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Pancreatic Exocrine Insufficiency and Enteral Feeding: a Practical Guide with Case Studies

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Pancreatic Exocrine Insufficiency and Enteral Feeding: a Practical Guide with Case Studies NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #181 NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #181 Carol Rees Parrish, M.S., R.D., Series Editor Pancreatic Exocrine Insufficiency and Enteral Feeding: A Practical Guide with Case Studies Mary E. Phillips Amy Berry Lucy S. Gettle Patients with pancreatic disease can develop severe malnutrition. Many factors contribute to the malnutrition seen in this patient population, one of the most problematic being pancreatic exocrine insufficiency (PEI) with resultant malabsorption. Pancreatic enzyme replacement therapies (PERT) are predominantly designed for oral administration, but this can be challenging in patients requiring enteral nutrition (EN). This review explores the use of PERT in complex patients who are on EN. Case studies will be utilized to demonstrate different methods available in order to provide practical guidance on administration, both in the United States (U.S.) and the United Kingdom (U.K.). INTRODUCTION atients with pancreatic disease, pancreatic medium-chain triglycerides, thereby decreasing resection, and cystic fibrosis often develop the dependence of pancreatic lipase for absorption. Psignificant malnutrition as a result of the However, some patients will continue to malasborb, numerous gastrointestinal (GI) complications even with semi-elemental products, worsening the preventing adequate oral intake. Malabsorption, malnutrition present. as well as side effects of medications such Traditional signs and symptoms of as antibiotics and opiates, adds an additional malabsorption include the presence of pale stools challenge to meeting nutritional requirements. In (often described as yellow or clay colored), floating patients requiring EN, standard elemental formulas or oily stools, stools with an unusually foul and may not be tolerated or absorbed. Semi-elemental offensive odor, abdominal bloating, cramping or (or peptide-based) formulas are often utilized, gas, urgency and/or frequent stools.1 The use of gut providing less long-chain triglycerides and more slowing medications, such as opiates, or the use Mary E. Phillips BSc (Hons) RD DipADP Advanced Specialist Dietitian (Hepato-pancreatico-biliary Surgery), Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, UK Amy Berry MS, RD, CNSC Nutrition Support Specialist (GI Surgery at the Emily Couric Cancer Center), University of Virginia Medical Center, Charlottesville VA Lucy S. Gettle, RDN CNSC Clinical Dietitian Specialist (Adult Cystic Fibrosis), University of Virginia Medical Center, Charlottesville VA 62 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 Pancreatic Exocrine Insufficiency and Enteral Feeding NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #181 NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #181 of low fat enteral feedings may result in reduction she was tolerating G-tube clamping around the of obvious clinical signs and mask ongoing clock. She transitioned to a nocturnal feeding malabsorption. In these patients, constipated or regimen that met her nutritional needs and was infrequent stools (vs. diarrhea) may be reported, kept NPO. as well as abnormal color, unusually large volume Once home, her diarrhea increased. Her stools, abnormal cramping and/or gas etc. The prokinetic dose was successfully weaned, with addition of antibiotics or prokinetics, can further no worsening of her nausea. The patient reported confuse the clinical picture. Hence, sometimes it is improvement in her diarrhea, yet, eventually the presence of more subtle signs of malnutrition frequent loose stools associated with cramps and such as difficulty with wound healing, worsening urgency were again reported. Her glycemic control functional status, ongoing weight loss, or recurrent was erratic; she began holding her long acting hypoglycemia/reduction in insulin requirement insulin due to episodes of hypoglycemia. despite adequate caloric intake, that should trigger Two weeks post discharge her weight was the consideration to consider an empiric trial of down 5 pounds (2.25 kg), and an area of her PERT. 2,3 midline wound opened, which required packing. EN and PERT products vary internationally. At this time, it was determined an EN change was The aim of this paper is to provide a guide in required. The elemental formula Vivonex® (Nestle, the management of this complex