Pancreatic Disorders Flashcards
Endocrine function of pancreas
Regulation of glucose homeostasis – Pancreas produces insulin & glucagon
Produces somatostatin
Exocrine functions of the pancreas
Synthesize & secrete digestive enzymes
- lipase, amylase, proteases (inactive)
- bicarbonate
Stimulation of Exocrine Pancreatic Secretions occurs to secrete _____ and ______
secretin
cholecystokinin (CCK)
Secreted is released in response to _______ in the _________
stimulates the duct cells to secrete ________=> which _________
acidic chyme
duodenum
bicarbonate
neutralize chyme
Cholecystokinin (CCK) is released in response to __________ in ______
Stimulates ______ cells to release ________
fat & protein
duodenum
acinar
digestive enzymes
Acute pancreatitis is believed to be inflamed when you have _______
Possibly due to ________
premature activation of the digestive enzymes within the pancreas
injury to pancreatic acinar cells
acute pancreatitis results in pancreatic inflammation, ______, _______, ______, and ______
edema
hemorrhage
fibrosis
necrosis
Causes of Acute Pancreatitis
Cholelithiasis (most common)
Acute or chronic alcohol abuse (2nd most common)
Others:
Idiopathic
Medications: corticosteroids
Abdominal trauma
Hypertriglyceridemia (TG >500 mg/dl) (genetic)
Hypercalcemia (can be from hyperparathyroidism)
Clinical Manifestations of acute pancreatitis
severe epigastric pain radiating to the back
- may get worse with ingestion of food
N/V
anorexia
abdominal distention
ileus
Complications of Severe, Acute Pancreatitis
Pancreatic abscess - now infected
Pancreatic pseudocyst - abscess that is walled off
Necrotizing pancreatitis - some tissue died
Hypovolemia, hypotension, shock - dehydration from vomiting or from inflammation causing leakage
Systemic Inflammatory Response Syndrome (SIRS) - massive inflammatory response
Multiple Organ Dysfunction Syndrome=> pulmonary, renal
Death
Diagnosis of Acute Pancreatitis
clinical manifestations
elevated serum lipase and amylase
CONFIRMED BY:
imaging studies - CT scan
Lab findings with acute pancreatitis
Altered electrolytes
Hypoalbuminemia
Hyperglycemia
Elevated WBC
Hypocalcemia
For hypoalbuminemia, remember to do the correction of total serum calcium.
equation ?
([4 – albumin (g/dL)] x 0.8) + Total Ca2+(mg/dL)
Nutritional Requirements for Acute Pancreatitis
Energy?
Protein?
patients are in _________, ________ state
25-35 kcal/kg (lower is for ICU sedated)
1.2-1.5 g/kg (may approach 2 g)
hyper metabolic, catabolic
MNT for Mild-to-Moderate Acute Pancreatitis
If pain & vomiting=> ________ to decrease pancreatic stimulation
When pain, N/V decreases=> __________
- To limit pancreatic stimulation
- Monitor for return of pain or GI distress
__________ meals may be better tolerated
Advance to regular diet or appropriate MNT based on _______
NPO with IVF
Low Fat Diet (40 g)
Frequent, small
cause of pancreatitis
MNT for Severe Acute Pancreatitis
Current guidelines recommend ___ over ____
Has been associated with less ____________ and shorter ______
EN
PN
infectious complications
hospital LOS
Enteral Nutrition should be Initiated within ______ hrs of admission (if ___________) for those with severe, acute pancreatitis
_____ feeding recommended to minimize pancreatic stimulation
- Short-term: _____
- Longer duration: _____
Formula: ______, ______
If fat malabsorption (not typical) => ____________
Monitor tolerance
Goal: transition to oral diet
24-48
hemodynamically stable
Jejunal
NJ tube
J-tube
polymeric, high protein
semi-elemental formula
Parenteral Nutrition (PN) should be used __________ and _____
only when prolonged SB ileus
Severe, acute pancreatitis and EN is not tolerated
For PN, _______ does not stimulate pancreatic secretions
Can use them unless _________
IV lipid
TG >400 mg/dL
Chronic Pancreatitis (CP) is Progressive, irreversible, inflammatory disease in which pancreatic tissue is slowly destroyed and replaced by ________
Results in permanent ______ and ______ impairment
Initial loss of function resulting in _____________ and then eventually also loss of ________
Evolves over many years
fibrotic tissues
structural & functional
pancreatic exocrine insufficiency (PEI)
endocrine function
Causes of Chronic Pancreatitis
Chronic alcohol use disorder (number 1 cause)
Smoking
Hypertriglyceridemia
Hypercalcemia
Genetic mutations
Autoimmune pancreatitis
Obstructions: strictures in pancreatic ducts
Idiopathic
Chronic Pancreatitis manifestations…
Recurrent attacks of epigastric pain
Worsens ________, particularly with consumption of _____ foods
_______, ______, _______, _______
Progressive pancreatic insufficiency leading to ______ => _____
