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72 year old female presented with abdominal pain, anorexia, indigestion and jaundice in October to her
PCP. Patient then underwent CT, lab work, and an ERCP (endoscopic retrograde
cholangiopancreatography). Patient had biliary stents placed. Results of the tests indicated patient to
have unresectable pancreatic cancer. She was treated with FOLFIRINOX (beginning in January)
rescanned and found to be resectable. Please note, during treatment patient complained of loose
bowel movements that were frequent and had an oiliness to them.
April underwent a total pancreatectomy, splenectomy, SMV resection. Pt was found to have positive
margins and then on began single agent gemcitabine (1 cycle) with initiation on 6-29 of weekly
gemcitabine plus radiation.
Ht: 166.7cm (56)
Wt history:
1/7 = 92.6kg
3/25 = 95.1kg
5/27= 87.8kg
7/8= 82.3kg
11% wt loss x 6 mo
8/5= 79kg
14.7% wt loss x 7 mo
10% wt loss x 3 mo
4 % wt loss x 1 mo
DBW: 59.1
ABW: 64.1kg
Labs from 8/5: glu 135, Na 130, K+ 4.0, cl 90, BUN 11, cr 0.51, alb 3.2, ca 9.0, alk phos 101, AST 26, ALT
20, T bili 1.5
Questions
1) What is FOLFIRINOX? And what side effects would you expect from this?
FOLFIRINOX is a combination chemotherapy regimen for patients with exocrine pancreatic
cancer recommended, especially for pt with mets. A cycle length is 14 days and it is composed of
four different drugsoxaliplatin, leucovorin, irinotecan, and two doses of fluorouracil. Because
the chemotherapy will cause a drop in WBC, pt are at increased risk of infection and are often
fatigued due to low RBC as well. Other side effects include mucositis, hair loss, diarrhea,
abdominal cramping, loss of appetite, blurred vision, nausea, vomiting, fatigue, and skin rashes.
Chemotherapy-related hepatotixicty and nephrotoxicity may also occur.
2) After her surgery please tell me what diet you would place her on for discharge and what you
would want to monitor?
For discharge, I would recommend the patient to maintain a low-fat diet with small frequent
meals. It is important to monitor levels of fat-soluble vitamins and B12. I would also monitor
tolerance to fat in regards to dose of pancreatic enzymes.
3) Patient is placed on pancreatic enzymes- why? What questions would you ask and what
symptoms would you use to determine if she is getting adequate enzyme replacement?
5. List the possible nutritional side effects for the patients listed medications, including
Clofarabine, the most recent chemo he received.
Clofarabine: N/V/ abdominal pain/ loss of appetite/ gingival bleeding/ mucositis/ oral
candidiasis
Imodium: constipation
Octreotide: abdominal pain/ loose stools/ N/ V/ gas/ cholelithiasis (depending on length
of therapy)
Cellcept: abdominal pain/ N/ V/D/C/ loss of appetite/ dyspepsia
Methylprednisone: increased appetite/ weight gain/ distention/ N/ V/dyspepsia/
increased blood sugar/ stomach pain
Actigall: N/V/D/C/ loss of appetite/gas/ bitter taste change
Nexium: D/ C/ gas/ bloody or black stools/ N/ V
Acyclovir: N/V/D
Prochlorperazine: increased appetite/ C/ N/ V/ weight gain/ xerostomia/ ileus
Esomeprazole: gas/ D/ abdominal pain/ N/ xerostomia/ C
References: Up-to-date, SCC 3 unit guideline, HSCT lecture
%DBW: 75
Questions
1. Describe the acute effects and long term effects of radiation therapy
Acute effects of radiation therapy include burning of the skin (resulting in breakdown, dryness,
flakiness, swelling, blistering, etc.) and underlying tissues. So, for esophageal CA, radiation will
have an impact on the ability it eat. Radiation treatment for other cancers such as lung, and
head and neck cancers will also impact eating. Any radiation done to the
esophagus/mediastinum area, or mouth- upper and/or lower palates- can make it difficult and
painful to chew and/or swallow. Radiation to or near the stomach or intestines can also cause
eating problems. Mucositis may occur as well as nausea, vomiting, dysphagia, taste change/loss
or loss of appetite. These effects translate into weight loss. Radiation may also cause fatigue and
hair loss (depending on where the radiation is targeting).
