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

A Case Study Presentation By Amy Torget

Gastric Outlet Obstruction by Pancreatic Head Mass: TPN and Electrolyte Disturbances

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 cessation N/V 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)

• n admit

170 lb on 3/27 Weight Change

• 7 lb (3.6 kg)

4% weight loss in ~10 days IBW 166 lb 98% of IBW BMI 23.4 Normal

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

Biochemical Data

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

• n lips

Malnutrition Criteria – Chronic Illness

Clinical Characteristic Non-Severe Malnutrition Severe Malnutrition Energy Intake < 75% of EER for ≥ 1 month ≤ 75% of EER for ≥ 1 month Weight Loss 5% in 1 month 7.5% in 3 months 10% in 6 months 20% in 12 months > 5% in 1 month > 7.5% in 3 months > 10% in 6 months >20% in 12 months Body Fat Mild depletion Severe depletion Muscle Mass Mild depletion Severe depletion Fluid Accumulation Mild Severe (≥ 3+ edema/ 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