Pancreatic Cancer

Florida Hospital Dietetic Internship Program

Pancreatic Cancer

Case Study 1

Melissa Cockley

May 26th, 2017

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Table of Contents
Introduction ..................................................................................................................................... 3
Social History.................................................................................................................................. 3
Normal Anatomy and Physiology of Applicable Body Parts: ........................................................ 4
Past Medical History: ...................................................................................................................... 5
Present Medical Status: ................................................................................................................... 5
Usual treatment of pancreatic cancer: ............................................................................................. 7
Communications and collaborations: .............................................................................................. 9
Laboratory Findings: ..................................................................................................................... 10
Medications: .................................................................................................................................. 12
Physical & Psychological changes................................................................................................ 13
Treatment: ..................................................................................................................................... 14
Nutrition History: .......................................................................................................................... 14
24 hour recall: ............................................................................................................................... 15
Prescribed diet:.............................................................................................................................. 17
Nutrition related Problems: PES ................................................................................................... 17
Evaluation of present nutritional status: ....................................................................................... 18
Other Nutrients to address: ........................................................................................................... 18
Goals, Interventions, Monitoring and Evaluating: ........................................................................ 18
Nutrition Education Process: ........................................................................................................ 19
Prognosis: ...................................................................................................................................... 20
Current Research:.......................................................................................................................... 20
Summary & Conclusion:............................................................................................................... 21
References: .................................................................................................................................... 23

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Introduction
My first case study is about a patient with the initials of B.P. B.P is a 70-year-old female

patient who was pancreatic ductal adenocarcinoma (PDA) and was admitted to the Transplant

unit at Florida Hospitals main campus. B.P. was admitted on April 23rd, 2017. Her admission

weight of 89.0 kg (195lbs) and height of 167.64 cm (66 inches). Her weight before being

discharged to a skilled nursing facility on May 8th, 2017, was 89.0 kg due to no other weights

recorded during her stay. Prior to admission, B.P. was previously at a skilled nursing facility,

where she had an episode of emesis, was found unresponsive on the floor and aspirated. B.P. was

then hospitalized at Winter Haven hospital, where she was intubated, placed on pressure support,

found to have Klebsiella pneumonia, and suffering from an intraabdominal infection. Once B.P.

was extubated and stabilized, she was transferred to Florida Hospital to get treatment for sepsis

due to a Whipple procedure for pancreatic ductal adenocarcinoma T3N1. Cultures from her

surgery were positive for Strep viridans, Enterobacter cloacae, and E. coli.
Anthropometrics

Height 167.64cm/ 66 in.

Admit Weight 89.0kg/ 195 lbs.

IBW 59.1kg/ 130 lbs.

IBW% 151%

ABW 66.5kg/ 146 lbs.

UBW 73.0kg/ 160.6 lbs.

BMI 31.7

Social History
B.P. had a history of smoking cigarettes for roughly 35 years, and quit in 1999. B.P.

rarely drinks alcohol, has a Catholic religion background, and was part of a supervised home

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living arrangement at a skilled nursing facility. Aside from physical therapy 5-7 times a week,

B.P. does not engage in physical activity due to her illness. B.P. has two children: a son and a

daughter.

Normal Anatomy and Physiology of Applicable Body Parts:

The pancreas is along, flat gland that is located in the upper abdomen behind the

stomach. The head of the pancreas fits below the liver, curving with the duodenum, while the tail

of the pancreas slants upward towards the

spleen. The pancreas preforms both endocrine

and exocrine functions. The endocrine function

regulates blood glucose levels by using the

cells of the pancreas to manufacture glucagon,

insulin, and somatostatin for absorption into the

blood stream. The exocrine function assists in

digestion by the pancreatic cells secreting enzymes into the intestinal lumen, where they help

digest proteins, fats, and carbohydrates. The pancreatic duct merges with the bile duct into a

combined opening where the bile and pancreatic juices are excreted into the duodenum. Neural

and hormonal response assist in regulating exocrine functions from the pancreas. The two

primary hormones that induce pancreatic secretions are secretin and cholecystokinin (CKK).

Secretin is a hormone that is secreted by the small intestine into the blood stream that stimulates

the secretion of pancreatic juice and prevents gastric acid secretion and emptying. CCK is a

hormone that acts as a neurotransmitter, informing the brain to decrease hunger and promote

satiety.

