Clinical Nutrition Case Study

Nutrition Considerations for Pancreatic Cancer Patients
Undergoing Pancreaticoduodenectomies
By Hannah Hallgarth
Virginia Tech Dietetic Internship 2014-2015
Written Case Study
ABSTRACT
As one of the most aggressive forms of cancer, pancreatic carcinoma poses its own unique nutrition
complications. Most cases go undetected until symptoms such as jaundice, weight loss, and malnutrition
develop in its late stages. Usually the result of a pancreatic head mass, most cases will include surgical
treatment. The classic Whipple procedure, or pancreaticoduodenectomy, is completed to remove the
malignant tumor and any metastatic tissue in the surrounding area. A high amount of complications can
arise from this surgery, many of them nutrition-related. Gastroparesis, pancreatic fistula, and diabetes
mellitus are all known to occur. Other issues such as malnutrition, anorexia, and cancer cachexia can be
exacerbated as a result of this intensive surgery. Registered dietitians, as a part of the healthcare team,
are faced with the challenge of intervening upon these predicted nutrition complications. The following
case study of a pancreatic cancer patient who undergoes a pancreaticoduodenectomy provides a
thorough investigation into the medical nutrition therapy involved in this disease state.
ASSESSMENT
AA is a 66 year-old non-English speaking Somalian female who was brought to the emergency room by
family members because of longstanding, increasing jaundice accompanied by weakness and fatigue. At
5’7” and 187 pounds, she presents with a BMI of 29.29, and claims to have a lack of appetite and weight
loss of about 20 pounds in the past 4 months. The patient has a past medical history of type II diabetes
mellitus and cholelithiasis. During her emergency room visit, an initial CT scan of her abdomen and
pelvis showed the presence of gallstones and a 1.5-2 cm mass in the head of the pancreas causing
obstruction of the bile duct. The patient underwent surgery to install a biliary stent and perform a biopsy
of the pancreatic head mass. The biopsy proved a tumor malignancy with no evidence of disease or
vascular involvement outside of the pancreas. AA suffers from poorly controlled diabetes resulting in
abnormally high blood glucose levels. At the time of the first interaction with a registered dietitian her
POCT glucose values were 193, 247, and 373 mg/dL and her hemoglobin A1C was 9.4%, indicating

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long-standing issues with blood glucose control. A consult for diabetes education was submitted to
nutrition services.
Pathophysiology
The etiology of pancreatic cancer is poorly understood and undergoing continued research. Its initial
development is in the head of the pancreas. This location is where ductal cells are exposed to pancreatic
secretions, bile, and environmental toxins and carcinogens. Chronic inflammation resulting from chronic
pancreatitis is also considered to be a causative factor in carcinoma1
. The relationship between diabetes
and pancreatic cancer is strengthening due to a surge in recent research. Studies have yet to determine
whether diabetes is a causative factor for pancreatic cancer or if, conversely, pancreatic cancer is
responsible for increased insulin resistance and diabetes2
. It is a question to keep in mind when
considering the situation of AA, who had been diagnosed with diabetes in the past.
Often times there are no physical signs and symptoms of pancreatic cancer until it has advanced to the
late stages. In AA’s case, she was already experiencing some of the most common symptoms of the
advanced disease including jaundice, weight loss, and anorexia. Other signs are depression, dark urine,
light colored stools, and abdominal pain radiating to the back1
. Laboratory tests and imaging are used to
help diagnose, but a biopsy is needed for a definitive diagnosis of carcinoma3
. Imaging tests commonly
used include the following: helical computed tomographic scan, magnetic resonance imaging scan,
endoscopic ultrasound, and laparoscopic ultrasound. Unlike other cancers, no tumor-specific markers
exist for pancreatic cancer. Most patients will have an elevated CA 19-9, which will increase with
progressive tumor growth3
.
Clinical Markers
Although not necessary for a positive diagnosis of pancreatic cancer, the patient’s laboratory values are
important to consider for effective medical therapy and medical nutrition therapy. A discussion of her
comprehensive metabolic panel laboratory values throughout hospitalization is as follows4
:

