Renukadevi

Senior Dietician, Department of Clinical Nutrition & Dietetics, Kauvery Hospital, Chennai.

Acute Pancreatitis: the nutrition care process

Background

Acute pancreatitis is a condition where the pancreas becomes inflamed (swollen) over a short period of time. The pancreas is a small organ, located behind the stomach, that helps with digestion. Pancreatitis can occur as acute pancreatitis – meaning it appears suddenly and lasts for days. Some people develop chronic pancreatitis, which is pancreatitis that occurs over many years.

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Sign and Symptoms

Acute pancreatitis signs and symptoms include:

  • Upper abdominal pain
  • Abdominal pain that radiates to your back
  • Tenderness when touching the abdomen
  • Fever
  • Rapid pulse
  • Nausea
  • Vomiting.

Pancreatitis occurs when digestive enzymes become activated while still in the pancreas, irritating the cells of the pancreas and causing inflammation. Conditions that can lead to acute pancreatitis include:

  • Gallstones
  • Alcoholism
  • Certain medications
  • High triglyceride levels in the blood (hypertriglyceridemia)
  • High calcium levels in the blood (hypercalcemia), which may be caused by an overactive parathyroid gland (hyperparathyroidism)
  • Pancreatic cancer
  • Abdominal surgery
  • Cystic fibrosis
  • Infection
  • Injury to the abdomen
  • Obesity
  • Trauma
  • Endoscopic retrograde cholangiopancreatography (ERCP), a procedure used to treat gallstones, also can lead to pancreatitis.

Case Scenario

A 35-year-old male was admitted with complaints of epigastric pain and abdominal distension, along with 2 episodes of vomiting. He also had shortness of breath.

USG abdomen showed pancreatitis. Patient was admitted to the ICU for further management.

Nutrition Care Process

1. Anthropometric Data

Height 165cm
Weight 72kg
Body Mass Index 26.4kg/m2

According to WHO BMI classification patient falls under overweight category
Ideal Body Weight 60-65 kg

2. Biochemical Data

Biochemial Parameters 9/6/22 10/6/22 11/6/22 13/6/22 14/6/22 17/6/22 18/6/22 19/6/22 24/6/22 26/6/22
Urea 108.5 80 47.5 47.4 54.2 51.1 39.1 14.4 18.2
creatinine  2.16 1.35 0.87 0.79 0.62 0.57 0.52 0.43 0.42
Na 132.7 137.2 135.6 134.5 140.6 140.4 144.2 136.7
K+ 4.71 4.14 3.91 4.09 5.12 6.18 4.64 4.42
cl2 97.6 105.3 101.4 105 109.8 104.6 98.4
HCO3 14 16.3 19.6 25.2 19 19.5 25.2
Sr. uric acid  7.79 6.06 6.05 6.6 7.17 6.92 2.71
T.cholesterol 156.5
Bilirubin – T 7.41 7.36 4.15 3.94 4.1 1.34 0.69 0.68
Bilirubin – D 5.41 5.36 2.02 2.94 3.24 0.38 0.39 0.42
Bilirubin – I 2 2 2.13 1 0.86 0.96 0.3 0.26
SGOT (AST) 81.2 84.9 72.9 58.9 65 52.7 47.4 36.9
SGPT  25.9 38.5 34.85 31.8 28.6 21.4 18.4 16.5
T. Protein 5.45 5.09 72 5.34 6.03 5.64 5.44 6.39
Albumin 2.83 2.6 2.41 2.53 2.74 2.2 2.53 3.1
Globulin 2.62 2.49 3.31 2.81 3.29 3.44 2.91 3.29
Calcium 5.35 6.77 7.22 7.48 6.61 6.96 7.97
Sr.Al. Phosphatase 43 39.2 60.4 64 121.4 70.7 40.3
Phosphorus 2.9 1.39 2.55 3.73 2.84 2.16 3.76
Magnesium 1.87
CRP 553.43 336.89 364.72 359.44
Amylase 192
Lipase 589.2 59.5 8.1

3. Clinical Data

Chief complaints  Abdominal pain, vomiting, loose stools,  tiredness
Diagnosis  Acute pancreatitis

Multiple organ dysfunction syndrome
History of past illness Nil
Plan of treatment Medical management
Nutrition-focused physical findings 
  1. Appearance (eyes, hair, nails, skin, lips & mouth were found to be normal)
  2. Ascites and edema were identified
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Fig. 1. Graphical Presentation of Abdominal Girth.

