Pancreatitis in an Adolescent

Pediatric Minor Case Study #2

Melissa Perry
December 8, 2013
Introduction:
C.B. is a 17 year old female who is 56 (1.676 m) and 130 lbs (59 k). C.B. was
admi!!ed !o "e!!erin #edi$al Cen!er on %o&ember '1( '013. )his s!*dy bean
%o&ember ''( '013 and ended a few days la!er on %o&ember '5( '013. C.B. +resen!ed !o
"e!!erin #edi$al Cen!er be$a*se of abdominal +ain whi$h s!ar!ed one week +rior !o
admi!!an$e. ,he $om+lained !he +ain worsened wi!h $er!ain mo&emen!s and wi!h food.
C.B. had no re$en! !ra*ma( no +renan$y( no *rinary $om+lain!s( and no +ar!i$*lar
in$i!in e&en!s. )he reason C.B. was $hosen for !he $ase s!*dy was d*e !o her s*dden
onse! of sym+!oms and abnormal dianosis for a 17 year old female. C.B.s admi!!in
dianosis was a$*!e +an$rea!i!is( whi$h is !he +rimary fo$*s of !his s!*dy.
Social History:
C.B. is a sinle female and has no his!ory of +renan$y. ,he denies re$en! al$ohol
*se and s!a!es !he las! !ime she had any was in ,e+!ember of '013- !wo mon!hs +rior !o
admi!!an$e. C.B. denies al$ohol and dr* ab*se in !he +as! and has no his!ory of smokin.
,he has ne&er had any $hroni$ abdominal +ain in !he +as!( b*! does ha&e a s!ron family
his!ory of biliary disease.
Normal anatomy and physiology of applicable body functions:
.an$rea!i!is is an inflamma!ion of !he +an$reas and is *s*ally $hara$!eri/ed by fa!
ne$rosis( $ell*lar e0*da!e( and edema. )he disease ranes from mild !o se&ere( and
s*ri$al in!er&en!ion is some!imes ne$essary. (1) )he +an$reas is an oran !ha! +rod*$es
en/ymes and !he hormones ins*lin and l*$aon. )his oran is lo$a!ed behind !he
s!oma$h and !he en/ymes are *s*ally only a$!i&e af!er !hey rea$h !he small in!es!ine(
where !hey hel+ dies! food. 1f !he en/ymes be$ome a$!i&e inside !he +an$reas( !his
$a*ses !hem !o dies! !he !iss*e of !he +an$reas- res*l!in in a$*!e +an$rea!i!is by
swellin( bleedin( and damain !he +an$reas. (') Common sym+!oms of a$*!e
+an$rea!i!is in$l*de se&ere abdominal +ain( na*sea( &omi!in( abdominal dis!en!ion(
s!ea!orrhea( and may worsen wi!h !he ines!ion of food. 2bsen$e of $er!ain en/ymes !ha!
*s*ally aid in !he dies!ion of food may lead !o s!ea!orrhea and *l!ima!ely malabsor+!ion
of n*!rien!s in !he body. (1)
Past Medical History:
)his was C.B.s firs! admission !o "e!!erin #edi$al Cen!er. ,he has no! had any
+rior medi$al his!ory +roblems and a++eared heal!hy( aside from her a$*!e +an$rea!i!is.
C.B. had an o&erall +hysi$al e0am when she +resen!ed !o !he hos+i!al. 1! was no!ed !ha!
she had normal &i!al sins( no m*rm*rs( no res+ira!ory dis!ress( no edema( normal
sensory f*n$!ion( and no a$*!e dis!ress. C.B. denied any his!ory of de+ression( anore0ia(
or emesis in !he +as!. C.B.s sym+!oms of a$*!e +an$rea!i!is bean one week before
admi!!an$e and !hey in$l*ded se&ere abdominal +ain when ea!in and when she made
s*dden mo&emen!s( s*$h as lyin on her lef! side.
Present Medical Status and Treatment:
2$*!e +an$rea!i!is (2.) is an inflamma!ion of !he +an$reas. )he e0o$rine +an$reas
se$re!es se&eral differen! en/ymes( in$l*din +ro!eoly!i$( li+oly!i$( and amyloly!i$
en/ymes( for n*!rien! dies!ion in !he in!es!ines. 2$*!e +an$rea!i!is beins inside !he
a$inar $ells by +rema!*re a$!i&a!ion of !he dies!i&e en/ymes and dis!*rban$es of
in!ra$ell*lar $al$i*m. 2. $an rane from a mild and brief hos+i!ali/a!ion !o a ra+idly
+roressi&e disorder res*l!in in se+sis or m*l!i+le oran dysf*n$!ions. (3)
2. may be $hara$!eri/ed by edema( fa! ne$rosis( and $ell*lar e0*da!e (3). )he
+an$reas is an oran !ha! +rod*$es en/ymes and !he hormones ins*lin and l*$aon. )his
oran is lo$a!ed behind !he s!oma$h and !he en/ymes are *s*ally only a$!i&e af!er !hey
rea$h !he small in!es!ine( where !hey hel+ dies! food. 1f !he en/ymes be$ome a$!i&e
inside !he +an$reas( !his $a*ses !hem !o dies! !he !iss*e of !he +an$reas- res*l!in in
a$*!e +an$rea!i!is by swellin( bleedin( and damain !he +an$reas. (') )he en/ymes are
s*++osed !o be a$!i&a!ed inside !he d*oden*m- no! !he +an$reas. )he +an$reas se$re!es
bile and i! also se$re!es en/ymes for dies!ion !ha! are *sed !o ne*!rali/e !he a$id !ha!
