Intraductal Papillary Mucinous Neoplasm of the Pancreas:
A Medical Surgical Case Study.
Lauren Walker
Dietetic Intern
Andrews University
March 2015
Introduction:
MK was an 81 year old female admitted with intraductal papillary mucinous neoplasm of
the pancreas, a condition in which tumors grow within the pancreatic ducts. She measured 157
centimeters in stature and weighed 59 kilograms at admission. She was chosen for this case study
due to the Whipple procedure she underwent, her brief period on TPN, and her willingness to
participate. This outlined case study started being followed by Medical Nutrition Therapy on
February 27th and ended March 9th. The focus of this study will be on her diagnosis of intraductal
papillary mucinous neoplasm and the Whipple procedure that was performed on February 24th.
Her past medical history includes coronary artery disease, peripheral vascular disease,
hyperlipidemia, and hypertension. She had ongoing tobacco abuse as well, smoking one pack per
day. Almost one third of pancreatic cancer is attributed to tobacco abuse. 1
Table 1.1 Weight Assessment
Admit Weight:
Weight at
Assessment:
Usual Body Weight:
Ideal Body Weight:
Body Mass Index:
59 kg
61.7 kg
57 kg
50 kg
24
MK fell in an appropriate body weight for her height; however it is pertinent to note that
she had a ten pound weight gain within two weeks. This was a 7% increase in body weight. At
the time of her admission, she was 104% of her usual body weight, and 118% of ideal body
weight. (Table 1.1)
Social History:
MK is a retired widow, who lives in a condominium by herself. She is a practicing
Catholic, who attends church every Sunday. MK is very active, and enjoys golfing in a woman’s
league over the summer. She doesn’t need any assistance for activities of daily living, and lives a
busy lifestyle. Although she lives alone, MK has two adult daughters and one adult son that
check on her regularly. She is a grandmother of 4 children and enjoys watching them when their
parents are working. MK has both Medicare and Blue Cross Blue Shield as insurance.
Normal Anatomy and Physiology of Applicable Body Functions:
The pancreas has two major nutritional functions. It produces enzymes that are necessary
for digestion and it produces hormones to regulate the use of body fuels, such as glucose. Most
patients with pancreatic cancer tend to have hyperglycemia due to impaired functioning of the
pancreas leading to decreased insulin secretion.2 This can been seen in Table 1.1 with MK’s labs
values. Regarding the pancreatic enzymes that are utilized in digestion, most pancreatic cancer
patients have to take exogenous forms of these enzymes with meals. 2
Present Medical Status and Treatment:
MK was found to have a pancreatic mass in 2010, which was watched closely over the
last year. She had been admitted in November to a nearby hospital for pancreatitis flare-ups,
where she was advised that she would need the Whipple procedure to remove the affected areas
of her pancreas. The indication for surgery was largely due to the increase in size of the mass and
the corresponding ductal dilation of the pancreas. Pancreatic cancer can be difficult to detect due
to lack of early symptoms and when symptoms do show, they are often mistaken for other
conditions. 1 Weight loss and anorexia tend to be common symptoms that are present at
diagnosis.2 90% of patients present with weight loss, 75% with malnutrition and 60% with
anorexia at time of diagnosis. 2
Intraductal papillary mucinous neoplasm of the pancreas occurs when mucin-producing
neoplasms grow on the main pancreatic ducts or the side ducts of the pancreas. These neoplasms
are usually found on the head of the pancreas rather than on the body. They mainly occur in men,
and appear later in life with a mean age of 65 years.3 These tumors have malignant potential;
therefore surgery is the preferred treatment option.4
Around 20% of patients with pancreatic cancer have a form that can be resected. 1 The
most familiar surgical procedure that is utilized for these particular patients is the
pancreaticoduodenectomy, which is commonly known as the Whipple procedure. This procedure
is indicated for tumors that are on the head of the pancreas. It is estimated that 50-70% of
pancreatic cancer patients have cancer in the head of the pancreas. 1 The surgeon resects the head
of the pancreas, the distal bile duct, a majority of the duodenum, and proximal jejunum. This is a
pylorus preserving technique, which is preferred because it maintains the complete gastric
reservoir, preserves the pyloric sphincter, and shortens operation time. Additionally, the pylorus
preserving Whipple procedure reduces the operative blood loss, avoids post-op dumping
syndrome, and potentially improves the quality of life and nutritional status in post Whipple
patients studied.5 Sometimes, the remainder of the duodenum must be resected, especially if the
duodenum is ischemic. In the final step, anastomoses is created between the pancreas, bile duct,
and stomach. In some cases, the duodenum is connected to the remaining jejunum. 6
In MK’s Whipple procedure, the gallbladder was removed. The jejunum was then
approximated to the pancreas. Stay sutures were placed at the superior and inferior aspects of the
pancreas, attaching it to the duodenum. The staple line on the bile duct was cauterized, and
sutures were utilized to create a duct-to-mucosa anastomosis. The pancreaticojejunostomy was
finalized. MK’s duodenum was then evaluated, appearing dusky, so a gastrojejunostomy was
undertaken in a hand-sewn fashion. The remainder of the pylorus and duodenum were sent to
pathology, thus the surgery was not pylorus preserving. A drain was placed near several of the
anastomoses and brought out through a separate incision.
