically confirmed using an ultra sound or CT scan

Question 6

What are the complications of pancreatitis?

Answer 6

circulating enzymes can decrease serum calcium
Hemorrhagic necrosis
glucose intolerance/hyperglycemia
exudates into the periotneal cavity
necrosis of mesenteric fat
increased permeability of lung alveoli - pulmonary edema

Question 7

What is the nutrition care provided for pancreatitis?

Answer 7

NPO - no pancreatic stimulation
Jejunal enteral feeds with elemental
TPN if enteral feedings are not tolerated
Insuln if elevated blood glucose - may require decreased CHO in enteral/parenteral feeds

Question 8

What steps need to be taken once the pancreatitis resolves?

Answer 8

clear fluids - advance slowly
low fat diet
small meals
no alcohol
may require enzyme replacement
continue to conrol blood sugars if required

Question 9

Where are chronic pancreatitis attacks commonly seen?

Answer 9

Alcoholism
Occasionally in cystic fibrosis

Question 10

What is pancreatic insufficiency and what can occur due to it?

Answer 10

Over 90% pancreatic tissue lost
Steatorrhea
glucose intolerance
malnutrition if left untreated

Question 11

What is the response if the chronic pancreatitis is due to alcoholism? What about gallstones?

Answer 11

Alcoholism - treatment as per alcoholic protocl - folic acid, thiamine, multivitamins

Gallstones - may improve with cholecystectomy

Question 12

What conditions predispose gall bladder disease?

Answer 12

More common in women
increased risk with obesity
Risk with multi party pregnancy or if you have more than one baby
high fat diets, high energy foods

Question 13

What is cholestasis?

Answer 13

slowing down of biliary flow from the liver

Question 14

What is cholelithiasis?

Answer 14

hardened deposits of digestive fluid that can form in your gallbladder - gallstones
Very common with pancreatitis
When the pancreas gets inflamed, it slows down the release of bile salts for digestion which can precipitate and form stones

Question 15

What are the complications of cholelithiasis?

Answer 15

Could be asymptomatic
inflammation of the gall bladder
obstruction of the bile duct

Question 16

What is cholecystitis

Answer 16

Inflammation of the gall bladder - usually from gall stones but may be caused by infections
After eating, the gall bladder is stimulated to contract but it is unable to push the gallstones out which can cause more damage

Question 17

What are the symptoms of cholelithiasis/cholecystitis?

Answer 17

Acute abdominal pain associated with eating

Question 18

How is cholecystitis treated?

Answer 18

Removal of the gallbladder - cholecystectomy
Most people are able to function normally because the bile duct of the liver takes over functions of the gallbladder

Question 19

What patient population is it very common to see cholecystitis in?

Answer 19

Patients on home TPN (GI isn’t stimulated, can lead to chronic inflammation and disuse)

Question 20

What recommendations can be made for gallbladder patients when their inflammation is chronic but not yet time for surgery? What about a TPN Patient?

Answer 20

Low fat diet
avoid ultraprocessed foods
weight loss
Clear fluids during the attack and then a slow progression after symptoms subside

With a TPN patient, the approach would not change the amount of IV lipids given but instead to stimulate the bowel with lower fat food items and lower fat enteral feeds

Question 21

What increases the risk of gallstones?

Answer 21

High intake of carbs and foods high on the glycemic index
high plasma Homocysteine concentrations
High intake of trans fatty acids
Decreased risk with - frequent nut consumption

Question 22

What is cystic fibrosis?

Answer 22

Disorder of mucin production and function. Mucin helps prevent bacterial infiltration and when abnormal, it becomes clumpy and makes it for bacteria to infect

Question 23

How is CF diagnosed?

Answer 23

Newborn screening - Elevated IRT, DNA testing
Because CF interferes with the way Na is taken up into the cells, sweat can be tested for abnormal levels of sodium

Question 24

What are the respiratory consequences of CF?

Answer 24

Infection: chronic cough, wheezing, shortness of breath
Thick secretions trap bacteria which lead to infection
Air trapping leads to barrel chest
destruction of lung tissue leads to respiratory failure - patients often end up getting lung transplants

Question 25

What are the consequences of CF?

Answer 25

Respiratory
GI
Pancreatic
Reproductive

Question 26

What are the GI manifestations of CF?

Answer 26

Thick meconium obstructs the GI tract which leads to vomiting, abdominal distension

Obstruction of the biliary system - can lead to cirrhosis

Intestinal Obstructions can lead to distal intestinal obstruction syndrome and meconium ileus - may require surgical intervention

Question 27

What impact does CF have on the pancreas?

Answer 27

Pancreatic destruction leads to insufficient digestive enzymes. This can cause protein/fat maldigestion and significant energy loss or failure to thrive

may cause diabetes mellitus

Question 28

How does CF impact the reproductive system?

Answer 28

Congenital absence of vas deferans in 95% of males leads to infertility
Female fertility reduced duet to thickened cervical mucosa although pregnancy is possible

Question 29

What therapies are used for pancreatitis?

Answer 29

Pulmonary: antibiotics, bronchodilators, chest physio
Nutritional: Vitamins ADEK, enzymes, supplemental feeds, HIGH kcal intake