Nutrition treatment course and recommendations for one male patient with chronic pancreatitis resulting in the placement of a gastrojejunal stent.

1. Case Study:
Endoscopic
Gastrojejunostomy
Patient Care
Presented by Skip Allen MS, RD, LDN

2. ▪Personal:
▪50 year old African-American
▪Living with friend in an apartment in
rural NC
▪Didn’t know where he was staying after
d/c (maybe daughter)
Meet G.R.

3. ▪Financial
▪Uninsured with no primary care
physician
▪Mostly unable to obtain medications
(Helping Hands)
▪Previously homeless
Meet G.R.

4. ▪ Social
▪ Smoked 1 pack every 2-3 days
▪ Denies current alcohol/ drug abuse
▪ * previously 24 beers daily
▪ Blind in left eye from a stab wound
▪ Family Hx
▪ Non contributory (unable to obtain?)
Meet G.R.

5. ▪ Medical Hx
▪ Chronic pancreatitis
▪ Alcohol abuse
▪ Tobacco abuse
▪ Hypertension
▪ Abdominal trauma (from vehicle accident)
▪ Constipation and ileus
▪ Pancreatic pseudocyst
▪ History of gram-positive sepsis (PICC line)
Medical History

6. Treatment Path

7. CCH- ER
12/26/2014
▪ Chronic pancreatitis
▪ On-going hypertension
▪ 3 day Hx of severe
nausea, vomiting, and
some diarrhea.
▪ Reported as a poor
historian
▪ Bloody emesis
▪ Red stools (not tarry)

8. ESPEN Factoids1
▪ Alcohol is the etiological factor in 60–70% of patients with chronic pancreatitis.
▪ 30–50% of patients with chronic pancreatitis have increased resting energy
expenditure.
▪ More than 80% of patients can be treated adequately with normal food
supplemented by pancreatic enzymes .
▪ 10–15% of all patients require oral nutrition support.
▪ TF is indicated in approximately 5% of patients with chronic pancreatitis.
▪ Except for stenosis of the duodenum, there are no contraindications to normal food
or EN.

9. CCH
Medical
▪ Treated for pancreatitis
▪ GI consult was ordered
due to continued severe
N/V
Nutrition
▪ Clear liquids – reduced
N/V
▪ Additional protein from
Prostat supplement
▪ Recommended to
advance diet as
tolerated.

10. Medical Diagnosis
▪Chronic Pancreatitis w/ a gastric outlet
obstruction secondary to inflammation.
▪ Inflammation process around pancreatic
head and neck junction as well as
inflammation of the antrum and
duodenum.

11. Research
Support
British Journal of Surgery-April 2013
Intro: European guidelines recommend
routine feeding after pancreato-
duodenectomy (PD), whereas American
recommendations do not. This study aimed
to determine the optimal feeding route after
PD.
Methods: systematic review of PubMed,
Embase, and Cochrane Library. Articles
included were studies on feeding routes after
PD that reported length of hospital stay
(primary outcome).
Reviewed 442 articles, 15 studies, and 3474
patients.
Systematic review of five feeding
routes after
pancreatoduodenectomy.2
A.Gerritsen, M.G.H. Besselink, D.J. Gouma,
E.Steenhagen, I.H.M.Borel Rinkes and
I.Q.Molenaar.

12. Research
Support
British Journal of Surgery-April 2013
Results: Mean length of stay was shortest in
oral diet and GJT (15 days), followed by JT
(19 days), TPN (20 days), and NJT (25 days).
Normal oral diet was established most
quickly by the oral diet group followed by the
NJT group.
Conclusion: No evidence to support routine
enteral or parenteral feeding after PD. Oral
diet may be considered as the preferred
routine feeding strategy after PD.
Systematic review of five feeding
routes after
pancreatoduodenectomy.
A.Gerritsen, M.G.H. Besselink, D.J. Gouma,
E.Steenhagen, I.H.M.Borel Rinkes and
I.Q.Molenaar.