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Marker Normal 9/10/14 9/12/14 9/24/14
Glucose 70-110 mg/dL 176 229 163
Hemoglobin A1C 4-7% 9.4
BUN 8-18 mg/dL 5 6 4
Creatinine 0.6-1.2 mg/dL 0.7 0.6 0.6
Sodium 136-145mEq/L 139 136 140
Potassium 3.5-5.5 mg/dL 3.7 3.8 4.1
Chloride 95-105mEq/L 108 106 105
Calcium 9-11 mg/dL 9.1 8.5
Magnesium 1.8-3 mg/dL 2
Phosphorous 2.3-4.7 mg/dL 3
ALT 4-36 IU/mL 468 773 118
AST 5-40 IU/mL 775 400 59
Alkaline Phos 30-135 IU/L 269 271
Bilirubin ≤
1 mg/dL 7.6 6.1
Total Protein 5.3-8 g/dL 6.4
Albumin 3.5-5 g/dL 2.9 2.7
Glucose/Hemoglobin A1C
As previously discussed, type II diabetes can be an early manifestation of pancreatic cancer, or it can be
a predisposing factor for the disease2
. The prevalence of diabetes and impaired glucose tolerance in
cases of pancreatic cancer is as high as 80%, with the diabetes diagnosis occurring roughly two years
before the cancer diagnosis. Regardless of the relationship between pancreatic cancer and diabetes,
patient AA is in need of stricter blood glucose control. Her abnormally high hemoglobin A1C of 9.4%
indicates a history of poorly controlled diabetes. Her blood glucose levels remained high throughout her
admission, despite being administered insulin, possibly due to steroidal drug administration and the
stress of surgery5
.
Electrolytes
Magnesium, potassium, and sodium laboratory values remained within the normal limits during AA’s
admission. When AA returned to the emergency room on 9/25, her calcium levels had dropped (8.5
mg/dL), which could indicate steatorrhea, malabsorption, and/or a vitamin D deficiency. Steatorrhea is a
common side effect of pancreatectomies and can cause fat-soluble vitamin deficiencies5
. She also had
high chloride levels on admission, which could be a result of dehydration as well as pancreatitis4
.
Liver Function Tests

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Liver function tests are often elevated in cases of pancreatic cancer. In AA’s case, alkaline phosphatase,
ALT, AST, and bilirubin were all above the normal limits3
. Elevation of both bilirubin and alkaline
phosphatase indicate cholestasis, or obstruction of the bile duct. Her jaundiced appearance at admission
is a result of the elevated liver function tests. After discharge, ALT and AST dropped dramatically,
indicating the success of the tumor removal.
Blood Urea Nitrogen
In the case of this patient, low blood urea nitrogen (BUN) may be related to pancreatic insufficiency.
BUN is often low in cases of liver disease, which is not necessarily present in this patient. However,
pancreatic tumors can influence liver function, thus lowering BUN. It could also result from chronic
malnutrition exhibited by AA’s recent significant weight loss and poor appetite4
.
Albumin
Albumin (and other acute-phase proteins) is no longer considered to be a marker for malnutrition by the
Academy of Nutrition and Dietetics or the American Society for Parenteral and Enteral Nutrition. It
does, however, reflect the severity of the inflammatory response and the illness. Pancreatic cancer
causes a moderate to severe inflammatory response, thus lowering acute-phase proteins like albumin6
.
Treatment Course
Treatment options available for pancreatic cancer depend upon the stage of the disease. Surgical
resection is the primary (and most effective) form of treatment for pancreatic cancer. As the disease
reaches stage IV, it is often no longer operable. Chemotherapy, chemoradiation, and palliative therapy
are adjunctive measures that can be utilized in any stage depending upon the individual case3
. However,
the efficacy of these adjunct therapies is controversial and the research is conflicting7
. After discussion
with the patient, her daughters, and the physician, it was decided that the initial plan of care for AA
would involve a pancreaticoduodenectomy, or Whipple procedure, in order to remove the malignant
tumor.
The Whipple procedure is considered a major surgery and involves many operations. AA’s entire
duodenum, head of the pancreas, pyloric region of the stomach, the distal bile duct, gallbladder, and
associated lymph nodes were removed in the surgery. The procedure completely removes the tumor as