Long term effects of radiation include risk of developing another cancer from treatment
exposure and also damage to organs receiving treatment. Lymphedema may also develop.
2. What does widely metastatic cancer mean?
According to the National Cancer Institute, metastatic cancer indicates that the disease has
spread from the primary site of where the cancer started to other organs and parts of the body
not directly connected. For example, small cell lung cancer frequently metastasizes to the brain
so the oncologist will offer prophylactic radiation therapy to the brain.
3. What are the risk factors for esophageal CA?
There are two main types of esophageal CAsquamous cell carcinoma (SCC) which usually
occurs in the upper 2/3 of the esophagus and adenocarcinoma which usually occurs in the lower
1/3 of the esophagus. Risk factors for the two CA differ; smoking, alcohol use, HPV, and H. Pylori
are risk factors for developing SCC while GERD, obesity, and Barretts esophagus are risk factors
for developing adenocarcinoma.
Calculate the TF rate and water flushes that will meet the patients estimated calorie,
protein and fluid requirements
55 mL/hr x 24 hr (1980 kcal, 90 g pro, 1027 mL free water, 1320 mL total volume)
Set up a home TF Regimen for this patient (List the TF supplies that the patient will need
to administer his TF)
The patient may either use the bag method or the syringe method for feeding. If the
patient chooses the bag method, he will need his feeding bag and tubing, IV pole or
hook, formula, 60 mL syringe, an empty cup, and a cup with enough room temperate
water for 2 flushes. If the patient chooses the syringe method, he will need 60 mL
syringe, formula, and a cup with enough room temperature water for 2 flushes.
Home TF regimenIsosource 1.5: 310 mL 4x day (1860 kcal, 84 g pro, 965 mL free
water, 1240 mL total volume) with 60 mL water flush pre/post and additional 250 mL
water flush once throughout the day.
Cans per day: 5
TF tolerance will be monitored via labs in part c (above) during in-patient care. Once the
patient is discharged and is administering tube feed at home, tolerance may be
monitored by checking stomach residuals prior to feeding. If gastric residuals are high
(over ~200-500 mL) this indicates that gastric emptying is very slow and more formula
should not be given at this time. Tolerance can also be monitored by noting any GI
symptoms such as diarrhea, dehydration, constipation, and/or nausea
7. The patient does not have health insurance. Please list at least two resources available to help
this patient receive TF at home.
One resource available to help this patient receive TF at home is the Oley Foundation. Patients
may also receive TF at home without insurance through the Nestle HealthCare Patient
Assistance Program.
8. List two nutrition goals for this patient. How would you assess/monitor these goals on followup?
Tube feed tolerance: monitor digestive function; evaluate whether pt has been
experiencing any GI issues
Maintain stable weight: compare initial visit weight to follow-up weight; ensure that
nutrition support is meeting 75% of nutrient needs.
References: American Cancer society, Oley Foundation
Weight hx:
04/09/2015 58.0 kg
08/06/2015 53.2 kg
10/15/2015 49.4 kg
DBW: 56.8 kg
6. What are your goals for this patient? What are some things you would monitor for to
see if patient is meeting her goals?
Goals: PO intake greater than or equal to 75% of meals, consume 3 oral supplements
per day, daily improvement in po intake/tolerance, maintain stable weight with gradual
weight gain.
Monitoring: PO intake and tolerance, weight trend, mealtime behavior, overall
appearance.
Mrs. S. was discharged from the hospital and continued to receive chemotherapy. She
completed 6 cycles of Carbo/Taxol. She returned to the outpatient clinic during routine follow
up and was found to have increasing abdominal girth, recent weight gain, and shortness of
breath. Mrs. S. was admitted to the hospital for further workup.
Onco hx:
July 2015: stage 3 moderately differentiated adenocarcinoma of the ovary
PMH: HTN, LE DVT
PSH: appendectomy, TAH BSO, s/p 6 cycles of adjuvant Carbo/Taxol
Medications: oxycodone, reglan, magnesium gluconate, colace, megestrol, senna,
pantoprazole, K-tab, metoprolol, mirtazapine
Height:
165.1 cm
Weight hx:
04/09/2015
08/06/2015
10/15/2015
01/15/2016
58.0 kg
53.2 kg
49.4 kg
53.6 kg
This patients most recent PET scan shows metastasis to the liver and malignant ascites. She
had 4 L of fluid removed during paracentesis and now weighs 48.2 kg. You went to visit her to
assess nutrition status. She feels weak and now reports early satiety and poor appetite.
