Cara Conti Post Dietetic Internship April 12th,...

Cara Conti

Post Dietetic Internship

April 12th, 2012

Rare tumor that occurs less than 1% compare to other cancers

American Cancer Society estimates for 2012: ◦ About 8,700 people in the US are diagnosed/year

◦ About 1,150 cases will result in death

Generally found in periampullary regions or ampullary regions that are near to the duodenum

Helicobacter pylori infection (H. Pylori)

Smoking

Bacteria Infection Most common

predisposing factor Common cause of

peptic ulcers ◦ Thrives in an acidic

environment

Commonly live & multiply within the mucous layer that covers and protects tissues that line the stomach & small intestine

Not clear how H. pylori spreads

Can be treated with antibiotics

Interfere with the protective lining of the stomach Making your

stomach more susceptible to the development of an ulcer

Smoking also increases stomach acid

Stress

Promote H. pylori infection

Can cause the production of excess stomach acid

A study of peptic ulcer patients in a Thai hospital showed that chronic stress was strongly associated with an increased risk of peptic ulcer,

Earlier dx vs. Advanced Stage

Nausea Vomiting Epigastric pain Weight loss Most suffer from poor prognosis that would reduce the survival rates by 5 years that ranges from 20%-40%

Earlier Duodenal Cancer could be easily found by an endoscopy procedure without identifying the symptoms of the disease

The advanced stage of the Duodenal Cancer is found as the ulcerated legins or polyploidy ◦ could only be found due to

the radiography and by endoscopy

Medical History and Physical Examination

Endoscopy with biopsies

CT scan of abdomen to determine extent of tumor spread

Blood Tests: CBC, electrolyte test and liver function tests ◦ Determine if spread

Depends on staging and lymph node metastasis

Surgery: Main option and sometimes the only option ◦ Resection

◦ Whipple

Chemotherapy and/or radiation

Chemotherapy Malnutrition ◦ Obstruction

N/V

Unintended weight loss

Loss of appetite

Diarrhea

Constipation

Acid Reflux

Anemia B12 & Iron

Xerostomia Taste Alterations Mouth Sores Low Blood Counts Fatigue ◦ Unable to perform ADLs

Depending on individual case and po tolerance/intake

Tube feedings

TPN or PPN

Liberalize diet if diet is restricted

Check Fluids and electrolytes

Small, frequent meals

Consume supplement in between meals

76 y/o female, JS, admitted to WUH on March 5th, 2012 c/o severe abdominal pain possibly 2˚ previous dx of duodenal CA in May 2011. JS reports N/V, unintentional 31.4% weight loss in 7 months, and unable to tolerate solid foods the past 3 weeks. Could only tolerate liquids in small amounts. Pt. also reports 7 months ago had a good appetite and good po intake.

Comprehensive Assessment

Diagnosis

Intervention

Monitoring & Evaluation

Follow-ups

JS

76 y.o. Female

Admitted: 3/05/2012

Discharged: 3/12/2012

This Hospital stay duration: 7 days

Admitting Dx: Abdominal Pain

Smoked 1 pack/day for 40 years

Strong Family Hx of

GI/Gastric cancer

Middle Class

Caucasian

Occupation: Retired Teacher

Martial Status: Single

Habits: ◦ NO ETOH abuse

◦ Quit tobacco 15 years ago

Family: Lives with sister in Mineola ◦ Other sister flew in from FL

to move in and help

Family Hx: ◦ Mother died at 83y.o. of

colorectal cancer

◦ Father died in his 70s of GI cancer

◦ Sister died in her 70s from gastric cancer

Duodenal CA (May 2011) ◦ Received Chemo RT August 2011 s/p attempted Whipple @

North Shore Hospital (January 2012) Found to have nonresectable disease D/C from North Shore

Hospital to Rehab for 2 weeks to regain strength

Breast CA s/p chemo RT and Left Breast lumpectomy ◦ 6 years ago (2006)

DVT ◦ associated c gastric outlet obstruction and MediportHTN

DM NASH HLD

Exploratory Was found to have a

nonresectable disease

Ultrasound ◦ Assess fluid-filled abdomen

NGT placement ◦ Suction fluid filled stomach

CT Scan ◦ Showed vascular mass in 3rd portion of

duodenum, causing biliary dilation ◦ Gastric Obstruction ◦ Multiple stones ◦ No evidence of mets