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well as the regions where it may have metastasized8
. The remaining pancreas is anastamosed to the
small bowel. The bile duct and stomach are then reconnected to the jejunum. The patient is usually kept
in the hospital for about 5-8 days status post surgery. Depending upon the individual clinical
circumstances of the patient, adjunctive therapies can be started six to eight weeks after surgery. There is
a variation of the classic Whipple procedure called the pylorus-preserving pancreaticoduodenectomy in
which the pylorus of the stomach is not resected9
. AA’s pylorus was removed, making it a classic
Whipple.
According to the surgeon and physician, AA’s surgery was completed successfully with no
complications and she was discharged 7 days after the procedure. She was discharged with erythromycin
to increase gut motility, oxycodone for pain control, Novolog and Lantus insulin for blood glucose
control, and pantoprazole to manage esophageal reflux. Two days after discharge, AA returned to the
hospital’s emergency room with complications related to post-Whipple procedure. Her chief complaints
were right-sided abdominal pain, nausea, and vomiting that had been occurring for 24 hours. She also
claimed to have an aversion to the taste of food with poor oral intake. She was advised by the ER
physician to eat multiple small meals throughout the day, refrain from drinking carbonated beverages,
remain upright for 30 minutes after eating, and to stop eating and drinking when she begins to feel full.
The patient understood these recommendations, did not need readmission to the hospital, and was
discharged from the ER that same day.
Prognosis
Mortality from pancreatectomies has improved over the years, but morbidity still remains high. In a
study conducted at Johns Hopkins Hospital including 650 patients, morbidity rates were 41%10
.
Although patient AA responded well to the surgical procedure her prognosis remains grave. The primary
factors that influence prognosis are whether the tumor is localized and can be completely resected and
whether the tumor has spread to lymph nodes or elsewhere. If the tumor can be completely removed and
hasn’t metastasized, the 5-year survival rate is 18-24%. Metastatic exocrine cancer is rarely curable and
has a survival rate of 5%3
. Overall, 95% of patients will not live past 5 years after diagnosis4
. The stage
of AA’s cancer was not specified in her chart notes. Based on the surgeon’s description of the performed
Whipple procedure, the cancer was localized in the pancreas. However, pancreatic cancer rarely exhibits
signs and symptoms until it becomes advanced3
. Since AA was admitted to the hospital with symptoms

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of jaundice, weakness, and weight loss, it would appear that she could possibly be suffering from a
severe form of the disease. It was also unclear based upon physician notes on whether or not AA would
be pursuing adjunctive chemotherapy, chemoradiation therapy, or palliative therapy as part of her plan
of care.
DIAGNOSIS
In order to create an accurate nutrition-related diagnosis and determine the patient’s nutrient needs, it is
necessary to analyze anthropometric values and consider her current nutrition status. As mentioned
earlier, she is 5’7” and 187 pounds with a BMI of 29.29, which is considered overweight (bordering on
stage I obesity). Her ideal body weight is 135 pounds, putting her at 138% of her ideal body weight and
classifying her as obese. Upon admission, she claimed to have lost roughly 20 pounds (9.7% weight
loss) in the past four months, which is interpreted as severe weight loss. Based upon self- and family-
reported consistent poor oral intake (≤75% of estimated needs for ≥ 1 month) and her percent weight
loss over time, AA is eligible to be diagnosed with severe malnutrition6
. Malnutrition is considered to be
a major risk factor for poor outcomes after pancreatic surgery and as such is an important nutrition
concern to address11
. A discussion addressing malnutrition in patients with pancreatic cancer will be
included in the intervention section of this case study.
While researching the patient’s current chart notes, it was noticed that AA and her family were given the
grave diagnosis the previous day. Upon entering the patient’s room it was clear that it was an
inappropriate time to fulfill that doctor’s consult. AA’s four daughters were in the room with their
mother and in apparent distress over her situation. AA seemed confused, withdrawn, and unengaged
from the RD. Because AA only speaks Somalian, her daughters were willing to translate, but it was
apparent that no one involved was receptive to receiving education at this time. The RD left a Somalian-
translated diabetes nutrition handout as well as her contact information if they had any questions for her.
She explained that she would return to educate after the patient’s Whipple procedure in a few days time
if desired.
Diet History
A thorough diet history was not obtained from this patient. As mentioned, the patient and family were
not open to speaking at length with the RD and wanted to be left alone. Upon admission they did state