en!ers !he d*oden*m( and !his is where !he en/ymes are !hen a$!i&a!ed. (3)
2$*!e .an$rea!i!is is more $ommon in men !han women( and be!ween !he aes of
35345 years (3). )he $ondi!ion is mos! of!en $a*sed by al$oholism and al$ohol ab*se. 1!
has been shown !ha! 705 of $ases in !he 6ni!ed ,!a!es res*l! from indi&id*als who
!y+i$ally $ons*me 5 !o 7 drinks +er day for 5 or more years. (') 8!her $a*ses of 2. may
in$l*de end3s!ae renal disease( l*+*s( abdominal !ra*ma( biliary !ra$! disease( a$9*ired
imm*nodefi$ien$y syndrome( and +an$rea!i$ $an$er. (3) 1! may also be !he res*l! of
alls!ones( $er!ain medi$a!ions( infe$!ion( family his!ory of +an$rea!i!is( and in some
$ases( !he $a*se is *nknown (4).
,ym+!oms of 2$*!e .an$rea!i!is may in$l*de na*sea( &omi!in( abdominal
dis!en!ion( s!ea!orrhea( and s*dden( se&ere abdominal +ain( whi$h may worsen wi!h !he
ines!ion of food (1). Com+li$a!ions may in$l*de se+sis( +an$rea!i$ ne$rosis( a$*!e renal
fail*re( and abdominal +ain may be $ons!an!. ,*rery may be needed and wo*ld in$l*de
ne$rose$!omy( +an$rea!i$od*odene$!omy( or s+hin$!ero!omy. (3)
)o dianose +an$rea!i!is( se&eral !es!s and +ro$ed*res are *sed. Blood !es!s !o
look for ele&a!ed le&els of +an$rea!i$ en/ymes( $om+*!eri/ed !omora+hy (C)) s$an !o
look for e0!en! of +an$reas inflamma!ion and alls!ones( abdominal *l!raso*nd( and
mane!i$ resonan$e imain (#:1) are all $ommon +ro$ed*res *sed !o dianose
+an$rea!i!is. 1ni!ial !rea!men!s for +an$rea!i!is may in$l*de fas!in for a few days !o i&e
yo*r +an$reas a $han$e !o re$o&er( +ain medi$a!ions( in!ra&eno*s fl*ids !o hel+ re+air !he
+an$reas( and in se&ere $ases s*rery may be +erformed. 8n$e !he inflamma!ion in !he
+an$reas is $on!rolled( yo* may bein drinkin $lear li9*ids and +roress !owards a
re*lar die!. 1f +ain and inflamma!ion +ersis!s( !hen en!eral n*!ri!ion !hro*h a feedin
!*be may be re$ommended !o hel+ +eo+le re$ei&e n*!ri!ion. (4) :e$en! s!*dies ha&e
shown !ha! en!eral n*!ri!ion &ia a ;e;*nal !*be is safe and may red*$e !he a$*!e +hase
res+onse( as well as !he mani!*de of !he inflamma!ory res+onse. 1n mos! $ases( !he
feedin !*be is +la$ed as a naso;e;*nal !*be and may las! a +eriod of 6 or more weeks. (3)
)he ;e;*nal !*be may be *sed be$a*se !he ;e;*n*m +asses !he ro*!e of !he +an$reas and
allows i! !o res! if +ain and inflamma!ion do +ersis!. )he role of !he *! in main!ainin
imm*ne sys!em in!eri!y is e0!remely im+or!an!( whi$h is why n*!ri!ion s*++or! !hro*h
an en!eral ro*!e is !he +referred me!hod in +a!ien!s wi!h 2.. (3)
6+on admission( !he ma;ori!y of C.B.s lab &al*es were wi!hin normal
limi!s( e0$e+! for her B6%( Crea!inine( C8'( #C<( #C=( and li+ase &al*es. C.B. does
no! ha&e a his!ory of renal iss*es( b*! her B6% and Crea!inine lab &al*es were bo!h lower
!han normal. Blood *rea ni!roen( B6%( and Crea!inine are bo!h ni!roen3$on!ainin
was!e +rod*$!s !ha! are enera!ed by m*s$*lar a$!i&i!y. (5) C.B.s Crea!inine le&el was a!