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There are three factors that are divided into phases that influence pancreatic secretions:

the cephalic phase, gastric distention and the intestinal phase. The cephalic phase is mediated by

the vagus nerve where the secretion of bicarbonate and pancreatic enzymes are a reaction to the

sight, smell, taste and anticipation of food. The gastric distention phase takes place when food

initiates pancreatic secretion, that stimulates enzyme secretion. The intestinal phase is mediated

by the release of CCK.

Past Medical History:

B.P.s past medical history includes obstructing jaundice, gastroesophageal reflux disease

(GERD), diabetes mellitus (DM), uterine cancer, hypertension (HTN), and hyperlipidemia. Past

procedures include nose surgery, carpal tunnel, Whipple procedure (3/29/17), central venous

access insertion port (12/2/16), endoscopic ultrasound exam (10/10/16), endoscopic retrograde

cholangiopa (10/10/16), fracture of tibial plateau (10/31/08) and abdominal hysterectomy

(10/31/83). B.P.s medical history of DM and uterine cancer does correlate with her current

pancreatic cancer.

Present Medical Status:

Pancreatic ductal adenocarcinoma is a cancer that begins in the cells that line the ducts of

the pancreas. Symptoms include pain in the upper abdomen that spreads to the back, loss of

appetite, unintended weight loss, depression, new-onset diabetes, blood clots, fatigue, and

jaundice. The causes of pancreatic ductal adenocarcinoma are not clear, but risk factors such as

a family history of genetic syndromes which include BRCA2 gene mutation (a form of breast

cancer), Lynch syndrome, Familial Atypical Mole- Malignant Melanoma syndrome, chronic

pancreatitis, family history of pancreatitis, diabetes, obesity, smoking, and older age increases.

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Complications of PDA are weight loss, pain, jaundice, and/or bowel obstruction. Weight

loss is common with any form of cancer due to side effects from treatments such as

chemotherapy and/or radiation which cause decreased appetite, nausea, and vomiting. Weight

loss with pancreatic ductal adenocarcinoma is possible due to the tumor growing on the pancreas

causing it to press on the stomach, making it difficult to eat. The pancreas may not be producing

enough digestive juices, causing maldigestion. When the pancreas does not produce enough

pancreatic enzymes, a supplement may be needed to aid in digestion. Pain is common because

the growing tumor may press on nerves in the abdomen. Jaundice occurs when the bile duct from

the liver is blocked and usually occurs in combination with abdominal pain. The skin and eyes

turn yellow, as well as having dark- colored urine, and pale colored stools. To help relieve

symptoms, a stent may be placed in the duct to hold it open allowing for the bile to be released.

Bowel obstructions may occur in the digestive tract due to the tumor pressing on the small

intestine. Stents and surgery recommended to keep the duodenum open and prevent bowel

obstructions from occurring.

Ultrasound, computerized tomography (CT) scans, majestic resonance imaging (MRI),

and occasionally positron emission tomography (PET) scans are used to diagnose PDA. Other

diagnostic options, such as biopsy of the pancreas or a blood test for CA 19-9, may be used to

diagnose pancreatic adenocarcinoma.

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Usual treatment of pancreatic cancer:

The treatment for pancreatic cancer ranges from surgery, to chemotherapy and radiation

to clinical trials. A common surgery for pancreatic cancer is a pancreaticoduodenectomy, also

known as a Whipple procedure. This

procedure removes cancer by removing

the antrum of the stomach, the first and

second sections of the duodenum, the

head of the pancreas, the common bile

duct, and the gallbladder. These organs

are removed because the head of the

pancreas and the duodenum share the

same arterial blood supply. The arteries go through the head of the pancreas, therefore both

organs need to be removed in order to sever the blood supply. When these organs are removed, it

is common for the patient to be at risk for vitamin and mineral deficiencies and will require

supplementation. Other surgeries include cholecystectomy, vagotomy, or a partial gastrectomy

which can be performed during the Whipple procedure.