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that AA’s oral intake and appetite had been abnormally low over the past few months. It is safe to
assume that AA’s intake was not meeting her nutrition needs at home. AA was placed on a
carbohydrate-controlled diabetic diet while in the hospital. Glucerna shakes were ordered three times a
day to supplement the patient’s PO intake pre-surgery. Her daughters mentioned that AA was not eating
a large portion of her meals but was drinking the Glucernas that were brought to her. At the time of the
assessment, she had no problems with chewing or swallowing or any current gastrointestinal issues such
as nausea, vomiting, diarrhea, or constipation.
Diagnosis Statement
Even though the doctor’s initial consult was related to diabetes, it was determined that this was not AA’s
most pressing nutrition-related concern. Instead, she was most at risk for morbidity and mortality based
on her severe degree of malnutrition. The chosen diagnosis statement is as follows:
Severe protein-calorie malnutrition related to pancreatic cancer as evidenced by 9.7% weight loss in 4
months and prolonged poor PO intake.
This diagnosis statement was chosen because it can be reasonably addressed in an acute-care setting. A
diagnosis statement regarding diabetes knowledge would be more appropriate in an outpatient setting
where the patient may be more receptive to education. Through interventions such as initiation of
nutrition support, supplementation, and encouragement of PO intake, the patient’s degree of
malnutrition may be improved throughout her hospital stay and after discharge.
INTERVENTION
In order to understand the nutrition risks associated with AA’s medical situation, it is necessary to delve
into the nutrition-related complications that can arise from both pancreatic cancer and a
pancreaticoduodenectomy procedure. Nutritional deficiency is a consistent finding in this patient
population and is therefore a major consideration prior to, and after, pancreaticoduodenectomy surgery.
Low preoperative nutrition status has been found to be associated with poor survival rate and a higher
rate of postoperative complications11
. Among the most common issues are malnutrition, cachexia,
anorexia, and diabetes mellitus. The most common complications resulting from surgery are pancreatic
fistulas and delayed gastric emptying.

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Possible Nutrition-Related Complications
Many patients with pancreatic cancer suffer from symptoms of the digestive tract, including
malnutrition, anorexia and malabsorption, abdominal pain, and vomiting. These symptoms are often
referred to as “cancer cachexia syndrome” and their prevalence can indicate a poor nutrition status and
medical prognosis11
. In cancer cachexia, patients lose both adipose and skeletal muscle mass. Muscle
wasting contributes to fatigue, weakness, respiratory complications, and overall reduced quality of life1
.
It is estimated that about 40% of patients are cachectic at the time of their pancreatic surgery, which
reduces their resection and survival rates. Protein supplementation cannot account for the dramatic
increase in protein turnover11
.
Anorexia causes weight loss in pancreatic cancer patients and can be a result of a few different factors.
The appetite-stimulant hormone ghrelin was found to be significantly lower in individuals with
pancreatic cancer, thus inhibiting hunger cues. Patients with gastrointestinal cancer also can experience
a decrease in taste and smell. Additionally, the tumor may release cytokines that directly contribute to
anorexia. Early satiety has also been noticed, even after eating very small portions of food. Treatment of
anorexia includes use of appetite stimulants and nutritional supplements11
.
Due to the clinical nature of the disease, many patients are malnourished at time of diagnosis and
leading up to their pancreatectomy. In AA’s case, she was admitted to the hospital in a state of severe
malnutrition due to significant recent weight loss and prolonged poor PO intake with anorexia. Despite
an increase in research and awareness, malnutrition still continues to be a common occurrence in
patients requiring surgery, reaching from 35-60% depending upon parameters used. One study found
that patients with increased nutrition risk had a four times longer length of stay and a higher morbidity
rate than patients not at malnutrition risk11
. There are many contributing factors to malnutrition, some of
which begin before diagnosis and some that don’t display until after pancreatic surgery. During the
Whipple procedure, the superior mesenteric artery, which regulates motility of the small bowel, is
dissected. This can cause diarrhea and malnutrition11
. After pancreatectomy, a decrease in pancreatic
enzymes causes steatorrhea, and subsequently, malabsorption of fat-soluble vitamins. Exocrine
insufficiency of the pancreas should be managed by administration of pancreatic enzymes5
. As
mentioned earlier, anorexia and cancer cachexia can be huge contributing factors for malnutrition in

