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Gemma Keating Sarah Dann HPB Clinical Nurse Specialist Clinical Lead HPB Dietitian Royal Free London NHS Foundation Trust
HPB CNS Role
Key contact for patients
Liaising with all MDT members
Facilitate the care pathway for patients requiring treatment of HPB cancers (surgical or oncological)
Symptom management, clinical expertise, education
CNS-led follow up clinics
Holistic Needs Assessment
Types of Pancreatic Surgery
Whipple
PPPD
Total Pancreatectomy
Distal Pancreatectomy & Splenectomy
Bypass
Pain Management Paracetamol, Ibuprofen
Tramadol/Co-codamol
Oramorph
Nerve Blocks
Referral to Pain Team if necessary
1. Patient dependant
2. Disease dependant
Follow Up
Telephone Clinic with HPB CNS
MDT meeting
Surgical Clinic
Oncology Clinic
Royal Free or locally
Clinical Trials
Surveillance CT Chest/Abdomen/Pelvis with contrast
3 monthly for 2 years.
6 monthly for the following 3 years.
Annually until 10 years post resection.
Tumour Markers and routine blood tests.
After Surgery Appetite/weight loss
Pain
Nausea
Steatorrhea
Delayed gastric emptying
Constipation
Diet
Diabetes
PERT
Bile/Pancreatic Leak
Wound Care
Thromboprophylaxis
Mobility
Post Chemo Symptoms
Nausea
Vomiting
Diarrhoea
Fatigue
Dry skin/nails
Hair loss
Sore Mouth/Ulcers
Pain
Emotional Support for Patients and Carers
CNS
Counsellors
MacMillan – finance, benefits, children
Charities, e.g. PCUK
GP/District Nurses
Patient Support Groups
Carer/Bereavement Support Groups
Hospice
Recurrence? CT CAP, tumour markers, referral to MDT
MDT
Outpatient clinic – surgery or oncology?
Counselling
Palliative Care – hospital and community
HPB Dietetic Service
Pre-op Referred by a CNS or consultant – we can offer telephone
consultations for these patients
Post op patients are referred if deemed high risk of malnutrition
based on our screening tool
However we aim to review all Whipples/total pancreatectomy patients
Post discharge home We do not have an outpatient clinic however can offer
telephone follow ups/see people in consultant clinics – otherwise they are referred on to local community teams
Dietary problems after surgery
Early problems
Feeling full
Weight loss
Poor appetite
Diarrhoea/steatorrhea
Vomiting/ delayed gastric emptying
Early/late dumping syndrome.
Late problems
Diabetes
Malabsorption
Vitamin/mineral deficiency: B12, Iron, fat soluble vitamins (A,E,D,K).
Dietary management advice Try eating ‘little and often’ - aim for 5-6 small snack-size meals per day
Do not skip meals. Try to eat something even if you are not hungry.
Use food fortification ideas i.e. Adding additional butter, cream, cheese to meals, switching to full fat milk
Eat a protein food with at least 2 main meals (e.g. lean meat, chicken, fish, eggs, lentils)
Do not fill up on low calorie drinks e.g. tea, coffee, Bovril, thin soups, diet drinks which have little nutrition
Keep fruit and vegetables to a minimum initially as they may fill you up
If you suffering from nausea or vomiting
keep away from cooking smells, which may make nausea worse.
Reduce greasy foods as these pass slowly through the gut and can cause ‘reflux’ or heartburn.
Dry foods such as toast or plain biscuits can be easier to take
Dumping Syndrome Early dumping syndrome
Normally, the stomach holds the food before it goes into the small bowel, but if the bottom portion of the stomach has been removed, ‘dumping’ can happen. Food rushes quickly through the gut and ‘dumps’ into the small bowel. It can happen 15-30 minutes after eating a meal. Symptoms include diarrhoea, fullness, stomach cramping and vomiting. You may also experience weakness after eating, redness of the face, dizziness and sweating.
Late dumping syndrome
This is related to blood sugar levels and can happen 2-3 hours after a meal. It happens because of a drop in blood sugar (hypoglycaemia). Symptoms include weakness, sweating, nausea (sickness), hunger and anxiety.
How do I deal with the symptoms of dumping syndrome?