Nutrition related effects that are associated with surgery of the pancreas include delayed

gastroparesis, fluid and electrolyte imbalance, hypercalcemia, early satiety, glucose intolerance,

bile acid insufficiency, diarrhea and fat malabsorption (vitamin A, D, E, K, B12; calcium, zinc

and iron).

Chemotherapy and radiation are common treatments for any form of cancer.

Chemotherapy is the use of therapeutic drugs that can either be taken orally, or injected into the

muscle or vein to slow tumor growth or prevent cancer cells from forming. Radiation therapy is

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ionizing radiation used in multiple fractioned doses to cure, control, or palliate cancer. It can be

delivered externally into the body from a megavoltage machine, or by placing a radioactive

source in or near the tumor to deliver a highly-localized dose. It is common for both

chemotherapy and radiation therapy to be used at the same time when surgery is not an option to

remove the tumor.

Clinical trials can become an option at some cancer institutes because they are potential

new cancer treatments that are not readily available. Clinical trials often entail the use of new

drugs, surgical procedures/techniques, as well as diagnostic treatments such as endoscopy and

immunotherapy.

Nutrition for pancreatic ductal adenocarcinoma is similar to other forms of cancer. Plant

based diets have been suggested because they may aid in cancer prevention. The American

Cancer Society Prevention guidelines suggest that a higher intake of fruits and vegetables results

in weight loss, and greater satiety, lowering the risk of obesity and reducing the overall risk of

cancer. Animal sources of protein should be limited because they have high amounts of fat and

an insignificant amount of fiber. Tumor development is suppressed by diets that contain levels

of protein below that required for optimal growth. Folate and folic acid are important as well.

Some studies have shown that higher intake of folate may decrease pancreatic and colon cancer

risks. However, high intakes of folic acid supplements may cause more damage with other

cancers. Coffee and tea are acceptable to consume because they contain antioxidants and phenols

that have been shown to contain anticancer properties.

B.P. previously recieved chemo-gemcitabine and abraxane in December of 2016, and

completed three cycles of it until February 2017. In late March of 2017, B.P. had a Whipple

procedure. B.P. denied following a theraputic diet. B.P. does not consume very much food

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orally, and was on a jejunostomy tube feeding part of the time she was in the hospital. Prior to

admission, B.P. was intubated at Winter Haven Hospital, preventing her from receiving oral

nutrition.

Communications and collaborations:

Communication amongst the multiple teams is essential when it comes to patient care.

B.P had a team of physicians, nursing, case management, physical therapist, speech language

therapist, pharmacy, wound care and the registered dietitian working together to provide her with

the best care possible. Originally, the physician had ordered for B.P. to have a tube feeding of

Glucerna 1.5. When the dietitian for the unit looked at B.P.s background, the RDN suggested

B.P. change to Osmolite 1.5 instead because it would be easier to tolerate with her condition.

Osmolite 1.5 has less fat than Glucerna 1.5, making it easier for her to digest. Nursing contacted

the attending physician, and he agreed to change the feeding.

Physical therapy started working with B.P. five days a week when she first arrived

emphasizing on strength and balance. The physical therapy team worked on strengthening

activities of daily living for B.P. by assisting her with exercises such as stretching, marching, gait

training, and leg raises to help her build strength. Towards the end of B.P.s stay, physical

therapy noted that she was working with them seven times a week and progressing with

increased activity tolerance. B.P. will still need to work on walking, and balance as well as other

activities while at a skilled nursing facility, but was making good progress.

Speech language therapy(ST) was consulted for B.P. soon after her arrival while she was

on a clear liquid diet. ST completed a swallow evaluation, stating she was tolerating clear

liquids without difficultypresenting mildly prolonged oral stage with regular solids Patient

felt safe on a PO diet. B.P. was advanced to a solid regular diet with thin liquids. B.P.s diet

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was changed to NPO to place her J-tube, but was advanced back to a solid regular diet as well as

continuous tube feedings.

The wound care team assists nursing by providing treatment for multiple types of wounds

such as pressure sores, ulcers, and incisions from surgery/procedures. Wound care was consulted

for B.P. because she arrived with redness/erythema on her coccyx. Wound care left

instructions with nursing to cleanse, and apply topical cream and foam every eight hours until

her wound was healed. B.P. also has sutures from the multiple tube placements that needed

attending. Nursing changed dressings and cleansed the area when needed. Further instructions

were placed for B.P. when she was discharged to a skilled nursing facility to attend to her

wounds.