4. Diet History

Diet Habit Ova – vegetarian
Food allergies Nil

Subjective Global Assessment

Rating B
Category  Well-nourished but at risk

PES Statement

Problem Etiology Symptom
Altered GI function Related to Underlying medical condition of the patient (ASBO) As evidenced by Abdominal pain, vomiting and loose stools

Medical Nutrition Therapy

Energy To provide adequate amount of energy to meet the requirements and to maintain optimal nutritional status
Carbohydrates To provide adequate amounts of carbohydrates to replenish energy reserves
Protein To provide a high protein diet to aid in tissue repair and prevent weight loss
Fat To provide moderate amount of fat to maintain normal bodily function
Fluids  Adequate fluids should be provided to prevent dehydration
Micronutrients Micronutrients are to be provided as per RDA to maintain physiological functions

Nutrition Prescription

Energy 1600 @25kcal/kg IBW
Carbohydrates 60% of total calories
Protein 65 @1 g/kg IBW Followed by 1.5 g/kg IBW
Fat 20% of total calories
Fluids  Liberal
Salt 3 g/day
Vitamins As per RDA
Minerals As per RDA

Diet History

Days Date Type of Diet Energy (Kcal) Protein (G) Remarks
Day 01 09-06-22 Renal, clear liquid diet; total volume: 750 ml 112.5 1.8 Oral soft solid bland diet initiated
Day 02 10-06-22 Oral clear liquids; total volume: 1200 ml 180 3 Diet was modified to liquid diet since the patient had c/o loose stools – 2 episodes
Day 03 11-06-22 Oral clear liquids; total volume: 690 ml 103.5 1.7
Day 04 12-06-22 Oral clear liquids; total volume: 520 ml 78 1.3
Day 05 13-06-22 Oral clear liquids; total volume: 450 ml 67.5 1.1
Day 06 14-06-22 Oral clear liquids; total volume: 760 ml 114 1.9 Suggested ONS 4 times a day (semi-elemental formula)
ONS 4 times in a day 612 24
Total 726 25.9
Day 07 15-06-22 Oral clear liquids; total volume: 310 ml 46.5 0.7
ONS 4 times a day 612 24 Initiated RTH by ICU team
Total 658.5 24.7
Day 08 16-06-22 Oral clear liquids; total volume: 510 ml 76.5 1.2
RTH @ 20 ml/h; total volume: 290 ml 435 18
Total 511.5 2.2
Day 09 17-06-22 Oral clear liquids; total volume: 300 ml 99 1.6
RTH @ 20 ml/h; Total volume: 440 ml 660 27 Oral egg scrambled trail
Total 759 28.6
Day 10 18-06-22 Oral clear liquids; total volume: 285 ml 42.7 0.7
RTH @ 30 ml/h; total volume: 460 ml 690 29
Total 732.7 29.7
Day 01 09-06-22 Renal, clear liquid diet; total volume: 750 ml 112.5 1.8 Oral soft solid bland diet initiated
Day 02 10-06-22 Oral clear liquids; total volume: 1200 ml 180 3 Diet was modified to liquid diet since the patient had c/o loose stools – 2 episodes
Day 03 11-06-22 Oral clear liquids; total volume: 690 ml 103.5 1.7
Day 04 12-06-22 Oral clear liquids; total volume: 520 ml 78 1.3
Day 05 13-06-22 Oral clear liquids; total volume: 450 ml 67.5 1.1
Day 06 14-06-22 Oral clear liquids; total volume: 760ml 114 1.9 suggested ONS 4 times a day (semi-elemental formula)
ONS 4 times a day 612 24
Total 726 25.9
Day 07 15-06-22 Oral clear liquids; total volume: 310 ml 46.5 0.7
ONS 4 times a day 612 24 Initiated RTH by ICU team
Total 658.5 24.7
Day 08 16-06-22 Oral clear liquids; total volume: 510 ml 76.5 1.2
RTH @ 20 ml/h; total volume: 290 ml 435 18
Total 511.5 2.2
Day 09 17-06-22 Oral clear liquids; total volume: 300 ml 99 1.6
RTH @ 20 ml/h; total volume: 440 ml 660 27 Oral egg scrambled trail
Total 759 28.6
Day 10 18-06-22 Oral clear liquids; total volume: 285 ml 42.7 0.7
RTH @ 30 ml/h; Total volume: 460 ml 690 29
Total 732.7 29.7
Day 11 19-06-22 Oral clear liquids; total volume: 800 ml 120 2