After surgery, MK complained of constipation, and continual abdominal pain that
radiated to her back. She had mild abdominal distention, pain in the epigastric region, and had
continual emesis. An X-ray of the abdomen revealed an ileus. A CT of the chest, abdomen, and
pelvis was then ordered. The results of the CT indicated right lower lobe pneumonia and right
pleural effusion. There was also a peripancreatic abscess that extended toward the porta hepatis.
MK was also found to have a gastric ulcer present. According to the British Journal of Surgery,
there is no evidence to support routine enteral or parenteral feeding after a Whipple procedure.
An oral diet may be considered an appropriate method.7 In MK’s case, her poor appetite,
peripancreatic abscess, gastric ulcer, and ileus indicated otherwise and TPN was initiated.
Table 1.2 Lab Values:
Date
Sodium
(mEq/L)
2/20
2/21
2/22
2/23
2/24
2/25
2/27
2/28
3/1
3/3
3/4
3/5
Normal
Levels
137
139
137
136
136
138
135
133
135
137
132
138
136-145
Potassium Chloride Bicarbonate Blood
(mEq/L)
(mEq/L) (mEq/L)
Urea
Nitrogen
(mg/dL)
3.6
100
25
19
3.7
102
25
18
3.4
97
28
11
3.1
97
26
9
3.9
99
25
26
3.5
95
27
29
3.0
94
29
18
3.7
96
27
30
3.7
97
24
24
3.3
98
29
20
4.1
97
26
22
4.3
102
25
21
3.5-5.0
98-106
22-28
10-20
Creatinine Glucose
(mg/dL)
(mg/dL)
0.75
0.80
0.70
0.57
0.67
0.69
0.73
0.73
0.70
0.65
0.56
0.57
0.5-1.1
146
121
104
84
104
114
131
131
112
117
119
106
70-105
Table 1.2 displays the lab values that were drawn for MK during her admission along with
normal reference ranges. While her electrolytes did vary, the majority of her labs were within
normal levels. Her glucose was elevated repeatedly throughout her stay, which is to be expected
in a hospitalized pancreatic impaired patient.
Table 1.3 Medications:
Medication
Purpose
Acetaminophen
Moderate to Severe
pain relief
Stimulant Laxative
Bisacodyl
Cefepime
Diphenhydramine
Fentanyl
Flumazenil
Heparin
Hydrochlorothiazide
Ibuprofen
Levothyroxine
Lidocaine
Magnesium Hydroxide
Naloxone
Nifedipine
Ondansetron
Oxycodone
Pantoprazole
Potassium Chloride
Rosuvastatin
Sucralfate
Sodium Chloride
Vancomycin
GI Side Effects
Nutrient
Interactions
Nausea and
Vomiting
Abdominal
cramping, Diarrhea,
Abdominal
distention, Vomiting
Antibacterial Agent
Uncommon
Antihistamine
Nausea, Dry Mouth
Pain Management
Nausea, Vomiting,
Constipation
Reversal of Sedation
Uncommon
Prevention of Blood
Melena,
Clotting, Treatment of Hyperkalemia,
Venous
Hyponatremia,
Thrombosis/Pulmonary Hypertriglyceridemia
Embolism
Diuretic
Hyponatremia,
Hypomagnesia,
Hypercalcemia,
Hyperglycemia
Anti-inflammatory
Nausea, Vomiting,
Abdominal Pain.