I was able to participate in case management rounding everyday while on the transplant

unit. Case management deals with the discharge of the hospitals patients, by contacting skilled

nursing facilities, hospice, rehabilitation centers, and multiple other locations to ensure the

patient will get the care they need. They will even contact insurance companies to help provide

equipment such as walkers, shower stools, and wheelchairs to assist the patient at their next

location. Case management does not only work with the hospital team, but with the patient and

their family members to ensure they are discharged to a location that is close to home, and that

will provide them with the appropriate care. B.P. returned to a skilled nursing facility when she

was discharged with instructions for pain management, incision/wound care and physical

therapy, feeding tube care, and for her sutures to be removed in seven to ten days.

Laboratory Findings:
Important lab values for diagnosing pancreatic cancer are Chromograinin (CgA),

Billirubin, and Carcinembryonic antigen (CA19-9/ CEA). CgA is a lab test that is done to help

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diagnose tumors of the pancreas. High or rising levels may indicate tumor growth in the

endocrine system. High levels of CA19-9/CEA are a good indicator of how treatment for the

tumor is working. Bilirubin is an important value to measure because it can indicate signs of

liver problems such as jaundice, which may be seen when the bile duct is blocked. B.P.s

bilirubin was within normal limits of 0.2 on May 8th. Unfortunately, there were no labs shown

for CgA and CA19-9/CEA.

Laboratory results
Lab value Clinical range Lab on 4/23/17 Lab on 5/8/17
Sodium >145 mEq/L 137 139
Potassium 3.5-5 mEq/L 4.1 4.0
Chloride 100-110 mEq/L 107 102
CO2 21-30 mEq/L 13 22
Glucose Level 70-109 mg/dL 221 266
BUN 10-20 mg/dL 39 15
Creatinine 0.60- 1.20 2.56 0.63
mg/dL
Calcium 9.0-10.5 mg/dL 7.9 9.2
Phosphorous 3.0-4.5 mg/dL N/A N/A
Albumin 3.5-5.0 g/dL N/A 4.0
White Blood 6-17 x 109/L 10.02 10.13
Cell
Red Blood Cell 4.2-5.2 10/L 3.03 3.99
Hemoglobin 12-16 g/dL 9.4 12.9
(Hgb)
Hematocrit 37-47% 28.8 38.4
(Hct)
Billirubin 0.1-1.5 mg/dL 0.3 0.2

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Medications:
Common medications used during pancreatic ductal adenocarcinoma treatment are listed below:
Medications: Uses/Symptoms:
Chemotherapy drugs - -To treat different forms of cancer.
Gemcitabine (Gemzar) Symptoms: decreased appetite, hair loss,
5-fluorouracil (5-FU) drowsiness, headaches, muscle joint or bone
Irinotecan (Camptosar) pain, sores on lips/mouth/throat, itching,
Oxaliplatin (Eloxatin) weight gain, swelling, trouble breathing, or
bruising.
Insulin -To regulate glucose levels in the blood.
Symptoms: rash/itching, shortness of breath,
dizziness, blurred vision, sweating, weakness,
muscle cramps, weight gain, or swelling.
Pain relievers -To elevate pain.
Symptoms: constipation, dizziness,
drowsiness, nausea, or vomiting.
Antidepressants -To treat depression.
Symptoms: Nausea, increased appetite,
weight gain, insomnia, fatigue, drowsiness,
and sexual side effects.

B.P.s list of medications pertains mainly to control diabetes, and to help fight her infection from

the Whipple Procedure.