after meals
high fat
Anorexia
N/V
diarrhea*
steatorrhea*
wt loss
malabsorption=> fat, fat soluble vitamins, protein, & CHO
Chronic Pancreatitis results in
Decreased_______ production=> ____
Malnutrition due to:
Decreased intake due to=> abdominal pain, anorexia, fear of eating
Malabsorption
Continued alcohol use
Hypermetabolism
Fat-restricted diets
________ deficiency
__________
insulin
DM
Vitamin B12
Metabolic bone disease
why B12 deficiency sometimes
B12 needs to be free
pancreas makes protease to separate some factor from B12 to be absorbed
Diagnosis & Evaluation of Chronic Pancreatitis
Combination of _____, _____, and ______
symptoms, imaging (CT scan or MRI), & functional tests
Pancreatic function tests:
72-hr fecal fat test: >7 g/d=> malabsorption
Fecal elastase-1 (one stool)
Secretin stimulation test: measures volume of pancreatic bicarbonate produced
CP Nutrition Assessment…
Anthropometrics
Nutrition-focused physical examination
Diet history
- Diet PTA
- Analysis of diet recall
- Wt loss despite eating well
- GI c/o
- _____ consumption
Alcohol
CP Assessment…
Labs: _____, ______, _____
Monitor for potential micronutrient deficiencies: ______, ___, ____, ____, ______, _____, _____
Food-medication interactions
High nutrition risk=> assess for malnutrition
electrolytes, glucose, fecal fat test
fat-soluble vitamins, Ca, Mg, Zn, vitamin B12, thiamin & folate
Chronic Pancreatitis
energy ?
Protein ?
35 kcal/kg
1-2 g/kg
MNT for Chronic Pancreatitis
No alcohol
High kcal, high protein diet
6-8 small meals per day
Avoid large meals with high fat foods
Micronutrient Supplementation for Chronic Pancreatitis
everyone gets _______
Possible ________ supplementation
Role of ________ supplements are being researched
If alcohol use disorder, recommend supplementation of:
________
_______
MVI with minerals
IM vitamin B12
antioxidant
Thiamin: 50-100 mg
Folic acid: 1 mg daily
MNT for Steatorrhea
If on pancreatic enzyme replacement therapy=> ________
- Unless fat malabsorption cannot be controlled by enzyme replacements alone
__________ supplementation
No fat restriction
Fat-soluble vitamin (in water-soluble form)
Pancreatic Enzyme Replacement Therapy Examples ? (3)
Creon
Pancreaze
Viokase
Pancreatic Enzyme Replacement Therapy…
Given ______ with _______
Contain _____, _____, and _____
Function best in a _____ environment
May require _____________ to decrease acidity
orally
all meals & snacks
lipase, protease, amylase
basic
H2 blockers/proton pump inhibitors
beads in enzyme replacement have ______ that’s resistant to _____ so that it reaches _____
enteric coating
acid
duodenum
Pancreatic Enzyme Replacement Therapy - Dosage
Individualized dosage based on severity of exocrine insufficiency and composition of meal or body wt
Example recommendations:
_____ units of lipase per ______
_____ units of lipase/________ and adjust as needed
1800
gram of fat
1000
kg per meal
Enteral Nutrition Support
Supplemental tube feeding may be required to meet nutritional needs
should be _______, _______ formula
Route: _______
High protein, calorically dense
gastric feeding
Enteral Nutrition Support – Pancreatic Insufficiency
The optimal way to dose pancreatic enzymes when on TF has not been established
___________________ formula
For cycle TF, provide _______________ at the _______ of the feeding and then _________ the feeding
Partially-hydrolyzed/semi-elemental
pancreatic enzymes orally
beginning
halfway through
Glucose Intolerance Management:
_______ therapy
MNT=>
________ diet
Balance CHO intake with insulin therapy
__________ if experiencing frequent episodes of hypoglycemia
Insulin
Consistent CHO
Small frequent meals
Pancreatic Surgeries
Whipple Procedure
What is the name for a Whipple?
Pancreaticoduodenectomy
Whipple is used to treat ___________
involves surgical removal of ______, ______, sometimes _______, and _______
pancreatic cancer
head of pancreas
duodenum
distal stomach
portion of common bile duct
WHIPPLE
stomach, lil duodenum, jejunum
pancreatic ducts attached to ______
reattach bile ducts to _______
jejunum
jejunum
Post-op complications from WHIPPLE
Delayed gastric emptying OR Dumping syndrome
Weight loss
Possible fat malabsorption=> provide pancreatic enzyme supplements
Possible development of DM
MNT s/p Whipple Procedure
When appropriate begin oral diet=> ______ meals/day
Adapt MNT if the patient is having delayed gastric emptying or dumping syndrome
If severe, delayed gastric emptying with N/V=> ______
Monitor for possible ______________
Monitor for _________
5-6 small
NPO with jejunal TF
pancreatic insufficiency
hyperglycemia