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pancreatic cancer patients. Identifying patients who are currently malnourished and/or at a high risk for
malnutrition can help decrease morbidity and mortality and improve patient outcomes12
.
A major concern after pancreaticoduodenectomy is delayed gastric emptying. Delayed gastric emptying,
or gastroparesis, occurs in roughly 20-50% of pancreaticoduodenectomy cases. It can prolong
hospitalization and severely alter the nutritional state of the patient by delaying progression of the diet.
During the surgery, the gastric pacemaker is removed with the pylorus of the stomach, resulting in
postoperative gastric stasis11
. Other causes include diabetes mellitus, decreased motilin secretion,
abdominal abcess, or pancreatic fistula5
. Early enteral feeds have been shown to reduce the prevalence
of delayed gastric emptying. Erythromycin acts as a gut-motility agent that reduces incidence of the
condition. A combination of both has been shown to have the most improvement over delayed gastric
emptying13
. Large volumes of feeds have been shown to delay gastric emptying, so generally patients
benefit from smaller, more frequent meals. Offering pureed or liquefied foods is also helpful as well as
foods that are low in fiber and fat14
.
The occurrence of pancreatic fistulas remains one of the most common complications of
pancreaticoduodenectomies12
. Pancreatic fistulas occur in roughly 10-20% of all pancreatectomies. One-
third of fistulas have been shown to be clinically insignificant, but the remainder has been associated
with morbidity and mortality5
. Low-grade fistulas can be maintained with abdominal drains. Re-
intervention through surgery may be necessary with higher-grade fistulas and can be responsible for
postoperative mortality5,12
. Medical nutrition therapy for fistulas includes parenteral nutrition, tube
feeding, oral diet, or a combination. A recent study indicated that enteral nutrition was associated with
faster closure rates of pancreatic fistulas15
, although it can be debated that parenteral nutrition is more
appropriate. The goal is to permit spontaneous closure or maintain nutritional status prior to surgical
closure14
.
The final great concern for this patient population is diabetes mellitus. There has been a long-standing
relationship between pancreatic tumors and diabetes. Nearly half of newly diagnosed pancreatic cancer
patients have diabetes, with 74% being diagnosed within 2 years prior, patient AA included. The
pancreatic tumor destroys islet cells, resulting in impaired blood glucose and diabetes mellitus. After
surgery, the lack of insulin and glucagon secretion from the non-existent pancreas can result in a form of

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diabetes that is very similar to type II5
. It is very important for these patients to develop rigorous blood
glucose monitoring procedures for their return home. For patients that were diagnosed with diabetes
very close to their pancreatic cancer diagnosis it is possible to improve blood glucose control after
surgery. One study’s aim was to analyze changes in exocrine pancreatic function after
pancreaticoduodenectomy. The results of the study showed endocrine impairment (DM, IFG, or raised
PP2) at 6 months post-surgery with a gradual improvement after their 12-month follow-up. Some
patients had better blood glucose control at 12 months post-surgery than they did before the resection of
their pancreas16
. Intervention involves medication, strict blood glucose monitoring, and modifications to
diet and lifestyle practices.
Nutrient Requirements
It is apparent that there are many nutrition-related concerns with pancreatic cancer and its subsequent
surgical procedures. Based on the descriptions above, it would appear that AA is suffering from a
number of the most common symptoms and complications associated with her condition. It is clear that
she is malnourished based on her 9.7% weight loss over four months and self- and family-reported
consistent poor oral intake (≤75% of estimated needs for 1 ≥month). Her poor oral intake and lack of
appetite indicates anorexia, which can lead to worsening malnutrition. She also suffers from diabetes
mellitus and had been experiencing high blood glucose levels prior to and during admission at the
hospital. To date, she has not experienced delayed gastric emptying, pancreatic fistula, or any other
complications from her surgery, aside from the abdominal pain and nausea during her visit to the
emergency room, which was succinctly resolved. Keeping in mind these current issues, her estimated
nutrient needs for post-surgery are as follows:
1. Calories: 25-27 kcal/kg Current Body Weight (85 kg)
• Provides a total of 2,125-2,295 kcals/day
• Goals:
o Promote wound healing after surgery
o Reduce malnutrition and preserve lean body mass
2. Protein: 1.3-1.5 g/kg Current Body Weight (85 kg)
• Provides a total of 110-127 g protein/day
• Goals:
o Promote wound healing after surgery
o Reduce malnutrition, preserve lean body mass, counteract cachexia
3. Fluid: 25-30 ml fluid/kg Current Body Weight (85 kg) or per MD

