Acute Pancreatitis: the nutrition care process

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.

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	Appearance (eyes, hair, nails, skin, lips & mouth were found to be normal) Ascites and edema were identified

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

Fig, 2. Graphical presentation of total parenteral nutrition.

Fig. 3. Graphical presentation of enteral nutrition.

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.

Ms. Renukadevi

Senior Dietician

Acute Pancreatitis: the nutrition care process

Renukadevi