Transcript Acute pancreatitis

Pancreatitis
PANCREATITIS
•Pancreatitis is an inflammation of the pancreas.
•The pancreas secretes digestive enzymes into the small
intestine through a tube called the pancreatic duct.
•These enzymes help digest fats, proteins, and carbohydrates
in food.
• The pancreas also releases the hormones insulin and
glucagon into the bloodstream. These hormones help the body
use the glucose it takes from food for energy.
Normally, digestive enzymes do not become active until they
reach the small intestine, where they begin digesting food. But in
pancreatitis these enzymes become active inside the pancreas,
&start "digesting" the pancreas itself.
Pancreatitis is classified as:
Acute pancreatitis
Chronic pancreatitis
Acute pancreatitis: is a condition that develops when the pancreas is
damaged by an inflammation that leads to swelling and sometimes to
Necrosis of parts of the pancreas.
In about 85% of patients, acute pancreatitis is mild disease and is
associated with a rapid recovery within a few days of onset of the illness
In about 15-20% of patients, acute pancreatitis can lead to severe
damage of the pancreas associated with the developments of pancreatic
necrosis.
Patients with severe acute pancreatitis are at the risk of developing
following complications:
 Failure of multiple body organ systems such as heart, lungs, liver and
kidney.
 Pancreatitis necrosis( part of pancreas becomes dead)
 Infected pancreatic necrosis( infection of the dead pancreas)
 Pancreatic abscess
 Pseudocyts
 Pancreatic fistula
Chronic pancreatitis: is a condition associated with widespread scarring
and destruction of pancreatic tissue.
The condition is most frequently associated with alcohol abuse and
excessive smoking.
Chronic pancreatitis is a slowly progressive disease that takes many
years to develop.
Patients with severe chronic pancreatitis are at the risk of developing
following complications:
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Severe chronic pain
Diabetes mellitus
Poor absorption of nutrients from the digestive tract especially fats
Cancer of pancreas
Blockage of bile ducts
Pseudocysts
Bleeding from the stomach
Causes of pancreatitis are:
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Alcohol
Gallstone
Medications,
Hereditary disease,
Exposure to certain chemicals
High fat levels in the blood.
Infections such as mumps (not common),
Surgery and other medical procedures,
Trauma,
• Abnormalities of the pancreas or intestine
• Auto digestion
Other factors that lead to pancreatitis are:
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Structural abnormalities of the pancreas
Viral infections like hepatitis
Pancreatic cancer, which can obstruct the flow of pancreatic enzymes
Inherited diseases, especially cystic fibrosis
Signs and symptoms of Pancreatitis
 Acute pancreatitis occurs abruptly, generally with gentle to
harsh pain in your upper abdomen that may spread out to
your back and rarely to your chest. The pain may become
worse when you have alcohol.
Other signs and symptoms of acute pancreatitis are:
 Swollen, tender abdomen
 Rapid pulse
 Fever
 Nausea and vomiting
 Dehydration and low blood pressure, internal bleeding, and
shock
DIAGNOSIS
Diagnosing acute pancreatitis is often difficult
because of the deep location of the pancreas. The
doctor will likely order one or more of the following
tests:
•Abdominal ultrasound
•Computerized tomography (CT) scan.
•Endoscopic ultrasound (EUS).
•Magnetic resonance cholangiopancreatography
(MRCP).
Treatment of Acute Pancreatitis
• Treatment depends on the severity of the attack. If
no kidney or lung complications occur, acute
pancreatitis usually improves on its own.
• A hospital stay will be necessary so that fluids can
be replaced intravenously.
• Unless the pancreatic duct or bile duct is blocked by
gallstones, an acute attack usually lasts only a few
days.
• Medication for pain and nausea are provided to
ease these symptoms and food is withheld until
these symptoms have subsided considerably.
• Antibiotics are often prescribed in cases of severe
acute pancreatitis or if infection occurs.