RTH @ 30 ml/hr; Total volume: 310ml 465 19 Oral semi-solid diet initiated
Total 585 21
Day 12 20-06-22 RTH @ 30 ml/h; total volume: 760 ml 1140 47
Oral semi-solid diet 83 4
Total 1123 51
Day 13 21-06-22 Oral clear liquids; total volume: 300 ml 45 0.7
RTH @ 30 ml/h; total volume: 460 ml 690 29 Suggested TPN
Total 735 29.7
Day 14 22-06-22 TPN initiated @ 30 ml/h followed by 60 ml/h 1600 75
RTH @ 30 ml/h; total volume: 870 ml 1305 54.5
Oral semi solid diet 157 10
Total 3062 139.5
Day 15 23-06-22 TPN @ 60 ml/h; total volume: 1320 1408 66 Suggested RT feed @200 ml 4th hourly
RT feed @200 ml 4th hourly 408 16
Oral 162 12
Total 1978 94
Day 24-06-22 TPN @ 60 ml/h; total volume: 1080 1204 55
16 RT feed @200ml 4th hourly; total Volume: 500ml 418 17
Oral semi solid diet 83 4
Total 1705 76
Day 17 25-06-22 TPN @ 60 ml/h; Total volume: 1380 1538 70
RT feed @200 ml 4th hourly; Total Volume: 200 ml 334 14
Oral semi solid diet 261 17
Total 2133 101
Day 18 26-06-22 TPN @ 60ml/hr; Total volume: 1320ml 1473 67
RT feed @200ml 4th hourly; Total Volume: 700ml 714 28
oral semi solid diet 200 8.65
Total 2387 103.05
Day 19 27-06-22 TPN @ 60ml/hr; Total volume: 1260ml 1406 64
RT feed @200ml 4th hourly; Total Volume: 700ml 714 28
oral semi solid diet 157 10.45
TOTAL 2277 102.45
Day 20 28-06-22 TPN @ 60ml/hr; Total volume: 1740ml 1272 59
RT feed @200ml 4th hourly; Total Volume: 500ml 510 20
oral semi solid diet 29 15
TOTAL 2074 94
Day 21 29-06-22 TPN @ 60ml/hr; Total volume: 660ml 726 33
RT feed @200ml 4th hourly; Total Volume: 600ml 408 16
oral semi solid diet 474 24
TOTAL 1608 73
Day 22 30-06-22 TPN @ 60ml/h; Total volume: 280ml 308 14
RT feed @200 ml; Total Volume: 1050 ml 1050 40
oral semi solid diet 505 23 suggested to Stop TPN and encouraged oral and RT feed only; modified RT feed to 5 times in a day
TOTAL 1863 79
Day 23 01-07-22 RT feed @200 ml; Total volume: 800 ml 800 38
Oral High protein diet 692 41
TOTAL 1492 73
Day 24 02-07-22 Oral High protein soft diet 1538 75 RT stopped
Day 25 03-07-22 Oral High protein soft diet 1600 75
Day 26 04-07-22 Discharge diet issued
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Fig, 2. Graphical presentation of total parenteral nutrition.

 

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Fig. 3. Graphical presentation of enteral nutrition.

 

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Fig. 4. Graphical presentation of oral feeds

Conclusion

A 35-years-aged male was admitted with complaints of epigastric pain and abdominal distension, along with episodes of vomiting. He also had shortness of breath at the time of admission. The patient was admitted in the ICU for further management and started on HFNC 60 litre. Necessary investigations were done. Elevated blood parameters were seen. Echo showed LV dysfunction. USG abdomen showed acute pancreatitis. The abdominal girth measurement was above 102cm. Medical and nutritional management was given accordingly.

Initially clear liquid diet and semi elemental formula was prescribed as the patient had episodes of vomiting and loose stools. Total Parenteral Nutrition was given to improve the nutritional status of the patient followed by Ryles tube feeds and transited to oral soft solid high protein diet. The patient’s condition gradually improved in nutritional status. The patient and family were educated on High protein diet at the time of discharge.

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Ms. Renukadevi

Senior Dietician

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