Endoscopy ◦ Stone Extraction ◦ Metal stent placement to correct obstruction

Height Weight BMI UBW %UBW IBW %IBW

August 2011 (7 Months ago)

5’3” (63”)

210# 37.2 210# 100% 115#±10%

166%

3/7/12 5’3” (63”)

144# 25.5 210# 69% 115#±10%

114%

JS had a 31.4% weight loss in 7 months *Unable to tolerate solid foods, N/V

HgbA1C: 4.6% WNL

Cholesterol: 127

Amylase: 14 433 144 42 15

Lipase: 38 900 302 96 39

Hgb Hct MCV Glu Na+ K+ BUN Crt Ca++ Adj. Ca++

Alb

3/5 11.9 WNL

36 WNL

98 WNL

105 WNL

141 WNL

4.3 WNL

13 WNL

0.8 WNL

8.8

9.1 WNL

3.6 WNL

3/12 9.9

29.2

96 WNL

96 WNL

138 WNL

3.7 WNL

8 WNL

0.5 WNL

7.8

8.9

2.6

*Requested a Pre-albumin

Discharged Meds

Lovenox (Anticoagulant)

◦ Prevent DVT

Novolog Correction

◦ For hyperglycemia/DM

Zofran

◦ Prevent N/V caused by CA chemotherapy, RT, and surgery

D5W-1/2NS @50ml/hr

2˚ to weight loss

◦ Metformin

◦ Metoprolol

Home Medications

Warfarin (Anticoagulant)

Zocor o Lowers LDL

Current Medications

Followed a regular diet, but watched sugar intake at home ◦ Good appetite and good po intake

Decreased po intake past 7 months ◦ 2˚ to abdominal pain, gastric obstruction, and chemo RT

Unable to tolerate solids the past 3 weeks ◦ 2˚ to severe abdominal pain and gastric obstruction

◦ Liquids in small amounts and sips of Ensure

Diet order: NPO ◦ 2˚ to tests, procedures, and stent placement

◦ NG Tube for suctioning of fluid filled stomach

N/V (duration of 3 weeks) ◦ Unable to tolerate food

Decreased appetite

Unintended weight loss the past 7 months ◦ Type 2 Diabetes

Off medication (Metformin), A1C 4.6%

◦ HTN

Off medication (Metoprolol)

Muscle Loss ◦ Rehab to regain muscle and strength back

On the Bright Side…

25-30kcals/KG ◦ For weight

maintenance/deter weight loss

◦ 1640-1965kcals/day

Fat: 35-40gm ◦ 2˚ to fat restriction

Based on current body weight: 65.5kg

1.0-1.2gms/KG ◦ For slightly increased

protein needs

◦ 65.5-79gms/day

CHO: 245Grams

Diet does not meet nutritional needs 2˚ to NPO status

Patient with unintended weight loss (NC-3.2) related to decreased ability to consume sufficient energy as evidenced by 31.4% weight loss in 7 months, poor po intake, and conditions associated with diagnosis and treatment (Chemo RT 2 to duodenal ca and gastric outlet obstruction)

Patient with altered GI function (NC-1.4) related to duodenal cancer as evidenced by N/V, abdominal distention, and NPOx4.

Deter further weight loss ◦ Meet nutritional needs when diet advances to ≥ 75% po

intake of meals

Manage GI side affects

Maintain skin integrity

Attain normalized albumin levels within the next 3 days ◦ Albumin: 3.5-5.0g/dL

Clears Full liquids Low-fiber

Will follow up after stent placement on po intake ◦ Provide supplements PRN ◦ Encourage mall, more

frequent meals ◦ Provide food preferences as

requested by patient when diet advances

Unintended weight loss ◦ Provide Supplement PRN

depending on po intake ◦ Recommend prostat

depending on po intake and albumin/prealbumin levels

When diet advances Recommend diet

Recommend pre-albumin ◦ further assess

nutritional status

Pre-albumin requested to assess nutritional status

Request daily weights

Record po intake % when diet advances ◦ Provide supplements PRN

Monitor lab values

N/V

Follow-Up

3/9/12

NPO x 4 days N/V Stent placed yesterday

(3/8/12) Acute pancreatitis likely from

procedure

Albumin 3.0 ◦ WNL

Skin: Intact Meds: Reviewed Continue with unintended

weight loss (NC-3.2) and altered GI function (NC-1.4)

