Gastric Outlet Obstruction by Pancreatic Head Mass: TPN and - PowerPoint PPT Presentation

Gastric Outlet Obstruction by Pancreatic Head Mass: TPN and Electrolyte Disturbances A Case Study Presentation By Amy Torget

Introduction to Patient  62 yo male  Resides in Vancouver, WA  Presented to ED on 4/6 with chief complaint of abdominal pain  2 week h/o progressive abdominal pain, N/V, decreased PO intake, and jaundice  Pain especially worse over 3-4 days prior to admit  No UO 4 days prior to admit

Issues to be Covered  History Prior to Admission  ED Course  Overview of GOO & Nutritional Implications  Nutrition Assessment & Diagnosis  Nutrition Intervention/MNT  Refeeding Syndrome  Electrolyte Disturbances  Outcomes and Discussion

Prior to Admit  Presented to PCP on 3/21 with jaundice  Labs showed elevated bilirubin and liver enzymes  CT scan on 3/27 showed:  Pancreatic head mass associated with pancreatic and biliary duct dilation  Suspicious for malignancy  Pt awaiting evaluation by GI http://www.nlm.nih.gov/medlineplus/ency/article/003.html

ED Admit  Presented to ED on 4/6, 10 days after CT scan  Initial vitals  BP of 83/37  Tachycardia  Afebrile  Labs  Leukocytosis  Elevated creatinine, BUN, lactate, CO2, blood pH  Low K, Na, and Cl

ED Issues and Course  Hypotension/shock  8 L NS given, systolic BP mildly responsive  Central line placed, started on norepinephrine drip  Started on Vancomycin and Zosyn  Concern for cholangitis  AKI  Elevated creatinine  Hypovolemia

ED Issues and Course  Metabolic alkalosis  Elevated CO2 and blood pH  Low Cl  Hypokalemia  2/2 emesis and decreased PO intake x 2 weeks  Replete cautiously 2/2 AKI  Check q 4 hours

ED Issues and Course  NGT inserted for decompression  800 ml of water/grey fluid removed  Transferred to ICU for further management of shock  Hypovolemia in setting of complete GOO  Septic vs. hemorrhagic shock with likely GI source

GOO Etiology  Consequence of any disease that produces impediment to gastric emptying  Benign vs. malignant  15-20% incidence in patients with pancreatic cancer  Intrinsic or extrinsic obstruction of the duodenum is most common pathophysiology

GOO Nutrition Issues  Nausea and vomiting  Loss of HCl and increase in plasma bicarbonate  Hypokalemic hypochloremic metabolic alkalosis  Abdominal pain  Dehydration  Increases in BUN and creatinine  Malnutrition/wt loss  TPN

GOO Treatment  Admit pt for hydration and correction of electrolyte abnormalities  Sodium chloride IVF  Potassium repletion if necessary  NGT to decompress stomach  Determine cause of obstruction  Surgery vs. stent placement

NUTRITION ASSESSMENT

Food/Nutrition Related History  2 week history of decreased PO intake  Unable to keep anything down 4 days prior to admit  Diet order: NPO  NPO > 6 days  Outpatient Meds  Lisinopril, Ranitidine, Simvastatin, Tramadol

Inpatient Drug/Nutrient Interactions Drug Indication Nutritional Implications Albuterol Anti-asthma Increased appetite, anorexia, N/V, dyspepsia, diarrhea Heparin Anticoagulant N/V, constipation, hyperkalemia Nicotine Patch Smoking N/V cessation Vancomycin Antibiotic Nausea, bitter taste Zosyn Antibiotic Dry mouth, N/V, diarrhea, anorexia

Anthropometric Measures Measurement Value Assessment Height 70 in (177.8 cm) Weight 163 lb (74.1 kg) 170 lb on 3/27 on admit Weight Change -7 lb (3.6 kg) 4% weight loss in ~10 days IBW 166 lb 98% of IBW BMI 23.4 Normal

Biochemical Data Lab Test Admit 4/6 Reference Range WBC 18.5 (H) 4.3-10.8 Lactate 8.0 (H) 0.5-2.2 BUN 56 (H) 8-25 Creatinine 3.9 (H) 0.8-1.5 Chloride 90 (L) 96-106 Potassium 2.9 (L) 3.5-5.0 Sodium 129 (L) 131-142 CO2 30 (H) 23-29 Total bilirubin 25 (H) 0.1-1.1 AST 169 (H) 10-34 Alkaline Phosphate 705 (H) 45-129 Blood pH 7.47 (H) 7.38-7.42

Nutrition Focused Physical Findings  Temporal muscle: slight depression  Orbital fat pad: WNL  Clavicle: WNL  Shoulder: slight protrusion  Triceps/biceps: mild depletion  Interosseous muscle: WNL  Calf muscle: LE moderate edema  Skin: jaundiced, poor turgor, cheilosis on lips

Malnutrition Criteria – Chronic Illness Clinical Non-Severe Malnutrition Severe Malnutrition Characteristic Energy Intake < 75% of EER for ≥ 1 month ≤ 75% of EER for ≥ 1 month Weight Loss 5% in 1 month > 5% in 1 month 7.5% in 3 months > 7.5% in 3 months 10% in 6 months > 10% in 6 months 20% in 12 months >20% in 12 months Body Fat Mild depletion Severe depletion Muscle Mass Mild depletion Severe depletion Fluid Mild Severe ( ≥ 3+ edema/ Accumulation anasarca/ascites) Grip Strength N/A Measurably reduced for age and gender

Patient History  Living situation: lives alone in Vancouver, WA  Social History: divorced  Alcohol use: none in the past month, social drinker before then  Drug use: none  Family history: noncontributory  Tobacco use: current smoker, 30+ pack per year history

Patient History - Medical  PVD  Left iliofemoral-popliteal artery occlusive disease  HTN  Hyperlipidemia  GERD

NUTRITION DIAGNOSIS Inadequate oral intake related to 2 week progressive abdominal pain and N/V from duodenal obstruction by pancreatic mass as evidenced by pt report upon admit of poor PO intake x 2 weeks, no PO tolerance x 4 days prior to admit, NPO status since admit on 4/6 and recent 7# weight loss (4% loss of initial BW x 10 days) .

HD #1  Resuscitated with 15 L IVF (NS) in 24 hours  NGT  4 L of suction within 24 hours  Still hypokalemic  Repletion with 20 mEq K  Remains NPO (hemodynamically unstable)

HD #2  Vitals stabilized  Pt off pressors/hemodynamically stable  Still requiring 200 ml/hr NS  K value normalized  Remains NPO