If pancreatic necrosis occur
and are considered large
enough to interfere with the
pancreas's healing, your doctor
may drain or surgically remove
them.
What is pancreatic necrosis?
•Severe pancreatitis causes death of parts of
the pancreas.
•The injured and dying pancreas releases
digestive enzymes in the pancreas, which
causes extensive death of fatty tissue in the
abdomen.
•This dead pancreas tissue is called
pancreatic necrosis and the dead fat around
the pancreas is called peripancreatic
necrosis.
Types of necrosis
•When the dead pancreas is not infected, it is
called sterile necrosis.
•When the dead pancreas is infected then it
is called infected necrosis.
• Surgery in patients with sterile necrosis is
conducted
when
patients
condition
appears not be improving and or continue
to deteriorate due to infection of necrotic
cells.
•Surgery is done usually after two
weeks,as by the time the dead pancreatic
tissue is demarcated (separated) from the
live tissue and can be easily removed.
Surgery for acute pancreatitis
• The surgery that is performed remove all the
dead pancreas is called Debridement of
pancreatic necrosis. The term debridement
means removal of all dead or necrotic tissue.
• In this surgery all dead or necrotic pancreas and
any dead tissue outside of the pancreas is
removed.
• The CT scan is very useful for planning surgery
and all areas identified on CT scan of having
necrotic or dead tissue are opened up and the
dead areas are removed.
LONG TERM OUTCOME AFTER SURGICAL
TREATMENT FOR PANCREATIC NECROSIS
Many patients often require multiple surgeries to
remove all the necrotic tissue. Patients often remain
critically ill for a long period after their surgery until
the infection subsides. The long-term complications
after surgical treatment of acute pancreatitis are
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• Pancreatic Fistula:
• Pancreatic Pseudo cyst
• Diabetes:
• Chronic Pancreatitis
Nutritional Management
Nutrition prior to surgery
•Good nutrition prior to surgery ensures fewer post operative
complications, better wound healing, short convalescence
and lower mortality.
•Patients who have lost much weight prior to surgery benefit
considerably by ingesting a high calorie, high protein diet for
even a week or two prior to surgery.
•Foods which provide a maximum amount of nutrients in a
minimum volume are essential
•Foods and fluids are generally allowed until midnight just
proceeding the day of operation.
It is essential that the stomach is empty prior to
administering the anesthesia so as to reduce the
incidence of vomiting.
The patient should not be operated in a state of
dehydration, since the dangers of acidosis are
great, parenteral fluids must be administered if
the patient is unable to ingest sufficient liquid by
mouth.
Nutritional management after
surgery
• The need for nutrients is greatly increased as a
result of loss of blood , plasma or pus from the
wound surface ,hemorrhage from the
gastrointestinal tract , vomiting and fever.
• High calorie ,high protein ,low fat and high
carbohydrate diet should be the goal.
ENERGY
• Calorie requirement must be increased to restore
weight status & maintain ideal weight.
• An intake of 40-50 K Cal/KG body weight is
recommended if the patient is underweight.
• Calories should be increased gradually to avoid
digestive disturbances
PROTEIN – A satisfactory state of protein nutrition
ensures:
• A rapid wound healing.
• Increases the resistance to infection.
• Exerts a protective action upon the liver against
the toxic effects of anesthesia.
• Reduces possibility of oedema at the site of
wound.
• Intake of 1.5 – 2.5 gm/ kg body weight or about
100gm of protein is necessary as a rule.
• FAT – About 20% of calories should be
from fat. MCT are preferred as they are
easily digested
• Usual foods which contain fat are permitted
but not fried foods. As they may cause
nausea & feeling of satiety.
• Intake of 20gm visible fat is recommended.
Intake can exceed the requirement as per
tolerance.
CARBOHYDRATES
• 50-60% of energy should come from
carbohydrates.
• Carbohydratess are Easily absorbable source of
energy.
• Sugars & Starches can make the increased
calorie intake.
VITAMINS
• Needed for healing process & utilization of
proteins & calories.