0.51 m>d? (normal rane@ 0.731.' m>d?) and her B6%( blood *rea ni!roen( le&el was
a! 5 m>d? (normal rane@ 73'1 m>d?). Ae$reased le&els of B6% in !he body $an be
$a*sed by +an$rea!i$ ins*ffi$ien$y. .an$rea!i$ ins*ffi$ien$y is a++aren! when yo*r
+an$reas doesn! se$re!e !he +ro+er amo*n! of $hemi$als and en/ymes for normal
dies!ion !o o$$*r. 2bsor+!ion of n*!rien!s in!o !he in!es!ine may be im+aired when
+an$rea!i$ defi$ien$y is se&ere. (6)
C.B.s C8'( $arbon dio0ide( lab &al*e was slih!ly ele&a!ed a! '6 mmol>?
(normal rane@ 163'5 mmol>?). 2 C8' blood !es! is *s*ally done as +ar! of an ele$!roly!e
or me!aboli$ +anel !es! and !he C8' le&els are normally affe$!ed by !he kidney or l*n
f*n$!ion. Chanes in a C8' le&el may im+ly a loss or re!en!ion of fl*id in !he body(
whi$h may $a*se an imbalan$e of ele$!roly!es. (7) C.B. had hiher !han normal lab &al*es
for #C< i! was a! 9' fl (normal rane@ 76.9390.6 fl) and #C= was 30.7 + (normal
rane@ '4.7330.' +). #ean $or+*s$*lar &ol*me (#C<) is !he a&erae &ol*me of red $ells
and mean $or+*s$*lar hemolobin (#C=) is a +ar! of !he ery!hro$y!e indi$es( whi$h are
meas*remen!s for de!erminin !he $on!en!( si/e( and hemolobin $on$en!ra!ion. ,ome
+ossible $a*ses of ha&in hiher lab &al*es for #C< and #C= in$l*de fola!e defi$ien$y
anemia( <i!amin B1' defi$ien$y anemia( li&er disease( hemoly!i$ anemia(
hy+o!hyroidism( and e0$essi&e al$ohol in!ake. (7) C.B. also had an ele&a!ed li+ase lab
&al*e( whi$h was a! 9700 6>? (normal rane@ 1453''6 6>?). ?i+ase is a &ery $ommon
blood !es! *sed !o meas*re en/ymes in order !o dianose a$*!e +an$rea!i!is. 2 hih le&el
of li+ase $o*ld be $a*sed by +an$rea!i!is( $hole$ys!i!is (inflamma!ion of !he allbladder)(
$hroni$ kidney disease( +roblems wi!h !he in!es!ines( +e+!i$ *l$er disease( and al$ohol or
dr* ab*se. (9) .hysi$ians may be able !o !ell if !his is !he res*l! of al$ohol ab*se be$a*se
!here is a !es! !o meas*re !he al$ohol le&el in !he blood.
Lab values: 11!11"
#esult $alue Normal #ange
B6% 5 m>d? 73'1 m>d?
Crea!inine 0.51 m>d? 0.731.' m>d?
C8' '6 mmol>? 163'5 mmol>?
#C< 9' fl 76.9390.6 fl
#C= 30.7 + '4.7330.' +
?i+ase 9700 6>? 1453''6 6>?
2no!her blood !es! was done on %o&ember ''( '013( !he day af!er C.B. was
admi!!ed !o !he hos+i!al( and her Crea!inine le&el had lowered e&en more from 0.51
m>d? !o 0.47 m>d? (normal rane 0.731.' m>d?). =er C8' lab &al*e in$reased !o '5
mmol>?( whi$h is wi!hin !he normal rane of 163'5 mmol>?. C.B.s 2,) lab &al*e was a!
14 6>? (normal rane@ 15337 6>?). 2,) (2s+ar!a!e amino!ransferase) is one of !he main
li&er en/ymes. =er ?i+ase lab &al*e lowered from 9700 6>? !o 6756 6>? and her
amylase lab &al*e( whi$h is also an en/yme *sed !o de!ermine +an$rea!i!is( was &al*ed a!
414 6>? (normal rane@ '531'5 6>?). )he o!her lab &al*es remained !he same.
Lab values: 11!!1"
#esult $alue Normal #ange
B6% 5 m>d? 73'1 m>d?
Crea!inine 0.47 m>d? 0.731.' m>d?
C8' '5 mmol>? 163'5 mmol>?
?i+ase 6756 6>? 1453''6 6>?
2mylase 414 6>? '531'5 6>?
2,) 14 6>? 15337 6>?
Bor !he ne0! few days while C.B. was in !he hos+i!al( her lab &al*es $on!in*ed !o
im+ro&e( e0$e+! for !he B6% and Crea!inine. )he B6% and Crea!inine lab &al*es
indi$a!e +an$rea!i$ ins*ffi$ien$y( b*! wi!h !ime and allowin her body !o res!( C.B. mih!
see an o&erall im+ro&emen! wi!h her lab &al*es.
Laboratory $alues
#esult 11!"1" 11!%1" 11!&1" Normal #ange
B6% 11 m>d? 5C m>d? 3C m>d? 73'1 m>d?
Crea!inine 0.59C m>d? 0.47C m>d? 0.5'C m>d? 0.731.' m>d?
C8' '0 mmol>? '0 mmol>? '3 mmol>? 163'5 mmol>?
?i+ase 4195 6>? 5373 6>? 4'77 6>? 1453''6 6>?