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• Provides a total of 2125-2550 ml fluid /day
• Goals:
o Maintain adequate hydration status
Prior to surgery, AA’s diet order was carbohydrate-controlled diabetic so her blood glucose levels could
be better controlled. She became NPO the night before the surgery and a nasogastric tube and IVF line
were placed. Three days later, the nasogastric tube was removed and her diet was advanced to clear
liquids only. By the next day, her diet returned to carbohydrate-controlled diabetic including Glucerna
shakes for nutrient supplementation. At this time, she was having flatus and bowel movements, and
taking Colace to prevent constipation. She was discharged on the diabetic diet with instructions on how
to best promote adequate PO intake and manage symptoms from surgery.
The role of nutrition support in pancreatic cancer involving surgery is confounded by conflicting
research. One study claimed a significant benefit to parenteral nutrition in patients with pancreatic
cancer and progressive cachexia17
. Another study found that parenteral nutrition initiation in patients
undergoing chemotherapy improved quality of life and increased appetite compared to PO alone18
.
However, it has long been thought that parenteral nutrition in postoperative pancreatic cancer cases
should not be recommended as a usual practice due to higher rates of infection and complications. Home
parenteral nutrition can be indicated if the patient is unable to consume food and is at risk of death from
starvation11
.
Compared to parenteral nutrition, early enteral nutrition post-surgery offers a greater benefit and lesser
risk to the patient, as well as lower healthcare costs. It has been shown that patients with early enteral
feeds develop fewer complications postoperatively, likely due to immunonutrition factors19
. Usage of
the gastrointestinal tract with enteral feeds prevents intestinal atrophy and bacterial translocation20
. Oral
nutrition is usually preferable, but enteral nutrition is an appropriate way to aid in improving nutritional
status or when relying solely on PO intake is inappropriate. Standard formulas containing isotonic
calories can be used, but immunomodulating formulas may offer additional benefit to the patient’s
immune status5
. Exocrine insufficiency of the pancreas should be managed by administration of
pancreatic enzymes. Pancreatic enzyme replacement therapy, calcium and vitamin supplementation, and
a calorie-dense diet can help prevent nutrient deficiencies and weight loss1
.

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Nutrition Interventions and Goals
After discussing the common complications and nutrient requirements for this patient, the RD’s
interventions and recommendations need to be included in the plan of care. The following interventions
and goals are for post-surgical treatment. They are based off of the information discussed above in the
“Intervention” section and chosen with the patient’s current nutritional status and potential
complications in mind.
1) After surgery, advance diet from clear liquidsfull liquidsdiabetic carbohydrate-
controlled as tolerated. If unable to advance diet from clear liquids within 5 days after
surgery, recommend use of NGT and enteral feeds.
Goals: Promote PO intake; meet nutrient requirements; proper wound healing s/p
surgery; preserve lean body mass
2) Provide Glucerna TID after meals as a nutrition supplement when advanced to at least a full
liquid diet
Goals: Help meet nutrient requirements; proper wound healing s/p surgery; stabilize
blood sugar levels within normal ranges; preserve lean body mass
3) Supplementation of fat-soluble vitamins (A, D, E, and K), vitamin B12, and iron
Goals: Prevent and/or treat micronutrient deficiencies resulting from malabsorption,
diarrhea, and steatorrhea
4) Supplementation of pancreatic enzymes
Goals: Prevent and/or treat micronutrient deficiencies due to malabsorption;
compensate for loss of pancreatic enzymes from pancreatectomy
5) Education for diabetes management and carbohydrate-counting diet
Goals: Patient and family understanding of diabetic diet recommendations and
methods: normalize patient’s blood glucose and hemoglobin A1C levels
In regards to coordination of care, the entire healthcare team was involved with the care for this patient.
The RD’s recommendations were documented and shared with other team members involved in the plan
of care. An appropriate discharge summary was written for the patient and included nutrition
information regarding both diabetic diet principles and recommendations for post-
pancreaticoduodenectomy nutrition.