Medications Uses/Symptoms
Carvediol (Coreg) -Beta blocking agent
May cause: weight gain, nausea, vomiting,
and diarrhea. May mask symptoms of diabetic
hyperglycemia.
Diphenoxlate- atropine -Treats diarrhea.
May cause: seizures, constipation, bloating.
Drowsiness, dizziness, headache, blurred
vision, dry mouth, decreased urine, irregular
heartbeat.
Heparin (500 units/ml) injection -Blood thinner.
May cause: dizziness, chest pains, numbness,
redness, pain, swelling, blistering, sores, or
rash where needle is placed, stomach pain,
unusual bleeding, bruising, or weakness.
Insulin glargine (Lantus) -Long acting insulin.
May cause: itching, dry mouth, nausea,
vomiting, weight gain, shaking of hands,

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ankles or feet, tiredness, sweating, hunger, or

lightheadedness.
Medications: Uses/ Symptoms:
Insulin lispro (Humalog) -Used to treat diabetes.
May cause: dry mouth, thirst, itching, nausea,
vomiting, weight gain, shaking of hands and
feet, sweating, hunger, or lightheadedness.
Micafungin -Antifungal.
May cause: itching, swelling, blistering, skin
rash, dark urine, pale stools, rapid weight
gain, nausea, vomiting, loss of appetite,
stomach pain, yellowing of skin, fever,
unusual bleeding, or bruising.
Pancreliase (Creon) -Improves digestion.
May cause: Itching, joint pain, swelling in
feet/legs, stomach pain, bloating,
constipation, diarrhea, nausea or vomiting.
Tamsulosin -Urinary retention medication.
May cause: Itching, blistering, red skin rash,
dizziness, fainting, headache, runny/stuffy
nose.
DiphenhydrAMINE (Benadryl) -Antihistamine.
May cause: itching, swelling, hallucinations,
lightheadedness, fainting, painful urinating,
clumsiness, constipation, nausea, upset
stomach, dry nose/mouth/throat, nervousness,
excitability, or thick mucus in nose & throat.
Morphine injection -Narcotic Agent.
May cause: sedation, respiratory depression,
dry mouth, and constipation.
Normal Saline 0.9% -Fluid and electrolyte replenished.
May cause: fever, redness, or infection at
injection site.

Physical & Psychological changes

B.P.'s admission weight on April 23rd, 2017 was 89.0 kg (195 lbs.), and no new weights

were taken by the time she discharged on May 8th, 2017. Her ideal body weight is 59.1 kg (130

lbs.), and her adjusted body weight was 66.5 kg (146 lbs.). Her BMI was 31.6, putting B.P in the

obese category. B.P. was receiving majority of her calories from her J-tube feeding.

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I was unable to perform a Nutrition Focused Physical Assessment on B.P. because she

was either being assisted by nursing or uninterested in having one done. From what I noticed

visually, she had slightly dark circles surrounding the eye, and well-rounded anterior thigh

muscles. B.P. had been working with physical therapy 5-7 times a week, and appearing stronger

each time I had seen her.

Treatment:
In December for2016, B.P. started three cycles of chemo-gemcitabine and abraxane. B.P.

finished her treatment in February 2017 and decreased the size of the tumor on her pancreas by

30%. B.P. received a CT scan of her abdominal area on April 23rd, that showed a large amount of

ascites localized by the head of the pancreas measuring 3.7 x 4.7 cm, as well as bilateral pleural

effusions and basilar infiltrates, coronary artery calcifications, mitral valve and aortic valve

calcifications at the base of B.P.s lungs. B.P. had three tubes located in her abdominal: one was

a pancreatic drain, another was a Foley catheter within her urinary bladder, and one was her

feeding tube going to her jejunum. While B.P. was in the hospital this time, she did not receive

chemotherapy or radiation, due to recovering from a Whipple procedure at the end of March.

The majority of B.P.s treatment was primarily for sepsis.

Nutrition History:
When B.P. arrived at the hospital on April 23rd, she was on a clear liquid diet. On

April 25th, B.P. was changed to NPO status for testing purposes, then was advanced to a solid

regular diet with thin liquids after passing her swallow evaluation on April 26th. On April 28th,

B.P. was placed back to NPO and had her j-tube placed to start tube feedings. B.P. was placed

back on a solid regular diet as well as continuous tube feedings through her j-tube on April 30th.

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B.P. consumes minimal amounts of food. She insisted that she has never been a big eater,

and with her treatment she has a decreased appetite. B.P. stated that she used to eat 5-6 small

meals a day but was now having trouble due to decreased appetite. B.P. is on cyclic tube

feedings of Osmolite 1.5 at 60mL/hr for 22 hours. B.P. did enjoy Chocolate Glucerna shakes,

twice a day while she was in the hospital. B.P. has a latex allergy, but did not state any foods that

she dislikes or avoids. B.P.s nutrition needs are as followed:

Calories (30- 1995-2328 per ABW

35kcal/kg)
Protein (1.2-1.5g/kg) 80-100g per ABW
Fluid (1 mL/kcal) 1995-2328mL
*Adjusted body weight is 66.5kg.