2mylase 33 379 6>? 35' 6>? '531'5 6>?
C.B. was no! on any medi$a!ions +rior !o admission !o !he hos+i!al on %o&ember
'1( '013. 2s of %o&ember ''( '013( she was +la$ed on !he followin medi$a!ions@
?a$!a!ed riners 1(000 m?
Dno0a+arin 40 m s*b$*!aneo*s daily
.an!o+ra/ole 40 m 1n!ra&eno*s or orally daily
2$e!amino+hen 1(000 m 1n!ra&eno*s e&ery 6 ho*rs

?a$!a!ed riners irria!ion is a s!erile sol*!ion of ele$!roly!es in wa!er for
in;e$!ion !ha! is in!ended for s!erile irria!ion( rinsin( or washin +*r+oses. ?a$!a!ed
riners $leanses and s!erili/es body $a&i!ies( !iss*es( wo*nds( s*ri$al drainae !*bes(
and i! is also *sed for +harma$e*!i$als +re+ara!ions. C.B. was also +la$ed on Dno0a+arin(
whi$h is an an!i$oa*lan! *sed !o +re&en! !he forma!ion of blood $lo!s. 1! is *sed !o
+re&en! dee+ &ein !hrombosis (A<)) whi$h $an o$$*r af!er $er!ain s*reries or in +eo+le
who are bedridden and hos+i!ali/ed for lon +eriods of !ime. .an!o+ra/ole is a +ro!on
+*m+ inhibi!or( whi$h is *sed !o blo$k !he +rod*$!ion of a$id by !he s!oma$h and is
*s*ally *sed !o !rea! *l$ers( ED:A (as!roeso+haeal refl*0 disease) and o!her $ondi!ions
$a*sed by s!oma$h a$id. .an!o+ra/ole blo$ks !he en/yme !he +rod*$es a$id in !he
s!oma$h and allows !he s!oma$h and eso+ha*s !o heal. 2$e!amino+hen was i&en !o
C.B. be$a*se i! is a +ain relie&er and a fe&er red*$er. )hese medi$a!ions sho*ld no! be
!aken wi!h al$ohol be$a*se !ha! will in!era$! wi!h !he medi$a!ion and may lead !o
sym+!oms of di//iness( heada$he( and +ossible $hanes in hear! ra!e. (10) ?a$!a!e
riners was dis$on!in*ed on %o&ember '3( '013 and a$e!amino+hen be$ame a .:% (as
needed) dr*. Dno0a+arin and .an!o+ra/ole were ea$h i&en on$e daily. )here are
se&eral medi$a!ions !ha! may $ommonly be *sed for a +a!ien! wi!h 2$*!e .an$rea!i!is
(,ee 2++endi0 2) (3).
)hro*ho*! C.B.s hos+i!ali/a!ion( her abdominal +ain was elimina!ed and she no
loner had !he dis$omfor! !ha! she ini!ially $ame in!o !he hos+i!al wi!h on 11>'1>13.
C.B. was ordered !o be %.8 (no!hin by mo*!h) for !he firs! !wo days she was in
!he hos+i!al. )he +*r+ose of +*!!in her on an %.8 die! was be$a*se she needed !o ha&e
se&eral differen! medi$al !es!s and !his also allowed her +an$reas and as!roin!es!inal !ra$!
!o res! in order for i! !o heal.
6+on admission !o !he hos+i!al( C.B. was i&en an abdominal *l!raso*nd. 1! was
fo*nd !ha! her $ommon bile d*$!( kidney( li&er( and allbladder all looked normal. ,he
was !hen i&en a C) ($om+*!ed !omora+hy) e0am of !he abdomen and !he +el&is. )he
findins res*l!ed in !he l*n bases were $lear and !he li&er and allbladder a++eared
*nremarkable. )here was fo*nd !o be a f*llness of !he +an$rea!i$ head wi!h mesen!eri$
s!randin reional !o !he en!ire +an$reas. Bl*id a++eared !o e0!end in!o !he he+a!i$ and !o
a lesser e0!en! !he s+leni$ re$ess wi!h e0!ension in!o !he +el&is( and !his fl*id was low
a!!en*a!ion. )here was no defini!i&e e&iden$e for +an$rea!i$ di&is*m or $al$ifi$
+an$rea!i!is. )he $ommon bile d*$! was normal in si/e wi!ho*! e&iden$e of obs!r*$!ion.
)he C) of !he +el&is showed !he a++endi0 !o be normal wi!h no inflamma!ion( as well as
!he *rinary bladder a++eared !o ha&e no !hi$kenin or fillin defe$!( e0$e+! !ha! i! was
mildly dis!ended.
)he o&erall findins of !he C) 03ray of !he abdomen and +el&is dis+layed f*llness
!o !he +an$rea!i$ head wi!h +eri+an$rea!i$ fa! s!randin( $om+a!ible wi!h a$*!e
+an$rea!i!is. )here was a small amo*n! of low3a!!en*a!ion fl*id !ha! e0!ended wi!hin !he
he+a!i$ re$ess down !he +ara$oli$ *!!ers and in!o !he +el&is. )here was also fl*id fo*nd
aro*nd !he a++endi0( howe&er i! was air3filled and nondila!ed. )he fl*id a++eared !o
e0!end from !he *++er abdomen. )he o&erall final im+ression was a$*!e +an$rea!i!is.