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MONITORING AND EVALUATION
There are many complications that can result from a Whipple procedure, and AA is at risk for
developing many of them. Considering her status pre- and post-surgery, the following should be
monitored and evaluated closely in the acute-care setting.
Gastrointestinal Tolerance to Diet Advancement
It is very possible for patients to develop gastrointestinal issues after a Whipple procedure. Diarrhea and
steatorrhea are common complications due to decreased pancreatic enzymes, and can lead to
malabsorption and deficiencies of vitamins and minerals5
. Gastroparesis is another issue with this type
of operation and should be monitored by checking residuals. The care team should also be observing the
patient for presence of pancreatic fistula, which poses its own unique nutritional complications including
increased nutrient needs13
. The patient should be questioned about her comfort level including presence
of vomiting, nausea, diarrhea, indigestion, constipation, and lack of appetite. Occurrence of any of these
problems could hinder diet advancement and PO intake. Tolerance should be evaluated after each diet
advancement.
Blood Glucose and Labs
Monitoring blood glucose levels is especially important in AA’s case because she had pre-existing
diabetes before surgical intervention. Her blood glucose values may be higher due to the stress response
that typically occurs post-surgery. Blood glucose levels should be addressed by administering the proper
dose of insulin to correct spikes. In addition to blood glucose, vitamin and mineral labs should be
evaluated as well. Vitamins A, D, E, K, B12, and iron should all be supplemented if the patient is found
to be deficient1
.
Weight
Weight should be monitored closely and preferably taken every day. Malnutrition is a common
complication in both Whipple procedures and pancreatic cancer. Monitoring daily weights helps ensure
that the patient’s weight is not dropping too quickly and subsequently increasing her risk for
malnutrition and its related complications1
. If noticed early, the right steps can be taken to help correct
malnutrition early on in treatment.

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Understanding of Diet Recommendations
AA has many changes to make to her diet to include diabetic and post-surgical recommendations. After
providing diet education, the “teach-back” method should be employed to evaluate patient and family
understanding of the provided education. Another method for evaluation includes having the patient
and/or family list three-five ways they can meet diet recommendations. If patient/family do not have a
good understanding, a follow-up meeting should take place with either an inpatient or outpatient RD.
CONCLUSION
When it comes to treating patients with medical nutrition therapy, it is important to have an accurate
view of all encompassing factors. This is especially important when it comes to addressing nutrition
concerns in patients who have received a recent Whipple procedure. This case study demonstrated how
to assess a pancreatic cancer patient’s nutrition risk pre-Whipple procedure, diagnose their most pressing
nutrition concerns, and make appropriate interventions for both pre- and post-surgery to address those
concerns and complications. It also provided recommendations on nutrient requirements specific to this
patient population and the most effective ways to meet those requirements. The disease prognosis may
not always be optimistic and the surgical procedure is invasive. However, medical nutrition therapy can
be utilized to improve outcomes and decrease the morbidity and mortality risks of the patient. By
reviewing literature and applying research-proven recommendations, the RD can work as a member of
the healthcare team to directly improve a patient’s nutritional status and overall health.

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9/21/2014-10/02/2014.
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3) National Cancer Institute at the National Institutes of Health. Pancreatic cancer treatment: general
information about pancreatic cancer.
http://www.cancer.gov/cancertopics/pdq/treatment/pancreatic/HealthProfessional. Accessed 9/27/2014.
4) Escott-Stump, S. Nutrition and Diagnosis-Related Care. 7th
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and other pancreas surgeries webpage.
http://www.hopkinsmedicine.org/kimmel_cancer_center/centers/pancreatic_cancer/treatments/whipple_
procedure.html. Accessed 9/25/2014.
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12) La Torre, M, Ziparo V, Nigri G, Cavallini M, Balducci G, Ramacciato G. Malnutrition and
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