Plan ◦ Recommend Pre-albumin

◦ Consider TPN/PPN until po tolerance can be established

◦ If diet advanced: clears Low-fat full liquidsLow-fiber, low fat

◦ Follow up with supplement prn when diet advances

◦ Follow up on labs

Amylase & Lipase

Pre-albumin

Amylase: 14 433 144 42 15 Lipase: 38 900 302 96 39

Diet advanced to Clear liquids last night (3/10/12) ◦ Will advance to low-fat full

liquids tonight for dinner

Albumin 2.4 ◦ Moderate protein depletion

Bloated after clear liquid dinner last night

Continuing clears and will advance to low-fat full liquid diet for dinner tonight ◦ 75% po intake

Continue with unintended weight loss (NC-3.2) and altered GI function (NC-1.4)

Skin: Intact Plan ◦ Provide 6oz. Enlive 2x/day

Provides 200kcal & 7gms. Protein 2x/day

◦ Recommned 30ml Prostat 2x/day

Provides 101kcal & 15gms. Protein 2x/day

◦ Recommend Pre-albumin

Follow-Up

3/11/12

CHO Protein Fat TOTAL

Total Grams 238 70 38 346

Total Kcals 960 280 342 1582

Total Percent 68.7% 20.2% 11%

Diet: low fat, low fiber mechanical soft ◦ No green leafy vegetables

◦ Tolerating well

◦ 75% po intake at breakfast

Labs: Albumin 2.6 ◦ Indicates moderate protein

depletion

Skin: Intact

Continue with unintended weight loss (NC-3.2)

Plan: ◦ Continue to encourage po

intake

Small, more frequent meals

◦ Will provide 6 oz Enlive

3x/day which provides 200 kcal and 7 gms protein 3x/day

◦ Recommend Pre-albumin

◦ Recommend MVI

Follow-Up

3/12/12

Prognosis was fair adequate Follow-up with primary care physician in 1-2

weeks and GI doctors prn Continue low fat, low fiber diet, but add fiber

as tolerated higher fiber intake Avoid Green vegetables until tolerated Education provided ◦ Fluid intake ◦ Diet guidelines

Increase fiber as tolerated

◦ Small, frequent meals

Prospective cohort study to determine the relationship between intake of dietary fiber/whole grains and the incidence of small intestinal cancer

Methods: analyzed dietary data collected in 1995 and 1996 from 293,703 men and 198,618 women in the National Institutes of Health–AARP Diet and Health Study ◦ used multivariate Cox proportional hazards models to estimate relative

risk (RR) and 2-sided 95% confidence intervals (CIs) for quintiles of dietary fiber and whole grain intake

Results: Through 2003, 165 individuals developed small intestinal cancers. Dietary fiber/whole grain intake was generally associated with a lower risk of small intestinal cancer.

Conclusions: Intake of fiber from grains and whole-grain foods was inversely associated with small intestinal cancer incidence ◦ Grain fiber & whole grain foods seem to protect against lower GI

cancers

American Cancer Society. Cancer Facts and Figures. Atlanta, Ga.

American Cancer Society, 2012. www.cancer.org Beyer P.L. (2008) In L.K. Mahan & S. Escott-Stump (Eds.), Krause's

Food , Nutrition & Diet Therapy . St. Louis, Missouri: Saunders Beers, M.H. & Porter, R.S. (2006). Small-Bowel Tumors. The Merck

Manual of Diagnosis and Therapy (p. 172-173). Whitestone Station, NJ: Merck & Co., Inc.

Escott-Stump, S. (2012), Nutrition and Diagnosis-Related Care 7th ed. Baltimore, Maryland and Philadelphia, PA: Lippincott Williams & Wilkins.

Litchford, MD. (2008). Assessment: Laboratory Data. In L.K. Mahan & S. Escott-Stump (Eds.), Krause's Food , Nutrition & Diet Therapy 12th ed.(pp. 415-427, 936-939). St. Louis, Missouri: Saunders

Pronsky, ZM & Crowe, JP. (2010). Food/Medication Interactions 16th ed. Birchrunville, PA.

Schatzkin A., & Park, Y (2008). Prospective Study of Dietary Fiber, Whole Grain Foods, and Small Intestinal Cancer. Gastroenterology 4 (p. 1163-1167). Washington, DC: Division of Cancer, Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services.

Questions??