13. Research
Support
Journal of Korean Medical Science 2012
Intro: Assessed postoperative nutrition status of
patients who had undergone PD according to the
postoperative nutritional methods (EEN vs TPN), and
compared the clinical outcomes of the two methods.
Methods: open, randomized, single center, parallel
group trial. Patients were >18y who had PD d/t
malignant periampullary pathology. Exclusion criteria
1) hx of major abdominal or pelvic surgery; 2) patients
with metastatic disease and palliative surgery; 3) hx
of pelvic or abdominal radiation; 4) currently taking
steroids or immunosuppressive medications. Post
surgery patients randomly assigned to EEN or TPN.
Full scope nutrition assessment: 7th, 14th, 21st, and
90th day post op.
Postoperative Nutritional Effects of
Early Enteral Feeding Compared with
Total Parental Nutrition in
Pancreaticoduodectomy Patients: A
Prospective, Randomized Study.3
Joon Seong Park, Hye-Kyung Chung, Ho Kyung
Hwang, Jae Keun Kim, and Dong Sup Yoon

14. Research
Support
Journal of Korean Medical Science 2012
Results:
40 pts recruited, two dropped out. 38 analyzed.
Mean age 61 years. 19 men and 19 women.
1) First day of BM and time taken to take a soft diet
was shorter in the EEN group.
2) No difference in risk of leakages
3) No difference in occurrence of delayed gastric
emptying
4) Pt who received EEN had higher prealbumin and
transferrin levels at all check ups
CONCLUSION:
EEN is safe and well tolerated and improves early and
long term postoperative nutritional status and whole
body protein kinetics.
Postoperative Nutritional Effects of
Early Enteral Feeding Compared with
Total Parental Nutrition in
Pancreaticoduodectomy Patients: A
Prospective, Randomized Study.
Joon Seong Park, Hye-Kyung Chung, Ho Kyung
Hwang, Jae Keun Kim, and Dong Sup Yoon

15. Research
Support
Surgery- September 2013.
Intro: Delayed gastric emptying (DGE) is a
common complication of
pancreatoduodenectomy. Study investigated
association between preoperative symptoms of
gastric outlet obstruction and DGE after PD in
attempt to identify patients in whom placement
of a feeding tube at time of operation might be
beneficial.
Methods: analyzed 401 consecutive patients
undergoing PD. Reviewed preoperative
symptoms like nausea, vomiting, loss of
appetite, weight loss, postprandial complaints,
and dysphagia. Reviewed primary outcomes with
clinically relevant DGE and the necessity of a NJ
feeding tube.
Association of preoperative symptoms of
gastric outlet obstruction with delayed
gastric emptying after
pancreatoduodenectomy.4
Jasper J. Atema, MD, Wieste J. Eshuis, MD, Olivier
R.C. Busch, MD, PhD, Thomas M. van Gulik, MD, PhD,
Dirk J. Gouma, MD, PhD

16. Research
Support
Surgery- September 2013.
Results: Incidence of clinically relevant DGE was
33.2% (133/401 patients). 119 patients had a N-J
tube placed.
>2 symptoms of gastric outlet obstruction except
weight loss (12.5% of patients), were at a greater risk
of DGE and the need for insertion of tube feeding
(21.8% vs 8.5%)
CONCLUSION:
Preoperative presence of > 2 symptoms of gastric
outlet obstruction is a significant predictor of
postoperative DGE after PD. With this information,
patients in whom a placement of a feeding tube
during surgery should be considered can be identified.
Association of preoperative symptoms of
gastric outlet obstruction with delayed
gastric emptying after
pancreatoduodenectomy.
Jasper J. Atema, MD, Wieste J. Eshuis, MD, Olivier
R.C. Busch, MD, PhD, Thomas M. van Gulik, MD, PhD,
Dirk J. Gouma, MD, PhD

17. G.R.’s Medical Journey
12/26/2014
Hospital 1
2/14/2015
GI Consult
Hospital 2
1/18/15
Gastroenterology

18. Surgical Factors
▪ 2 endoscopies (revealed duodenopathy)
▪ Dilation and Axios Stent placed
▪ Gastrojejunal stent (commonly for post bariatric
surgery anastomosis)
▪ Repeat endoscopy (still duodenopathy)
▪ Placed nasojejunal TF
▪ Sphincterotomy
▪ Removal of pancreatic duct stone

19. Surgical factors

20. Anthropometrics
Height: 171 cm
Weight: 65 kg
UBW: 12/29 69.5 (loss of 2-13 lbs prior)
IBW : 67 kg (60 -74kg)
% IBW: 97%
BMI 22 – Normal
Wt. change : 6%-14%

21. 58
60
62
64
66
68
70
72
74
76
78
Prior 12/29/2014 2/16/2015 2/18/2015 2/20/2018
Weight Trends
Realistic Estimate Conservative Estimate

22. Interpretation of Weight Loss: A.S.P.E.N.
Severe – Chronic illness
>5% in 1 month
>7.5% in 3 months
>10 % in 6 months
>20% in 1 year

23. Nutritional Focused Physical Findings
No issues in chewing or swallowing
In the context of malnutrition: no significant muscle wasting or
subcutaneous fat loss
No ascites
Varied appetite and N/V/D/C
J tube placed.