24-hour recall:
B.P.s 24- hour recall consists of:
Breakfast: 1 small cup of applesauce
Lunch: Glucerna Shake
Dinner: Glucerna Shake
And Osmolite 1.5 @ 60ml/hr x 22 hours
Through the tube feeding of Osmlite and Glucerna Shakes BID:
Osmlite 1.5 Glucerna Shake Totals
Total Vol. 1320mL 16 floz./473mL 1793mL
Kcal 1980kcal 380kcal 2360kcal
Protein 82g 20g 102g
CHO 269g 46g 315g
Water 1006mL 380mL 1386mL
Total Fat 64g 14g 78g
Fiber 0g 6g 6g
Sodium 1820mg 420mg 2240mg
Potassium 2340mg 760mg 3100mg

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Vitamins/Minerals Osmolite Glucerna Shake Total

1.5
Calcium 1300mg 500mg 1800mh
Iron 23mg 9mg 32mg
Vitamin A 10,816IU 2500IU 13316IU
Vitamin B12 15.6mcg 3mg 18.6mg
Vitamin C 312mg 120mg 422mg
Vitamin K 104mcg 40mcg 144mcg
Vitamin D 520IU 640IU 1160IU
Total RDIs 132% N/A

*B.P. also receives IV fluids of 400 mL, and 180mL flushes 6 times a day= 2866mL of fluid.

Fluid needs: 1995-2328 mL/day. Meeting an average of 133% of daily fluid needs.

Total calories= 2360kcal/day (not including applesauce)

Calories needed: 1995-2328 kcal/day. Meeting an average of 109% of daily calorie needs.

Total Protein= 102g/day

Protein needs: 80-100g/day. Meeting an average of 113% of daily protein needs.

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B.P. is receiving over 100% amount of fluids, calories and protein she needs on a daily basis,

even though she is rarely consuming food by mouth.

Prescribed diet:
There are multiple complications after a Whipple procedure related to digestion and

absorption. Recommendations are to use pancreatic enzyme replacements, eat small, more

frequent low fat meals and snacks, and to avoid simple carbohydrates to aid digestion and

absorption.

B.P.s diet started as a clear liquid diet. After passing a swallow evaluation with speech

therapy, B.P. was advanced to a solid regular diet with thin liquids. B.P. was not consuming

enough food orally, so a feeding tube was placed. B.P. was able to eat solid regular foods of her

choosing. B.P.s J-tube feeding was originally Glucerna 1.5 at 60mL/ hour for 22 hours, but was

changed to Osmolite 1.5 at 60mL/hour for 22 hours per dietitian recommendations. Glucerna 1.5

has 75g of fat per liter compared to Osmolite 1.5 containing 49.1g of fat per liter, making it

easier to digest.

Nutrition related Problems: PES

B.P.s original PES statement is as follows: Inadequate protein-energy intake due to

decreased ability to consume sufficient energy and protein as evidenced by estimated intake less

than estimated needs. After B.P. was placed on continuous tube feedings, her nutrition care

problem was resolved because she was receiving all of her energy and protein needs through the

continuous tube feeding of Osmolite 1.5.

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Evaluation of present nutritional status:

B.P.s nutritional needs had to be increased due to infection and pancreatic ductal

adenocarcinoma. B.P. initially needed 25-30kcal/kg/day because of sepsis, but needed 30-

35kcal/kg/day for her caloric needs due to pancreatic ductal adenocarcinoma. B.P.s protein

needs were also increased to 1.2-1.5g/kg/day due to stress. Additional protein is needed in the

body to help rebuild tissues that have been broken down by previous cancer treatments and to try

and maintain a healthy immune system. B.P.s fluid needs were the same as her caloric needs of

1995-2328 mL/day. B.P. was receiving more than her recommended amount of fluids through

her tube feeding, Glucerna shakes, and IV fluids.

