EXAM 3 STUDY GUIDE DIE 4244 Medical Nutrition Therapy Spring 2013 1 Gallbladder and Pancreatic Disorders a What is the gallbladder and what are its main functions Located under right lobe of liver Main fucntions concentrate excrete store bile produced by liver Bile is made up of cholesterol bilirubin bile salts Bile is excreted into the duodenum of small intestine with pancreatic juice b What are cholestasis cholelithiasis cholecystitis and cholangitis What are the symptoms and diseases conditions associated with each What are their pathophysiologies What is the medical surgical management What is MNT for each Cholestasis MNT Cholelitiasis Little or no bile secreted or flow of bile to digestive tract is obstructed Pathophysiology o Often in NPO pts without EN for prolonged periods o Genetics o Intrahepatic cholestasis of pregnancy o Occurs when no EN feedings need stimulation of biliary motility and secretions by EN if NPO Gallstones calculi composed of cholesterol bilirubin Ca salts When gallstones slip into bile ducts create obstruction pain cramps choledocholithiasis Symptoms duodenum Pathophysiology o Generally asymptomatic o May pass into common bile duct and stay there indefinably or may pass into o High fat diet may case liver to increase bile secretion o Rapid weight loss o Obesity insulin resistance diabetes o Medications lipid lowering drugs oral contraceptives MNT o Avoid obesity and fasting o Follow a low fat diet Cholecystitis Inflammation of the gallbladder Usually caused by gallstones obstructing the bile ducts Acute cholecystitis o May occur in critically ill pts or if bile flow is impaired o MNT Hold feedings or PN then low fat diet Chronic cholecystitis o Casued by repeated mild attachs of acute cholecystitis leads to Thickening of gallbladder walls Gallbladder shrinks and loses functional ability Aggravated by high fat diet o MNT Long term low fat diet 25 30 kcal fat Cholangitis Inflammation of bile ducts Sclerosing cholangitis can result in sepsis and liver failure MNT fluids c What is a cholecystectomy and what is it used for Surgical removal of gallbladder when gallstones are numerous large or calcified d What is the pancreas and what are its main functions Elongated flattened gland in upper duodenum behind stomach Endocrine and exocrine functions o Pancreatic cells produce insulin glucagon somatostatin for absorption into blood stream endocrine o Pancrease cells secrete enzymes and other substances directly into the intestinal lumen for digesting ptns fats CHOs exocrine e What tests are used for pancreatic function Describe each Secretin stimulation measure pancreatic secretion particularly bicarbonate in response to secretin stimulation Glucose tolerance test assess endocrine function of the pancreas by measuring insulin response to a glucose load 72hr stool fat test asses exocrine function of the pancreas by measuring fat absorption that reflects pancreatic lipase secretion f What is pancreatitis acute vs chronic Describe its symptoms pathophysiology and medical surgical management Inflammation of the pancreas Characterized by o Edema cellular exudate and fat necrosis o Can result in autodigestion necrosis and hemorrhage of pancreatic tissue Symptoms o Continuous or intermittent pain of varying intensity o Severe upper abdominal pain that may radiate to back o Nausea vomiting abdominal distension and steatorrhea o May lead to decreased serum Ca levels and hypoalbumina Risk factors o Alcohol use o Smoking o Body weight o Diet o Genetic factors o Medications MNT o Acute pancreatitis With hold oral feeding maintain hydration by IV Progress diet as tolerated clear liquids low fat six small meals once inflammation reduced Nutrition support as needed EN use of GIT decreases stress response associated with less infections and decreased hospital stay less expensive associated with faster return to normal diet o Chronic pancreatitis High risk for PEM Antioxidants pancreatic enzymes MCT Avoid large meals high fat foods alcohol Glucose intolerance due to pancreatic cell destruction g Describe Ranson s criteria to classify the severity of pancreatitis At admission diagnosis o Age 55yrs o WBC 16000m3 o Glucose 200mL o Lactate dehydrogenase 350units L o Aspartate transaminase 250units L During initial 48hrs o Hct decrease of 10mg o BUN increase of 5mg o Arterial PO2 60mm o Base deficit 4mEq L o Serum Ca 8mg L o Fluid sequestration 6000mL Score 3 severe pancreatits likely Score 3 severe pancreatitis unlikely o Score 0 2 2 mortality o Score 3 4 15 mortality o Score 5 6 40 mortality o Score 7 8 100 mortality h What is MNT for pancreatitis acute vs chronic Acute pancreatitis o With hold oral feeding maintain hydration by IV o Progress diet as tolerated clear liquids low fat six small meals once inflammation reduced o Nutrition support as needed o EN use of GIT decreases stress response associated with less infections and decreased hospital stay less expensive associated with faster return to normal diet Chronic Pancreatitis o High risk for PEM o Antioxidants pancreatic enzymes MCT o Avoid large meals high fat foods alcohol o Glucose intolerance due to pancreatic cell destruction 2 Pancreatic Cancer a Describe pancreatic cancer including symptoms and side effects risk factors etc 10th most common cancer 4th leading cause of cancer deaths 5 yr survival rate of 5 10 Frequently diagnosed late due to vague and nonspecific symptoms Difficult to diagnose when still localized and surgically resectable to the pancreas Symptoms weight loss malnutrition and anorexia are common symptoms at presentation Risk factors chronic pancreatitis diabetes smoking and obesity Side effects diarrehea pancreatic exocrine insufficiency due to obstruction of pancreatic duct glucose intolerance diabetes nausea vomiting loss of appetite weight loss taste changes early satiety pain when eating fatigue constipation dumping syndrome more common with surgery b Why is it better to use enteral than parenteral nutrition Because it stimulates the GIT c What is a whipple procedure Describe in detail Pancreaticoduodenectomy surgical procedure used for pancreatic cancer Removal of pancreatic head duodenum gallbladder and bile duct with or without the gastric antrum Pancreatic duct is then re joined to the jejunum May be accompanied by a cholecystectomy vagotomy or a partial gastrectomy May cause partial or complete pancreatic insufficiency d What are the postsurgical complications that may occur Delayed gastric