24. Clinical Finding 2/15
Hgb (12.5-16.8) 10.8 Na (136-145) 135
HCT (37.5-48.8) 33.4 K (3.6-5.1) 4
MCV (80.0-94.0) 84.1 Ca (8.8-10.2) 9.7
MCH (27.0-31.0) 27.3 Mg (1.9-2.5) 1.9
Phosphate (2.4-4.7) 4.5
BUN (8-20) 13 Albumin (3.5-5.0) 3.7
Cr (.4-1) .7 Glucose 106
Tchol 156: HDL 38: LDL 102: TG 78

25. Clinical Finding 2/18
Hgb (12.5-16.8) 9.9 Na (136-145) 139
HCT (37.5-48.8) 32 K (3.6-5.1) 3.9
MCV (80.0-94.0) 84.2 Ca (8.8-10.2) 9.5
MCH (27.0-31.0) 26.2
BUN (8-20) 13 Albumin (3.5-5.0) 3.6
Cr (.4-1) .6 Glucose 118

26. Interpretation of Labs
Patient likely has nutritional deficiencies
Anemia
Malnutrition?
Malabsorption?
Surgery?
Hx of dehydration throughout case

27. Nutritional History
12/31- Clear liquid Diet: not tolerated
1/2 - TPN at 70 ml/hr with lipids q72hr. Also 50% from Clear Liquids
1/12- Continued TPN. Attempt to advance to full liquids (not tolerated)
1/15- NPO with TPN. Discussing a J-tube
2/16- Peptamen bariatric at 40ml/hr in J-tube. (order was for 60ml/hr)

28. Nutrition Diagnosis
Altered GI function related to history of alcohol abuse as evidenced by
chronic pancreatitis and partial gastric outlet obstruction.
* Altered GI function related to chronic pancreatitis w/ a gastric outlet
obstruction as evidenced by GI consult notes and placement of
gastrojejunal stent.

29. Estimated Needs
Mifflin-St. Jeor Equation
M: REE = 10 (65kg) + 6.25 (171cm) – 5(50y) + 5
REE (1476) x PAL 1.2-1.3= 1770-1920 kcal day
Protein
(Chronic Pancreatitis)
65 kg x 1-1.5 g/kg = 65-98 g/day
Fluids
(65.2kg - 20kg) x 15ml + 1500ml = 2180ml/ day

30. Medications
▪ Lovenox
▪ Remeron
▪ Nicoderm
▪ Nortriptyline
▪ Tylenol
▪ Ibuprofen
▪ Oxycodone
▪ Phenergan
▪ Ultram
▪ Trazadone
▪ Docusate – stool softener
▪ Lovenox - anticoagulant
▪ Zofran – antiemesis, antinausea
▪ Protonix – proton pump inhibitor,
antiGERD
▪ Miralax - laxative
▪ Senna - laxative
▪ Bisacodyl - laxative
▪ Promethazine – antiemesis, antinausea
▪ Simethicone – antifoaming agent
(reduces gas/ bloating)

31. Medical Team Nutrition Goals
Tolerate Tube feeding within 3 days with no N/V/D/C
Meet 75% of estimated needs from all sources
Transition to oral diet
Tolerate oral diet by d/c

32. Monitor
TF tolerance
Diet/ Supplement tolerance
Oral intakes
Lab results
Results of small bowl follow-through
Weight

33. Intervention 2/16
TF with Fibersource HN at 65ml/hr over 12 hrs (8pm-8am) to provide:
• 936 kcal
• 42g Protein
• 125g CHO
• 30.5g Fat
• 8g Fiber
• 632 ml fluids
Patient would potentially have a pump at home and could feed at night.
This would meet 50% of needs. Continue to encourage PO-full liquid.
Rationale: Gauging tolerance. Pt home care is a relevant factor.