Other Nutrients to address:

After reviewing B.P.s laboratory values the day of her discharge, her glucose levels were

elevated, as well as her BUN and creatinine. Glucose levels are commonly elevated after having

a Whipple surgery because the head of the pancreas is removed, which contains tissues where

insulin is produced. Patients with diabetes often have higher glucose levels after a Whipple

procedure and require higher insulin doses. Elevated BUN levels are caused by prerenal failure,

excessive protein intake, or possible GI bleeding. If creatinine levels are elevated, it is possible

there is kidney failure, or dehydration.

B.P. also has low levels of hemoglobin and hematocrit levels. Low levels can lead to iron

deficiency anemia. Low albumin levels may be secondary to dehydration or blood loss. Low

albumin levels are associated with retention of sodium and fluid resulting in edema.

Goals, Interventions, Monitoring and Evaluating:

B.P. was unable to orally consume food due to decreased appetite. Because her oral

intake was small, a tube feeding was administered via J-tube to provide her with the

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recommended daily energy needs. B.P.s goal rate was 60 mL/hour for 22 hours of Osmolite 1.5,

as well as being on a solid regular diet to encourage her oral intake. After meeting with B.P. on

the first occasion, I encouraged her to try more foods orally even though she was receiving tube

feedings. During my second encounter, B.P. mentioned she really enjoyed the oral supplement of

Glucerna shakes and would like to consume at least two each day, as well as trying to eat bites of

food. By my third encounter, B.P. was drinking two Glucerna shakes a day, and eating small

amounts of food when she felt hungry.

I spoke with nursing occasionally to check and she how she was doing before I went in to

speak with her. One nurse agreed that her appetite has slowly gotten better but, B.P. has a

decreased appetite from her infection and PDA.

Nutrition Education Process:

When I had my first encounter with B.P., it was very short. In the past, I dont think she

liked encounters with dietitians because she feels pressured to eat large meals. When I asked her

how she was eating she replied saying Not very good. I like to eat small amounts of food, and I

feel that I have to apologize for that. I felt bad with how upset she seemed, and she was trying

to eat more food, but was having difficulty. B.P. stated some foods dont taste like they used

to. And I am not hungry as I used to be. At first I was concerned because I didnt think she

was getting all of the nutrients she needed. After learning she had undergone chemotherapy a

few months prior, and a Whipple procedure which reduced her stomach, I understood why she

consumes small amounts.

The previous dietitian had ordered B. Ps tube feeding supplement to be Osmolite 1.5, but

the physician thought Glucerna 1.5 would be better since her glucose levels were elevated.

During case management rounds, nursing had stated that B.P. was having diarrhea for a few

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days. My preceptor informed nursing that she requested Osmolite 1.5 in the place of Glucerna

1.5 because she may be able to tolerate it better because it has a lower fat content. Nursing spoke

with the physician and he agreed to change the feeding formula to Osmolite and adding Banatrol

twice a day to help elevate her diarrhea. Shortly after B.P. was up to goal rate, her diarrhea had

resolved, and Banatrol was removed. I followed up with B.P. a few days later and she said she

was tolerating the Osmolite 1.5 well and requested Glucerna shakes twice a day. I was excited

that she wanted to consume something orally since she was not eating. I was able to get the

chocolate Glucerna ordered that day. When I followed up with her the third time, B.P. was happy

to see me. B.P. informed me she had been eating applesauce once a day, and consuming

chocolate Glucerna shakes twice a day. Two days later B.P. was discharged to a skilled nursing

facility.

Prognosis:
B.P. was discharged from Florida Hospital on May 8th. She went to a skilled nursing

facility where they will continue her tube feedings, wound care, and physical therapy. There was

no record indicated if they were going to continue treatment for her pancreatic cancer.

Current Research:
Current published research displays the idea that nicotinamide adenine dinucleotide

phosphate: quinone oxidoreducase 1 (NQO1), which is a protein located on a chromosome, may

be a biochemical marker for pancreatic cancer. NQO1 is important in protecting normal cells in

the body from injury and carcinogens, and can be found on human tumors. The study included

126 patients with pancreatic ductal adenocarcinoma and 55 patients without pancreatic ductal

adenocarcinoma and studied if stained NQO1 proteins on the participants pancreas reproduced.