• Ascorbic acid is important for wound healing &
should be provided in increased amounts.
• Vitamin “K” must be incorporated in diet to avoid
bleeding.
MINERALS
•Large amount of phosphorus & potassium are
lost in proportion of breakdown of body tissue.
•Vomiting may lead to sodium & chloride
losses.
•Iron deficiency anaemia occurs in association
with mal absorption or excessive blood loss.
•Liberal mineral intake is recommended to
meet these losses.
FIBRE – Fibre should be a part of diet to avoid
constipation.
10 gm albumin care providesEnergy- 29.4 kcal and Protein-6.5gm
7th day
9:00
11:00
1:00
4:00
7:00
Dalia (milk-200 ml+ dalia- 25gm)
Soya milk- 200 ml
Khichri- 35 gm
Curd- ½ katori (50 gm)
Milk- 200 ml
Albumin care- 10 gm
Bread- 2 slice + Jam- 10 gm
Khichri- 1 serving (35gm)
Curd- ½ katori(50 gm)
Calories- 813 kcal
Protein- 41.8 gm
Soya milk (sofit) providesEnergy -69.4 kcal and Protein -6.4 gm
8th day
9:00
Dalia was replaced by Milk- 200 ml
Albumin care- 10 gm
Bread- 2 slice
11:00
Soya milk was replaced by sweet vermicelli
(without oil)- 20 gm
1:00
Khichri- 2 servings (70 gm)
Curd- 100 gm
Paneer- 25 gm
4:00
Milk- 200 ml
Albumin care- 10 gm
Upma( suji- 20 gm, vegetables-30gm)
7:00
Khichri- 1 serving (35gm)
Curd- 1/2 katori(50 gm)
Paneer- 25 gm
Calories- 1200 kcal
Protein- 50 gm
Sweet vermicilli provides
Energy -150 kcal and Protein-1.6gm
Upma provides
Energy -81.5 kcal and Protein-3.8 gm
9th day
9:00
11:00
Breakfast was same as 8th day
sweet vermicelli was replaced by fruit custard( milk- 150 ml, apple- 30 gm, banana-50 gm)
1:00
khichri was replaced with Dal- 30 gm & Rice- 50
gm
Curd- 100 gm
Paneer- 50 gm
4:00
Milk- 250 ml
Albumin care- 15 gm
Upma was replaced with veg. Dalia (dalia- 20
gm, veg.- 30 gm)
7:00
Khichri- 1 serving (35gm)
Curd- 1/2 katori(50 gm)
Paneer- 50 gm
Calories- 1370 kcal
Protein- 72 gm
Fruit custard provides
Energy- 230 kcal and protein- 5.8 gm
Veg. Dalia provides
Energy- 80 kcal and protein- 3.6 gm
10th day
9:00
11:00
1:00
4:00
7:00
Breakfast was same
Fruit custard was replaced by Suji
Kheer- 250 ml
lunch was same as 9th day
Milk- 250 ml
Albumin care- 15 gm
Veg. Dalia was replaced with Besan
Chilla- 30 gm
Dinner was same as lunch
Calories- 1600 kcal
Protein- 83 gm
Suji kheer provides
Energy- 237kcal and Protein- 9.8
Besan Chilla provides
Energy-165.5 kcal and protein- 7.1
11TH day
9:00
11:00
1:00
4:00
7:00
Breakfast was same
suji kheer was replaced by Banana
shake- 1 glass
same as 10th day + chapatti- 1
Milk- 250 ml
Albumin care- 15 gm
Besan chilla was replaced with Paneer
sandwich ( bread- 2 slice, paneer- 50
gm, veg.- 20 gm)
same as day 10th day
Calories- 1826 kcal
Protein- 90 gm
Banana Shake provides
Energy- 230 kcal and Protein- 11.2 gm
Paneer Sandwich provides
Energy- 250kcal and Protein- 13.3 gm
12th day
9:00
11:00
1:00
4:00
7:00
Breakfast was same
Banana shake was replaced with
H.P Feed
same as 11th day + chapatti- 2
Milk- 250 ml
Albumin care- 15 gm