)hro*ho*! !he $o*rse of C.B. hos+i!ali/a!ion( !he a$*!e +an$rea!i!is $ame from
an *nknown e!ioloy. ,he denied al$ohol or dr* ab*se and !here were no s!ones or
$ommon bile d*$! dila!ion no!ed on !he C) 03ray. )here was no s*ri$al +ro$ed*re. .er
.hysi$ian no!e 11>''>13( C.B. was allowed !o s!ar! on a $lear li9*id die! beinnin 11>'3
if she was doin well in !he mornin. 1! was also arraned !ha! C.B. follow3*+ wi!h !he
8*!+a!ien! $en!er af!er her dis$hare from !he hos+i!al.
Medical Nutrition Therapy:
A*e !o C.B. only bein 17 years old and no +as! medi$al his!ory( she has had no
o!her die!s !han a :e*lar die! in !he +as!. C.B. also had no known food alleries. 8n$e
she was admi!!ed !o !he hos+i!al( C.B. was +la$ed on %.8 (no!hin by mo*!h) in order !o
i&e her +an$reas and as!roin!es!inal !ra$! a res!( and be$a*se she was oin !o ha&e
se&eral medi$al !es!s. Fhen a +a!ien! is labeled %.8 !hey $anno! ha&e food( be&eraes(
and of!en!imes medi$a!ions. )he %.8 die! order may be +la$ed for a medi$al +ro$ed*re(
a medi$al !es!( or s*rery. )here are a few n*!ri!ion in!er&en!ions $ommonly *sed for a
+a!ien! wi!h 2$*!e .an$rea!i!is (,ee 2++endi0 B) (3).
C.B. was %.8 s!ar!in *+on admission on )h*rsday( %o&ember '1( '013. )he
ini!ial assessmen! was done !he day af!er her admission on Briday %o&ember ''( '013.
Pediatric Nutrition 'ssessment:
(ietitian)s #ecommendations: 2d&an$e die! &ers*s ini!ia!ion of n*!ri!ion s*++or! wi!hin
7' ho*rs. 1f +a!ien! is *nable !o ad&an$e !o an oral die!( $onsider )*be Beed of .e+!amen
wi!h .rebio a! a oal ra!e of 90 m? +er ho*r !o +ro&ide '160 $alories( 76 rams +ro!ein(
and 1736 $$ free wa!er (37 $alories +er k( 1.45 rams +ro!ein +er k). Bl*sh !*be wi!h an
addi!ional 150 $$ wa!er !wi$e daily.
*stimated Nutritional Needs:
Calories 35340 +er k .ro!ein 131.' rams +er k Bl*id needs if on )*be Beed
'0653'360 $alories 59371 rams +ro!ein 1 m? +er k$al
%*!ri!ional needs based on@ 2$!*al body weih!@ 130 lbs>59 k
Nutrition (iagnosis: .a!ien! wi!h inade9*a!e oral in!ake d*e !o abdominal +ain rela!ed !o
a$*!e +an$rea!i!is as e&iden$ed by %.8 s!a!*s.
Nutrition Intervention:
?ef! re$ommenda!ion abo&e@ +o ad&an$emen! &ers*s ini!ia!ion of n*!ri!ion s*++or!.
Fill ro*!inely moni!or and follow for !oleran$e.
Nutrition +oals:
1. .o ad&an$emen! &ers*s ini!ia!ion of n*!ri!ion s*++or! wi!hin 7' ho*rs.
'. )oleran$e of !*be feed if ini!ia!ed.
#eason for 'ssessment:
6n+lanned weih! loss
.oor 8ral in!ake of less !han '55 or rea!er !han 3 days
,!ae '( 3( 4 +ress*re *l$er or non3healin wo*nd
%*!ri!ion ,*++or!
Baden s$ore of 11 or less
B#1
G 8!her@ abdominal +ain when ea!in
Height: 56 (1.676m) ,eight: 130 lbs>59 k -MI: '0.99 k>(mH')
=eih! .er$en!ile
Based on
ae>ender
row!h $har!
Feih! .er$en!ile
Based on
ae>ender row!h
$har!
B#1 .er$en!ile
Based on
ae>ender
row!h $har!
6s*al body
weih!
Feih!
$hane 5
and !ime
frame
75
!h
Be!ween 50
!h
375
!h
50
!h
%one no!ed. %one no!ed.
.urrent (iagnosis: 2$*!e .an$rea!i!is
Labs: 11>'1@ C8' '6( B6% 5( Crea!inine 0.51( #C< 9'( #C= 30.7( ?i+ase 9700
-arriers for ade/uate nutrition:
%one no!ed %a*sea(
<omi!in
Darly sa!ie!y ?oss of a++e!i!e
Chewin
diffi$*l!ies
,wallowin
diffi$*l!ies
Blind>diffi$*l!y
seein
Conf*sion
Cons!i+a!ion Aiarrhea 2nore0ia
%er&osa
B*limia>Binin
.sy$hosis :ef*sal !o ea! .*rin G 8!her@ abdominal
+ain when ea!in
.linical Status:
G %one no!ed Beedin )*be 8s!omy )ra$heos!omy
Ddema %on3res+onsi&e 2+hasia =ard of
hearin>deaf
2m+*!a!ion %on3&erbal Ae+ression 8!her@
,ounds: none no!ed.