Synthetic form of
Uncommon
Thyroxine
Antiarrhythmic
Nausea and
Vomiting with
toxicity
Gastric Ulcer treatment Diarrhea, Gastric
discomfort
Narcotic
Uncommon
Treats hypertension
Rapid weight gain
Calcium interferes
with absorption
Surgical nausea and
Constipation
vomiting prevention
Pain reliever
Constipation
Treats erosive
Uncommon
May decrease
esophagitis
absorption of
Vitamin B12
Treats hypokalemia
Uncommon
Reduces LDL, Raises
Uncommon
HDL
Treats ulcerations
Uncommon
Hydration with NaCl
Uncommon
Antibiotic
Abdominal pain,
Zolpidem
Sedative, treats
insomnia
nausea, vomiting
Nausea, vomiting,
diarrhea
Medical Nutrition Therapy:
MK stated that she ate small, frequent meals at home. Due to living alone, she chose
foods that were convenient and easy to make. She tried to avoid high fat and greasy foods,
because they aggravated her pancreatitis. She prepared and ate her meals at home, but did go out
to eat with her friends from church or family occasionally. Prior to surgery, MK had a strong
appetite, and ate when she was hungry. During her time as a patient, MK was eating roughly
25% of her meals.
Her 24 hour dietary recall was performed to the best of her ability. (See Appendix for
entire recall) This recall, which is intended to represent an average intake prior to admission,
provided 1,312 kilocalories and 46 grams of protein. This met around 90% of her estimated daily
caloric needs and around 80% of her estimated daily protein needs. These calculated needs are
summarized in Table 1.4. Calculation of the 24 hour recall was provided by Super Tracker, The
United States Department of Agriculture’s nutrient database. It was beneficial to assess MK’s
nutritional intake prior to surgery. Impaired nutritional status prior to surgery adversely affects
long term outcomes once surgery is performed.8
Table 1.4 MK’s 24 hour Recall
Meal
Breakfast
Mid-Morning Snack
Lunch
Dinner
Bed-time snack
Components
Granola bar, 8 fl oz skim milk
½ cup of grapes, 8 fl oz coffee with 1 liquid creamer, 2 sugar
packets
2 slices whole wheat bread, 2 tablespoons peanut butter, 1
clementine, 6 oz strawberry yogurt
¼ cup noodles, ¼ cup spaghetti sauce, 12 fl oz Pepsi, 1 cup iceberg
lettuce, ¼ cup chopped cucumbers, ¼ cup tomatoes, 2 tablespoons
ranch dressing
2 medium sized chocolate chip cookies
Table 1.5 Estimated Nutrition Needs.
Needs
Caloric
Protein
Fluid
Amount
1,475-1,770 kcals
59-71 g protein
1,475 mL
Based on
25-30 kcal/kg
1-1.2g/kg
25 mL/kg
Table 1.6 Nutrition Diagnosis on 2/27
Nutrition Diagnosis:
Etiology:
Signs and Symptoms:
Suboptimal Oral intake
Dislikes clear liquid diet, early satiety, poor appetite, abdominal pain
Pt on clear liquid/NPO x7 days, Pt reports consuming around 25% of
clear liquid diet trays.
MK started with a general diet. She was nothing by mouth (NPO) prior to the Whipple
procedure, and was permitted to have clear liquid intake after. Her initial nutrition assessment
occurred at this time. A consult was triggered for Medical Nutrition Therapy due to seven days
of clear liquid/NPO orders. MK had Ensure Clear (a nutritional supplement) ordered. A full
liquid diet was attempted, but MK did not tolerate the full liquid advancement and was restarted
on a clear liquid diet. A calorie count was started to assess MK’s nutritional intake. Due to
frequent emesis, discovery of a peripancreatic abcess, gastric ulcer, and ileus, total parenteral
nutrition was initiated. The calorie count was stopped, and then restarted as she was weaning off
TPN. A three day summary of the calorie count concluded that MK was meeting around 40% of
her energy needs and 40% of her protein needs. She attributed her poor oral intake to the pain
she was experiencing in her abdomen, and early satiety due to constipation. Several of the
medications summarized in Table 1.3 could be responsible for constipation. MK did admit that
she suffers from chronic constipation, and the ileus that was revealed on the abdominal X-ray
also played a role.
Several interventions were attempted to increase MK’s oral intake during hospitalization.
When she was on a clear liquid diet, two supplements were trialed. Ensure clear provided MK
with 200 calories and 7 grams of protein. Unjury, a calorie and protein enhanced chicken broth
supplement, provided her with 100 calories and 21 grams of protein. Unfortunately, MK was not
fond of either supplement. When the diet was advanced to full liquids, Ensure was attempted,
which provides 250 calories and 9 grams of protein. When her diet was advanced to soft solids,
Ensure was encouraged again with ordering snacks when appetite returned. MK was provided
with the kitchen’s number to order snacks. She was encouraged to eat when hungry, and to
choose high protein foods. Her main concern appeared to be with constipation and not with her
appetite. Fiber and physical activity were discussed.