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The patients with pancreatic ductal adenocarcinoma expressed higher counts of NQO1 than

patients without it, providing a new way of diagnosing pancreatic ductal adenocarcinoma.

In the Indian Journal of Surgical Oncology published research concerning nutrition status

and support before and after surgery for pancreatic cancer. This study discusses whether enteral

or parenteral nutrition is best for patients after having a procedure such as a pancreatectomy or

Whipple. Malnutrition and weight loss are symptoms when someone has cancer. Trying to keep

a cancer patient well-nourished is a hard goal to achieve if they are not eating orally. Ideally,

having patients receive their nutrients orally is the best thing, but it can be difficult when

someone is nauseated by the smell or look of food. This article discusses that enteral nutrition is

preferred over parenteral nutrition to prevent attenuate cachexia. Oral supplements are also

promoted because they can reduce mortality, and infections after a procedure. Placement for a

nasojejunal tube is ideal so the patient will avoid the risk of another surgery for tube placement.

Cyclic feedings are suggested because they lower the chances of having postoperative gastric

stasis. Total parental nutrition may be used in certain circumstances after careful individual

evaluation. Pancreatic enzyme supplements work best when given with the appropriate feedings

or supplement.

Summary & Conclusion:

Pancreatic ductal adenocarcinoma is an interesting form of cancer that I was not very

familiar with before this case study. The survival rate for this cancer is 6% in five years after

having a surgery such as a Whipple or pancreatomy. This cancer is deadly because of the

arteries that are located in the pancreas that circulate blood flow to the nearby organs, meaning

the cancer can spread quickly and easily to other parts of your body. Treatments such as

chemotherapy and radiation therapy are available and may possibly work in some cancer cases. I

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was surprised to find that a small amount of people are eligible for Whipple surgeries. If the

cancer is at stage 4 they would not be able to remove it. I am impressed with all of the

medications and surgeries available to patients with pancreatic ductal adenocarcinoma. It was

also interesting that research states enteral feedings may decrease the chance of cachexia and

infection after a pancreatic surgery.

The role in nutrition in preventing pancreatic ductal adenocarcinoma is important because

your intestinal tract may not be absorbing nutrients as well as it had been. Vitamins and minerals

will not be absorbed, resulting in deficiencies. There is limited research available on any nutrient

that can help decrease the risk of this cancer specifically, but I am looking forward to the

research that will be done on this topic. All of the research for this case study has helped me

understand the human body a little bit better, and will help me in the future in my dietetics

career.

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References:
1) Mahan, L. Kathleen, and Janice L Raymond. Krause's Food & Nutrition Care Process.
14th ed. St. Louis: Elsevier, 2017. Print.

2) Pancreatic cancer. Mayo Clinic. http://www.mayoclinic.org/diseases-

conditions/pancreatic-cancer/symptoms-causes/dxc-20268506. Published April 29, 2017.
Accessed May 18, 2017.

3) Pancreas Cancer Treatment. Moffitt Cancer Center.

https://moffitt.org/cancers/pancreatic-cancer/treatment/. Accessed May 19, 2017.

4) Tests for Pancreatic Cancer. American Cancer Society.

https://www.cancer.org/cancer/pancreatic-cancer/detection-diagnosis-staging/how-
diagnosed.html. Last revised: May 31, 2016. Accessed May 20, 2017.

5) Drugs Approved for Pancreatic Cancer. National Cancer Institute.

https://www.cancer.gov/about-cancer/treatment/drugs/pancreatic. Published May 4, 2011.
Accessed May 20, 2017.

6) 2016-2017 Abbott Nutrition Product Reference. (2017). Abbott Laboratiries.

7) Ji M, Jin A, Sun J, et al. Clinicopathological implications of NQO1 overexpression in the

prognosis of pancreatic adenocarcinoma. Oncology Letters.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5431416/?report=classic . July 2017.
Accessed May 20, 2017.

8) Karagianni VT, Papalois AE, Triantafillidis JK. Nutritional Status and Nutritional
Support Before and After Pancreatectomy for Pancreatic Cancer and Chronic
Pancreatitis. Indian Journal of Surgical Oncology.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3521551/?report=classic. Published
December 3, 2012. Accessed May 20, 2017.

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