7. Calculate her energy needs. Identify which weight you would use to make your
estimations and why.
Kcal: 1350 1450 (28-30 kcal/kg)
Pro: 60 70 (1.2 1.45 g/kg)
These needs are based off her weight of 48.2kg after fluid has been removed. I based
her needs off of this weight because it reflects true weight loss and not fluid status
changes.
8. What are some suggestions you could make to help her meet her estimated
energy/protein needs?
In order to meet energy/protein needs, I would suggest that she eat small frequent
meals/snacks throughout the day consisting of high kcal-high pro foods. Examples of
such meals/snacks include Greek yogurt with fruit, peanut butter and jelly sandwiches,
smoothies/milkshakes with whole milk, scrambled eggs with cheese, and dishes with
sourcream/extra gravy/butter/ salad dressing, etc. Also, I would recommend she try
nutritional supplements such as Resource Breeze, Boost Plus and/or Pro-stat. If she is
unable to meet her needs orally in the hospital, I would suggest an overnight TF regimen
to help prevent further weight loss and wasting.
9. With the new findings on PET scan, patient now has Stg. IV disease. If the patient is
transitioned to hospice care, would your nutrition goals change?
If the patient is transitioned to hospice care, my nutrition goals would change. Rather
than preventing further nutritional decline, I would instead focus on comfort through
nutrition. I would ask the patient if she is interested in any nutritional supplements for
her comfort.
No allergies.
Medications: Omeprazole (40 mg daily), Metformin (500 mg t.i.d.), Hydrochlorothiazide,
Lisinopril, Pravastatin, ProAir inhaler, Nystatin, and Mirtazapine
Mrs. L presented at diagnosis with anorexia and weight loss. Today she continues to lose
weight and c/o odynophagia when swallowing- even when swallowing water. She rates her
pain at an 8/10. Her intake is poor, reporting one egg, C of mashed potatoes, a slice of
watermelon and 1 each 16.9 oz. water bottle all day yesterday.
She does not check her BS regularly, however, her homecare nurse performed a finger stick 2
days ago in the a.m. and found her level to be 59 mg/dL.
Physical findings deferred- white, patchy tongue on exam per RN/MD.
Case Study Questions:
1. Calculate Mrs. Ls estimated nutritional needs for calories, protein and fluid.
Kcal: 2100-2400 (31-35 kcal/kg)
Pro: 90-100 (1.3-1.5 g/kg) Fluid: ~2000mL or per MD
2. What is/are Mrs. Ls nutritional diagnosis?
Increased nutrient (protein-kcal) needs r/t GI issues (odynophagia, possible thrush) in
setting of hypermetabolic disease state AEB 10.6% wt loss x 4 mo, loss of appetite, poor
PO intake, elevated protein and kcal needs required to prevent further catabolism
*If weight continues to trend downward and pt unable to tolerate PO intake, on low
threshold of mild PCM
odynophagia. His skin is beginning to break down as well. Pain is controlled with oxycodone 10mg q 4
hrs.
4. Given his current symptoms, which of his previously assessed nutrient needs (question2) might
increase?
At this point, the pt has elevated protein needs. Because he is experiencing mucositis, thrush,
and unable to swallow oral supplements, he is probably losing weight resulting in the loss of
lean body mass. Additionally, extra protein is needed for his skin breakdown.
5. Provide a home PEG tube feeding and free water schedule for this patient. Include formula,
amount, and administration method.
At home, the patient should use Isosource 1.5, 4 times daily via the syringe method if he is
comfortable with that.
405 mL 4x day (2430 kcal, 110 g pro, 1260 mL free water, 1620 mL total fluid) with 60 mL water
flush pre/post and two additional 250 mL water flushes in between feeds.
Cans per day: 6.5 if the patient finds it easier, do 1.5 cans for 3 feeds and then on the fourth
feed, do 2 full cans to equal 6 cans.