0ood allergiesIntolerances: %o known food alleries.
Nutritional 'de/uacy
.urrent (iet 1rder: %.8
1ral inta2e: %one no!ed.
'ppetite: 6nable !o assess.
+eneral Information: %o!ed +a!ien! has a$*!e +an$rea!i!is. .er :% no!e 11>'1>13(
+a!ien! s!a!es she has +ain when she ea!s and lies on her lef! side. %o!ed +a!ien! denies
al$ohol and dr* ab*se in !he +as!.
*stimated Nutritional Needs:
2e Calories>k .ro!ein>k
436 90 1.'
7310 70 1.0
11314 Boys 55
Eirls 47
1.0
1.0
15317 Boys 45
Eirls 40
0.9
0.7
Nutritional #is2Level of .are
G =ih 3 #odera!e ' ?ow 1
,ill follo3 per protocol4
(ietitian Name: #elissa .erry( Aie!e!i$ 1n!ern (ate: 11>''>13
C*rren! e&iden$e has shown !ha! en!eral n*!ri!ion is fa&ored o&er +aren!eral
n*!ri!ion for +a!ien!s wi!h a$*!e +an$rea!i!is (11). .a!ien!s ha&e a be!!er o*!$ome when
en!eral n*!ri!ion is *sed in +la$e of +aren!eral n*!ri!ion. Bail*re !o *se !he as!roin!es!inal
!ra$! may lead !o rea!er in$iden$e of disease se&eri!y and $om+li$a!ions in +a!ien!s wi!h
a$*!e +an$rea!i!is. (1') )he !y+e of en!eral n*!ri!ion is also &ery im+or!an!. Bor +a!ien!s
!ha! $anno! ad&an$e !o an oral die!( en!eral n*!ri!ion is fa&ored o&er +aren!eral n*!ri!ion.
)he en!eral ro*!e is +referred be$a*se of !he benefi$ial effe$!s of s!im*la!in !he *! and
+re&en!in ba$!erial o&errow!h. Dn!eral n*!ri!ion also red*$es !he risk of infe$!ions(
red*$es !he len!h of hos+i!al s!ay( and lowers !he need for s*ri$al in!er&en!ion. )here is
a benefi! !o elemen!al form*las *sed for +a!ien!s wi!h +an$rea!i!is be$a*se i! +*!s !he
+an$reas !o res! $om+ared !o s!andard form*las !ha! ha&e in!a$! +ro!ein or blenderi/ed
die!s. )he .e+!amen wi!h .rebio form*la( re$ommended abo&e( is an elemen!al form*la.
Dlemen!al form*las $a*se less s!im*la!ion !han s!andard form*las be$a*se of !heir low fa!
$on!en!. )hey also ha&e free aminoa$ids in +la$e of in!a$! +ro!eins whi$h bind !o !he free
!ry+sin in !he *!. )his $a*ses !ry+sin le&els !o fall( whi$h leads !o less a$id +rod*$!ion
from !he s!oma$h. (13)
C.B. was %.8 from )h*rsday( %o&ember '1( '013 !o ,a!*rday( %o&ember '3(
'013. ,he was !hen +la$ed on a Clear ?i9*id die! on %o&ember '3( '013. 2! !his momen!
in !ime( C.B. was only ha&in mild abdominal !enderness. 2 '43ho*r re$all was done for
!he li9*ids C.B. $ons*med on %o&ember '3( '013 while she was on !he Clear ?i9*id
Aie!.
%*!rien! analysis on Clear ?i9*id Aie!
-rea2fast3 Ae$af $offee( ra+e ;*i$e( bro!h $hi$ken( and orane ;ello
%*!rien! )o!al
Calories 137
.ro!ein () 1.35
Ba! () 1.06
Carbohydra!es () 31.'7
Lunch3 ,ierra mis!( de$af $offee( a++le ;*i$e( beef bro!h( orane i!alian i$e( and
s!rawberry ;ello
%*!rien! )o!al
Calories 494
.ro!ein () '.19
Ba! () 3.06
Carbohydra!es () 117.'9
(inner3 ,ierra mis!( de$af $offee( $ranberry ;*i$e( bro!h $hi$ken( $herry i!alian i$e(
lemon ;ello
%*!rien! )o!al
Calories 409
.ro!ein () 1.35
Ba! () 1
Carbohydra!es () 100
C.B. $ons*med 1005 of her meal. ,he !olera!ed !he Clear ?i9*id Aie! wi!ho*!
any +ain or na*sea and &omi!in. .er .hysi$ian no!e 11>'3( C.B. s!a!ed she was h*nry
and wo*ld like !o ea! Ire*lar food.