Eat 6 + small meal per day, instead of 2-3 big meals Eat slowly, chew well and sit up straight when eating Avoid very sweet or sugary food and drink e.g. coke etc., juices, sweets, jellies, cakes,
doughnuts, sweet biscuits, honey, jam - which can all rush through the gut Do not take large amounts of fluid during your meals (take sips only). Eat protein with each meal. Protein will move more slowly through the gut, e.g. eggs,
meat, chicken, fish, milk, yoghurt, cheese
Pancreatic Exocrine Insufficiency
Loose watery stool
Undigested food in the stool
Post-prandial abdominal pain
Nausea / colicky abdominal pain
Gastro-oesophageal reflux symptoms
Bloating / flatulence
Weight loss despite good oral intake
Steatorrhoea (pale, floating, oily stool)
Vitamin deficiencies (especially A,D,E,K,)
Hypoglycaemia in patients with diabetes (Friess & Michalski, 2009)
Steatorrhoea Normal fat losses <7g/day
Severe insufficiency >15g/day.
Visible oil suggests losses 30-40g/day
Up to 55g faecal fat losses may occur with no abdominal symptoms
Low fat diets!
Constipation
How much do we need?
No two patients are the same!
Mean Intra-
digestive
Post Prandial
Peak
Lipase up to 1000u/min 3000 –
6000u/min
Amylase 50 – 250u/min 500 – 1000u/min
Proteases
(Trypsin)
50 – 100u/min 200 – 1000u/min
Enzymes release continues for approximately 2 hours post prandially (360,000 - 720,000u) Keller & Layer, 2005
Why are we all different? Variations in:
Pancreatic function (atrophy / obstruction / resection / disease)
PPI use
Chewing patterns / temperature of meals
Dietary intake / meal patterns / duration of meals
Salivary / gastric / intestinal enzyme secretion
Intestinal transit (opiates / SMA/SMV invasion)
NOT JUST FAT.......
Recommended dose
STARTING DOSE....
44 - 50,000 units with meals
22 - 25,000 units with snacks
25 - 50,000 units with supplements
Will probably need higher dose with larger meals
Increase until symptom control
How should enzymes be taken?
At the beginning of meal
With a cold drink
Split dose if slow eater
If more than one capsule required – take the second half way through the meal
Patient choice on size of capsule vs. number of capsules.
Consider storage – below 25 / 15oC (cars, windowsills, trouser pockets!!)
What if they don’t work? Adequate dose?
Correct timings?
PPI?
Compliance?
Reduce fibre content of diet?
Correct preparation?
Are we missing something?
Lankisch P.G, 1999; 60: 97-104
Bruno M.J, 2001; 1(suppl 1): 55-61
Other conditions to exclude: Bile acid malabsorption (caused by acidic environment
causing bile salt precipitation) most common after cholecystectomy
Bacterial overgrowth
Infective diarrhoea
Other GI disease
Coeliac Disease!
Lactase deficiency
Lankisch P.G, 1999; 60: 97-104
Bruno M.J, 2001; 1(suppl 1): 55-61
Vitamin and mineral deficiencies
Fat soluble vitamins: A, E, D, K. Higher risk of deficiencies if not absorbing fat efficiently.
Bone disease can occur after this surgery due to a decreased intake, and sometimes, poor absorption, of calcium and vitamin D-rich foods (Adcal D).
B12 - stomach makes a special protein (intrinsic factor) which helps the body absorb Vitamin B12.
Iron – deficiency can be common after surgery, this may be because of a reduced intake or poor absorption of iron in the gut
Diabetes
Diabetes secondary to either an inflammation, tumour, trauma or surgery on your pancreas is known as Type 3c diabetes
Can be more brittle diabetes and difficult to control
More research is required as it is not a well understood condition
Can be managed through diet and exercise, oral hypoglycaemics or insulin.
References Bruno MJ (2001) Maldigestion and exocrine pancreatic
insufficiency after pancreatic resection for malignant disease. Pancreatology; Vol 1, issue 1 supp, 55-61
Friess H, Michalski CW (2009) Diagnosing exocrine pancreatic insufficiency after surgery: when and which patients to treat. The official Journal of international Hepato-Pancreato-Biliary Association; 11(Suppl 3): 7-10
Keller J and Layer P (2005) Human pancreatic exocrine response to nutrients in health and disease. Gut;54 (suppl VI):vi1-vi28
Lankisch PG (1999) What to do when a patient with pancreatic exocrine insufficiency does not respond to pancreatic enzyme substitution: a practical guide. 60: 97-104.
Any questions?