34. Follow up #1
2/18- pt wasn’t tolerating full liquids
• Fatty stools
• Downgraded to clear liquid diet
• TF was held because small bowel follow through would be
today
• TF @ 65 ml/ hr for 24 hours upon restart
• Discussed BRAT diet
• Discussed Pancrealipase

35. Follow up #2
2/20- tolerating TF
• Ongoing severe nausea
• Advanced to BRAT diet
• No BMs since diet advance (~24 hours)
• Started on pancreatic enzymes
• GI consult showed no bowel obstruction
*noticed pancrealipase was ordered lower than goal. Coordinated care with pharmacy, GI MD, and
PA-C to increase lipase. Discussed with RN the importance of giving pancreatic enzymes before
every meal. Discussed with GI MD the possible use of semi elemental formula if enzymes didn’t
help improve BMs.

36. Follow up #3
2/21 – Tolerating BRAT diet
• Low intakes
• No vomiting
• Greasy and smelly stools
• Nausea improving
• Changed to Elemental Formula
• Began discussing pt. oral diet for home care

37. Follow up #4
2/23- Diet Advanced per RD recommendations
• GI Soft/ Low-fat/ mechanical soft with ground meats and 6 small feedings a
day. TF (Vital AF/ Peptamen AF at 60ml/hr with 30 ml flush q4hr) at night from
8pm-8am.
2/25 – Tolerating diet
• No new N/V/D
• 50-100% meals + some snacks
• Appetite returning and satiated after meals
• Checked with PA-C to ensure lipase given prior to meals and snacks
• Recommended decrease TF to 30 ml/hr at night.

38. Final Follow up
3/3- Tolerating oral diet
• Eating 6 meals a day
• TF d/c
• 100% intakes with rare nausea
• Two BMs (still black and tarry)
• Provided education for home care
*PES added: Food and Nutrition related knowledge deficit related to
lack of exposure to low-fat diets and eating to improve GI function
as evidenced by patient stated lack of knowledge

39. Education
Primary Goals:
Chew Foods thoroughly
Eat 5-6 small meals per day as needed
Eat slowly and take small bites
Remain in upright position for 30-60 minutes (primary
goal: patient liked to sleep after meals)
Information from Digestive Health Center, University of Virginia Health System 4

40. Education
Secondary Goals:
Drink fluids between meals if you feel “full” with meals
Sit upright while eating
Avoid tough, hard to chew, or hard to swallow foods
Nutritional drinks if weight is hard to maintain (currently
68.6 kg compared to 65 kg)
Recommended a low-fat diet (was having black tarry
stools)

41. Referrals
RD contact information provided

42. Changes to care provided?
Confident in care plan- what do you
think?

43. Bibliography
Meier R. Ockenga J. Pertkiewicz M. Pap A. Milinic N. MacFie J. DGEM, Loser C. Keim V. ESPEN. ESPEN
Guidelines on Enteral Nutrition: Pancreas. http://espen.info/documents/enpancreas.pdf. Published January
2006. Accessed April 11, 2015.
Gerritsen A, Besselink MGH, Gouma DJ, Steenhagen E, Borel Rinkes IHM, Molenaar IQ. Systematic review of
five feeding routes after pancreatoduodenectomy. Br J Surg. 2013;100:589-598. http://0-
onlinelibrary.wiley.com.library.meredith.edu/doi/10.1002/bjs.9049/epdf. Accessed April 11, 2015.
Park JS, Chung H-K, Hwang HK, Kim JK, Yoon DS. Postoperative Nutritional Effects of Early Enteral Feeding
Compared with Total Parental Nutrition in Pancreaticoduodectomy Patients: A Prosepective, Randomized
Study. Journal of Korean Medical Science. 2012;27(3):261-267.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3286772/?tool=pmcentrez. Accessed April 11, 2015.
Loch M, Kahaleh M. Stents for the Gastrointestinal Tract and Nutritional Implications, Practical
Gastroenterology. 2007; 46: 48-57.
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/clinical-
care/nutrition-support-team/nutrition-articles/LochArticle.pdf. Accessed April 11,2015.
Jasper J. Atema, MD, Wieste J. Eshuis, MD, Olivier R.C. Busch, MD, PhD, Thomas M. van Gulik, MD, PhD, Dirk
J. Gouma, MD, PhD. Association of preoperative symptoms of gastric outlet obstruction with delayed gastric
emptying after pancreatoduodenectomy. Surgery. 2013;154(3):583-8.
http://www.ncbi.nlm.nih.gov/pubmed/23972659. Accessed April 11, 2015.