C.B. was !hen ad&an$ed !o a :e*lar die! !he mornin of %o&ember '4( '013. .er
.hysi$ian no!e 11>'4( C.B.s +ain was well $on!rolled and she denied na*sea and
&omi!in. =er ?i+ase in$reased from 4195 !o 5373 o&ernih! and !hey res*med fl*id
res*s$i!a!ion and $on!in*ed !o moni!or. C.B had an *l!raso*nd done and i! was nea!i&e
for alls!ones. =er ?i+ase bean !rendin down.
.er n*rsin no!e 11>'4( C.B. had asked if her +an$rea!i!is was rela!ed !o wha! she
was ea!in. )he n*rse !old her !ha! a lo! of 17 year olds don! ha&e !he bes! die!s and !hey
don! e! +an$rea!i!is. )he n*rse fo*nd some die! informa!ion from online be$a*se !he
:eis!ered Aie!i!ians were no! $ons*l!ed a! !his !ime !o dis$*ss her die!. )he die!
informa!ion was based on a low fa! die! for +a!ien!s wi!h or !hose who ha&e e0+erien$ed
+an$rea!i!is. C.B. had no $om+lain!s of na*sea or +ain a! !his !ime.
)he mornin of %o&ember '5( '013( !he Eas!roen!erolois! &isi!ed wi!h C.B. and
$leared her for dis$hare. )he .hysi$ian $o*nseled !he +a!ien! on !he im+or!an$e of
a&oidin al$ohol and smokin as !hey $an be !he $a*se of +an$rea!i!is. ,he was s$hed*led
!o be seen as an o*!+a!ien! a! a la!er !ime for a follow3*+ a++oin!men!.
Prognosis:
1! was s!a!ed in C.B.s admission no!e !ha! she wan!ed !o be able !o ea! a re*lar
die! and o ba$k home. C.B. had s*ffered from a$*!e +an$rea!i!is. #os! +eo+le !ha! ha&e
a$*!e +an$rea!i!is re$o&er $om+le!ely and !he +an$reas re!*rns ba$k !o normal wi!ho*!
any lon3!erm effe$!s. 1! is +ossible for +an$rea!i!is !o re!*rn if !he *nderlyin $a*se is no!
elimina!ed. (14) )he e!ioloy for C.B.s +an$rea!i!is is s!ill *nknown. ,he s!a!es she had
no! had any al$ohol sin$e !he ,e+!ember before !his in$iden!( b*! i! is *n$lear on if !here
was a his!ory of any al$ohol ab*se. ,he was $o*nseled on !he im+or!an$e of a&oidin
al$ohol and smokin( as well as followin a low fa! die!. 1f C.B. $on!in*es !o follow !hese
+lans( !hen i! is belie&ed !ha! she will ha&e f*ll re$o&ery from her +an$rea!i!is.
Summary 5 .onclusion:
1 ha&e learned a lo! !hro*h doin !his e0!ensi&e resear$h $ase s!*dy. 1 ha&e
be$ome familiar wi!h !he +ossible sym+!oms of +an$rea!i!is( !he key risk fa$!ors( $ommon
medi$a!ions *sed for +eo+le wi!h as!roin!es!inal +roblems( dr*3n*!rien! in!era$!ions(
and +ro+er n*!ri!ion +res$ri+!ions for +eo+le re$o&erin from +an$rea!i!is or a similar
heal!h iss*e. )his has i&en me !he o++or!*ni!y !o +ra$!i$e e0!ensi&e do$*men!a!ion in
!he medi$al re$ords. 1 ha&e also had a rea! e0+erien$e in ;*s!ifyin !he $orre$! #edi$al
%*!ri!ion )hera+y for +a!ien!s( alon wi!h sele$!in a++ro+ria!e n*!ri!ion dianoses(
in!er&en!ions( and oals. )his $ase s!*dy has ;*s!ified !he im+or!an$e of !akin
+re&en!a!i&e meas*res in order !o ha&e a heal!hy lifes!yle.
'ppendi6 '
Medications 7sed in 'cute Pancreatitis
Medication (escription
2n!ibio!i$s 2n!ibio!i$s may be needed !o manae ne$rosis
and sys!emi$ $om+li$a!ions.
Bile ,al!s Bile sal!s or wa!er3mis$ible forms of fa!3
sol*ble &i!amins may be needed.
Ai*re!i$s Ai*re!i$s s*$h as a$e!a/olamide (Aiamo0) may
be needed !o $on!rol fl*id re!en!ion. %a*sea(
&omi!in( and diarrhea may res*l!.
1ns*lin 1ns*lin may be ne$essary. #oni!or for
hy+oly$emia d*rin *se.
8$!reo!ide 8$!reo!ide may ha&e a benefi$ial role in !he
manaemen! of a$*!e +an$rea!i!is.
8+ia!es 8+ia!es may be +res$ribed for +ain.
.an$rea!i$ en/ymes 30(000 16 +er meal may be needed !o red*$e
s!ea!orrhea !o less !han '0 >d. Dn!eri$ $oa!in
is ne$essary !o +re&en! des!r*$!ion by en/ymes.