According to the Journal of the Academy of Nutrition and Dietetics, the most common
nutrients of concern following a Whipple diet are iron, calcium, zinc, copper, selenium, and the
fat soluble vitamins, A,D,E, and K. 8 Additionally, due to the nature of the Whipple procedure,
pancreatico-biliary secretions must now travel down an intestinal limb to catch up with the
chyme somewhere in the mid-jejunum. This results in less time for the digestive enzymes to
break down the macronutrients and renders the patient with a shorter length of absorption in the
small intestine.10
MK was educated on the post Whipple diet. The general nutrition guidelines following a
Whipple procedure are summarized in Table 1.7. Emphasis during the nutrition education was on
eating small meals and limiting high fat or greasy foods. Delayed gastric emptying was discussed
and dumping syndrome was explained, and the need for supplements outside of hospitalization
was considered. MK verbalized understanding which foods were to be limited, avoided, and
allowed on the post Whipple diet.
Table 1.7
Nutritional Guidelines post Whipple procedure provided by the Academy of Nutrition and
Dietetics
Eat small frequent feedings (5 to 6 meals per day).
Limit fluids at 4 to 5 fl oz per meal.
Eat slowly and chew foods thoroughly.
Avoid simple sugars in foods and drinks.
Include protein at each meal.
Limit fat to less than 30%.
Avoid sugar alcohols.
Prognosis:
The prognosis for patients that undergo resection of the pancreas with intraductal
papillary mucinous neoplasm is fair. The mean survival for patients is 10 years. The recurrence
rate of intraductal papillary mucinous neoplasm in the remaining pancreas ranges from 0-20%. 1
Based on clinical data, MK has a fair prognosis as long as the remainder of her pancreas is
routinely assessed to ensure that recurrence does not occur. She has a strong support system
within her family. Compliance to the Whipple diet she was educated on seems probable,
considering she is aware of discomfort that is associated with eating greasy foods that are high in
fat. Note current research is finding that patients who undergo the Whipple procedure rapidly
lose weight after surgery and do not regain it. Nutrition support is overlooked with the
assumption that they may improve over time. Nutrition support in the hospital may be vital in
preventing muscular losses, and ongoing diet counseling should be pursued.11
MK will need to continually follow up for assessments of her pancreas. It is crucial that
she not only follow her diet and take pancreatic enzymes as needed, but she will need to ensure
that her pancreatic cancer has not affected the remainder of her pancreas. She was encouraged to
share the material regarding the Whipple diet with her family, as compliance to a diet can be
easier when there is family support involved. MK was discharged to a sub-acute rehab facility,
where she will be working with Physical Therapists, Occupational Therapists, and a Registered
Dietitian in attempts to get her physical activity and nutritional status back to baseline. She will
need to monitor her weight and consider nutritional supplements if her weight starts decreasing
and appetite remains poor.
MK originally had a strong desire and motivation to get back to her activity baseline prior
to admission, but as her hospitalization ensued, her biggest barriers were depression with her
current status, and the loss of willpower. Keeping her motivated while in sub acute rehab will be
crucial. Towards the end of her hospital admission, she was beginning to accept her new
appetite, and did not have a strong desire to rely on supplementation to increase her caloric and
protein intake for healing.
Summary and Conclusion:
I have learned that there is an integral role for nutrition for proper healing post surgery,
and while in a catabolic state. Withholding nutrition for an extensive amount of time can lead to
longer recovery time and inadequate healing. Additionally, I have learned that resecting the
pancreas and small intestine can lead to malabsorption and weight loss, which are two critical
nutrition issues. I have realized the complicated, and invasive nature of the Whipple procedure,
and the prognosis associated with the procedure and pancreatic cancer in general. I have a better
understanding of what a Whipple procedure is, which patients benefit from it, and the likelihood
that total parenteral nutrition may be needed after surgery.
Bibliography
1. Stump SE. Nutrition and Diagnosis Related Care. 7th ed. Baltimore Maryland: Lippincott
Williams & Wilkins; 2012.
2. Nelms A, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology. 2nd ed.
Belmont, CA: Cengage; 2011.
3. Gattuso P, Reddy VB, David O, Spitz DJ, Haber MH. Differential Diagnosis in Surgical
Pathology. 3rd ed. Saunders: Elsevier; 2015.
4. Cameron JL, Cameron AM. Current Surgical Therapy. 11th ed. Elsevier; 2014.
5. Parish et al. Post-Whipple: A Practical Approach to Nutrition Management. Nutrition
Issues in Gastroenterology. Series #108. August 2012.
6. Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE. Abeloff’s Clinical
Oncology. 5th ed. Churchill Livingstone: Elsevier; 2014.
7. Gerritsen et al. Systematic Review of five feeding routes after pancreatoduodenectomy.
British Journal of Sugery. Volume 100, Issue 5. 589-598. January 2013.
8. Sanford D et al. Severe Nutritional Risk Predicts Decreased Long Term Survival in
Geriatric Patients Undergoing Pancreaticoduodenectomy for Benign Disease. Journal of
American College of Surgeons. Volume 219, Issue 6. 1149-1156. 2014.
9. Marcason, W. What is the Whipple Procedure and What is the Appropriate Nutrition
Therapy for It? Journal of Academy of Nutrition and Dietetics. Volume 115. Issue 1:
168. January 2015.
10. Nolan JD, Johnston IM, Walters RF. Physiology of Malnutrition.Surgery. Volume 30,
Issue 6. Elsevier. 268-274. 2012.
11. Carey S et al. Long term nutritional status and quality of life following major upper
gastrointestinal surgery- A cross-sectional study. Clinical Nutrition. Volume 30, Issue 6.
774-779. 2011.
Appendix
MK's Nutrients Report
Personal Calorie goal is 1475. These plan amounts are based on meeting designated nutrient needs.
Nutrients
Target
Average Eaten
Status
Total Calories
1475 Calories
1312 Calories
OK
Protein (g)***
46 g
40 g
Under
Protein (% Calories)***
10 - 35% Calories
12% Calories
OK
Carbohydrate (g)***
130 g
197 g
OK
Carbohydrate (% Calories)***
45 - 65% Calories
60% Calories
OK
Dietary Fiber
21 g
13 g
Under
Total Sugars
No Daily Target or
Limit
138 g
No Daily Target or
Limit
Added Sugars
No Daily Target or
Limit
80 g
No Daily Target or
Limit
Total Fat
20 - 35% Calories
31% Calories
OK
Saturated Fat
< 10% Calories
6% Calories
OK
Polyunsaturated Fat
No Daily Target or
Limit
10% Calories
No Daily Target or
Limit
Monounsaturated Fat
No Daily Target or
Limit
12% Calories
No Daily Target or
Limit
Linoleic Acid (g)***
11 g
13 g
OK
Linoleic Acid (% Calories)***
5 - 10% Calories
9% Calories
OK
α-Linolenic Acid (% Calories)***
0.6 - 1.2% Calories
0.8% Calories
OK
α-Linolenic Acid (g)***
1.1 g
1.1 g
OK
Omega 3 - EPA
No Daily Target or
Limit
0 mg
No Daily Target or
Limit
Omega 3 - DHA
No Daily Target or
Limit
0 mg
No Daily Target or
Limit
Cholesterol
< 300 mg
11 mg
OK
Minerals
Target
Average Eaten
Status
Calcium
1200 mg
740 mg
Under
Potassium
4700 mg
2061 mg
Under
Sodium**
1500 mg
1110 mg
OK
Copper
900 µg
940 µg
OK
Iron
8 mg
6 mg
Under
Magnesium
320 mg
244 mg
Under
Phosphorus
700 mg
928 mg
OK
Selenium
55 µg
57 µg
OK
Zinc
8 mg
6 mg
Under
Vitamins
Target
Average Eaten
Status
Vitamin A
700 µg RAE
251 µg RAE
Under
Vitamin B6
1.5 mg
0.9 mg
Under
Vitamin B12
2.4 µg
2.0 µg
Under
Vitamin C
75 mg
41 mg
Under
Vitamin D
15 µg
4 µg
Under
Vitamin E
15 mg AT
9 mg AT
Under
Vitamin K
90 µg
64 µg
Under
Folate
400 µg DFE
228 µg DFE
Under
Thiamin
1.1 mg
0.8 mg
Under
Riboflavin
1.1 mg
1.4 mg
OK
Niacin
14 mg
13 mg
Under
Choline
425 mg
160 mg
Under
Information about dietary supplements.
** If you are African American, hypertensive, diabetic, or have chronic kidney disease, reduce your sodium to 1500 mg a day. In
addition, people who are age 51 and
older need to reduce sodium to 1500 mg a day. All others need to reduce sodium to less than 2300 mg a day.
*** Nutrients that appear twice (protein, carbohydrate, linoleic acid, and α-linolenic acid) have two separate
recommendations:
1) Amount eaten (in grams) compared to your minimum recommended intake.
2) Percent of Calories eaten from that nutrient compared to the recommended range.
You may see different messages in the status column for these 2 different recommendations.