Paneer sandwich was replaced with
veg. omelet ( eggs- 2, veg.- 30 gm)
same as day 10 + 1 chapatti
Calories- 1950 kcal
Protein-102gm
High protein feed provides
Energy- 240 kcal and protein- 11 gm
Veg. omelet provides
Energy- 251 kcal and Protein- 13.5
From 13th day patient was given Burn B diet
13th day
9:00
Milk- 250 ml
Albumin care- 15 gm
Bread- 2 slice
11:00
Burn A1 feed- 250 ml
1:00 /
Chapatti- 2+2
7:00
Rice- 50 + 50 gm
Dal- 35 + 35 gm
Vegetable- 100 + 100 gm
Curd-125 gm
Paneer- 50 + 50 gm
4:00
Burn A1 feed- 250 ml
Calories- 2250 kcal
Protein- 114 gm
BIOCHEMICAL PARAMETERS
PARAMETERS
NORMAL
AT ADMISSION
RANGE
AFTER
AT
SURGERY
DISCHARGE
Protein
6.4-8.3
5.46
6.1
7.3
Albumin
3.5-5.2
2.6
2.5
3.6
Calcium
8.6-10.2
7.6
8.1
8.7
H.B
12-15
11.8
11.2
11.3
Weight
65-70
46
40
44.2
Discharge menu
7:00
9:00
11:30
1:00
lemon water/ Tea/ Fruit Juice
Milk- 250 ml
Bread- 2 slice/ Dalia-25gm/ cornflakes-25gm
Egg white- 2
Or Stuffed roti-2 ( aloo, gobi,muli,methi)
Curd- 100 gm
sweet lassi/ milk shake/ coconut water- 1 glass
any fruit( grapes/banana/papaya/orange)
veg pulav with soya nuggets- 50 gm
Curd- 100 gm
Or Plain rice- 50 gm
Paneer curry/ chicken curry
4:00
7:30
Milk/Tea/ Fruit juice
Rusk-2/ poha-30gm/veg dalia 30 gm/ Besan
chilla- 30 gm/ omlete/ veg sandwich
veg. soup- 1 bowl
Chapatti- 3
Seasonal veg.- 150 gm
Curd/ dal- 100gm/ 35 gm
Calories-2200 kcal
Proteins- 75gm
Do’s and Don’t,s
• Quit alcohol and nicotine. This is because they stimulate the pancreas to a
great extent. Stop smoking and chewing tobacco also.
• Maintain a low fat diet consisting of 15% fat.
• Try to eat food that is high in carbohydrates and proteins as they reduce
the work pressure of your pancreas.
• Stop eating rich and spicy food to reduce the chance of another attack
Don’t try to eat large meals at a time. Rather go for small frequent meals.
• Avoid concentrated sweets and desserts that are very sweet if your blood
glucose level is high or above normal.
• Caffeine and gas-forming food items stimulate pancreas. So avoid these
type of food.
• Margarine, butter etc., should also be avoided
• Quit red meat. Rather go for chicken.
• You can include soybeans in your diet as they are very good anti-oxidants.
• You can eat light chicken soups or vegetable soups frequently.
• Green leafy vegetables are also very good for pancretitis.
• Keep some fruit juice with you and whenever you are tempted to have
alcohol, sip it.
• Drink plenty of fluids in the form of soups and juices.
Conclusion
• Biochemical parameters like protein, albumin
and calcium and anthropometric parameters
like weight of the patient showed
improvement
• Hence dietary modification helped in
improving the nutritional status of the patient
References
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Krause Food nutrition and diet therapy
Clinical nutrition and dietetics by Antia
Dietetics by B. Srilakshmi
www. Wikipedia .com
www.zadehsurgical.com
www.surgery.usg.com
Thank
you
.
Pancreatitis