Ca+s*les or !able!s sho*ld be swallowed
whole. )ake en!eri$3$oa!ed en/ymes wi!h
$ime!idine( food( or an!a$ids.
'ppendi6 -
.ommon Nutrition Interventions for 'cute Pancreatitis
:ed*$e +ain and a$hie&e +an$rea!i$ res!( b*! wi!h *! *se.
3Bail*re !o *se !he E1 !ra$! in 2. may e0a$erba!e !he s!ress res+onse and disease
se&eri!y.
2&oid +an$rea!i$ irri!an!s( es+e$ially al$ohol and $affeine. #oni!or for in$reased
need for +an$rea!i$ en/ymes wi!h !he *se of !*be feedin.
2&oid o&erfeedin.
3)he e0a$! &ol*me of feedins !ha! $an red*$e *! +ermeabili!y and mod*la!e !he
s!ress res+onse has ye! !o be de!ermined.
Corre$! fl*id and ele$!roly!e imbalan$es and maln*!ri!ion.
32$id3base imbalan$e is $ommon wi!h %asoas!ri$ s*$!ionin( fis!*la losses( renal
fail*re( na*sea( and &omi!in.
:ed*$e fe&er- +re&en! sho$k and hy+o&olemia( hy+erme!abolism( se+sis( and
$om+ression of !he s!oma$h or $olon.
32&oid or $on!rol o!her $om+li$a!ions- +re&en! oran fail*re.
8nly *se ).% id abdominal +ain is refra$!ory- o!herwise *se en!eral n*!ri!ion.
3).% *se may +romo!e +osi!i&e ni!roen imbalan$e.
#*0*#*N.*S:
1. #ahan ?"( Ds$o!!3,!*m+ ,. Krauses Food and Nutrition Therapy. 13
!h
Dd. ,!.
?o*is@ ,a*nders Dlse&ier- '011.
'. .*b#ed =eal!h. 2$*!e .an$rea!i!is. 2&ailable a! h!!+@>>www.n$bi.nlm.nih.o&
>+*bmedheal!h>.#=000133'>. 2$$essed 2+ril 9( '014.
3. Ds$o!!3,!*m+ ,. Nutrition and Diagnosis-Related Care. 7
!h
Dd. .hiladel+hia@
Fol!ers "l*wer- '011.
4. #ayo Clini$. .an$rea!i!is. 2&ailable a! h!!+@>>www.mayo$lini$.or>diseases3
$ondi!ions>+an$rea!i!is>basi$s>$a*ses>$on3'00'74'1. 2$$essed 2+ril 9( '014.
5. ?i&e,!ron Bo*nda!ion. Ca*ses of 1n$reased B6% and Crea!inine 6nrela!ed !o
"idney B*n$!ion. 2&ailable a! h!!+@>>www.li&es!ron.$om>ar!i$le>1'39973$a*ses3
in$reased3b*n3$rea!inine>. 2$$essed 2+ril 9( '014.
6. ?i&e,!ron Bo*nda!ion. 2&ailable a! h!!+@>>www.li&es!ron.$om>ar!i$le>'974003
!hins3!ha!3lower3b*n3$rea!inine3le&els>. 2$$essed 2+ril 11( '014.
7. #ed?ine .l*s. C8' Blood )es!. 2&ailable a! h!!+@>>www.nlm.nih.o&>
medline+l*s>en$y> ar!i$le>003469.h!m. 2$$essed 2+ril 11( '014.
7. #ed,$a+e. #ean Cor+*s$*lar <ol*me. 2&ailable a! h!!+@>>emedi$ine.meds$a+e.
$om>ar!i$le>'0757703o&er&iewJaw'aab6b3. 2$$essed 2+ril 15( '014.
9. Feb#A. .an$rea!i!is D0ams and )es!s. 2&ailable a! h!!+@>>www.webmd.$om>
dies!i&e3disorders>!$>+an$rea!i!is3e0ams3and3!es!s. 2$$essed 2+ril 16( '014.
10. Ar*s.$om. Ar*s 2 !o K. 2&ailable a! h!!+@>>www.dr*s.$om>dr*Linforma!ion.
h!ml. 2$$essed 2+ril 16( '014.
11. Drs!ad B?. Dn!eral %*!ri!ion ,*++or! in 2$*!e .an$rea!i!is. The Annals in
Pharmacotherapy. '006- 30@'513'53.
1'. #$Cla&e ,2( Chan F"( Ahaliwal :( =eyland A". %*!ri!ion ,*++or! in 2$*!e
.an$rea!i!is @ 2 ,ys!ema!i$ :e&iew of !he ?i!era!*re. Journal o !nteral and
Parenteral Nutrition. '006- 30@1433156.
13. ,+anier BF( Br*no #M( #a!h*s D#. Dn!eral %*!ri!ion and 2$*!e .an$rea!i!is.
"astroenterology Research and Practice. '011- '011@ 37347.
14. D#edi$ine =eal!h. .an$rea!i!is. 2&ailable a! h!!+@>>www.emedi$ineheal!h.
$om>+an$rea!i!is>+ae11Lem.h!m. 2$$essed 2+ril '1( '014.