patient group, U.S.) was considered for its very low fat profile, combining the experience of dietitians specializing however the patient was quite volume sensitive and in patients with PEI, both in the U.S. and the would not have tolerated the rate increase needed. U.K. We will also provide practical guidance She was to be tried on a non-enteric coated PERT in implementing the various modalities that can (Viokace®; Aptalis Pharma, U.S.), that could be be utilized when it is determined that a patient crushed and added directly to her EN, but her is malabsorbing on their current EN regimen, as insurance denied coverage for this product. We direction provided in the literature is sparse.4-10 were hesitant to attempt enteric coated granules to mix with EN (described elsewhere6,7) for fear of tube clogging, as the patient was completely CASE #1 dependent on her jejunal EN. A 62 year old female with pancreatic cancer Fortunately, she advanced to oral intake. and poorly controlled diabetes (HbA1c = 8.3%) Full liquids were tolerated and she was able to completed a neo-adjuvant course of chemo-radiation take medications by mouth. She began to take prior to surgery. She reported a recent reduction her enteric coated PERT (2 capsules of Zenpep® in her insulin dose due to multiple episodes of 25,000 USP; Aptalis Pharma, U.S.) by mouth at severe hypoglycemia. Her oncologist also recently the start of feedings, ~3 hours into her feeding started her on enteric coated PERT due to reported cycle, and again before turning her EN off in the yellow, oily stools and continued weight loss. She morning. Her stools firmed and improved; however, underwent a classic Whipple procedure, combined she still reported urgency and pale stools in the with a percutaneous gastro-jejunostomy (PEG-J) middle of the night. We increased her oral PERT tube placement. Semi-elemental EN (Perative®, administration to four times during her nocturnal Abbott, U.S.) was chosen due to the presence of cycle (she reported being awake and ambulatory malabsorption preoperatively. Her recovery was at night, and agreeable to medication at this time), complicated by delayed gastric emptying requiring with one loperamide at the start of EN. This finally NPO (nil per os) status, and she was treated with resulted in normalization of stooling and weight a prokinetic and high dose proton pump inhibitor maintenance. She also resumed her intermediate (PPI) given via her J-port. Her gastric port was acting insulin due to rising blood glucose with vented as needed for gastric decompression. She improved absorption; her blood glucoses now was experiencing diarrhea, but was receiving remaining in the 80-200mg/dL range. Over the next enteral electrolyte replacement therapy (including 2 months she increased her weight by 12 pounds magnesium oxide) and a prokinetic. On discharge, (5.5 kg) and her abdominal wound began to heal. PRACTICAL GASTROENTEROLOGY • NOVEMBER 2018 63 Pancreatic Exocrine Insufficiency and Enteral Feeding NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #181 Table 1. Clinical Parameters Pre- and Post-PERT Parameter Case 1 Case 2 Case 3 Case 4 Case 5 Diagnosis Pancreatic cancer, Cystic fibrosis related PEI, Total gastrectomy, total Pancreatic cancer, gastric outlet Total pancreatectomy; Post Whipple (classic) no anatomic abnormalities colectomy; severe chronic obstruction duodenectomy, hepatico- pancreatitis jejunostomy on roux loop IBW 52.3 kg/ 115 lbs 75 kg/ 166 lbs UK does not use 64.5 kg/ 142 lbs UK does not use Goal wt 62.7 kg/ 138 lbs 72 kg/ 160 lbs 65 kg/ 143 lbs 64.5 kg/ 142 lbs 84 kg/ 185 lbs EN Access PEG-J Low profile G-tube Jejunostomy PEG-J Naso-jejunal Timing Pre-PERT Post-PERT Pre-PERT Post-PERT Pre-PERT Post-PERT Pre-PERT Post-PERT Pre-PERT Post-PERT PERT N/A 3 Zenpep® 25,000 USP Viokace® 2 Relizorb® N/A Pancrex V® N/A Creon® 24,000 N/A Pancrex V® units. Taken orally at crushed and cartridges/day powder 4g USP units; 2 powder 4g start of EN, mid-EN x 2, mixed directly (100,000 units) capsules/can (100,000 units)/ end of EN. Alternatively, to EN /400mL EN of EN; opened 400mL EN crush and add 1-2 tablets, and mixed with 10,440 USP units of Nabicarb tabs Viokace® to EN. and 60mL water for 30 minutes; flush via tube q 4 hours during EN infusion Weight 62.7 kg/138 lbs 70 kg/154 lbs 54 kg/119 lbs 64 kg/141 lbs 52 kg/114 lbs 57 kg/125 lbs 59.1 kg/130 lbs 64.5 kg/142 lbs 84 kg/185 lbs Fluid overloaded Stool Constant loose Color normalization, Loose stools, 2-3 formed High volume Stoma output Frequent, Constipated, Brown formed Brown formed Output stools w/ EN; clay formed, decreased fecal urgency in stools daily stoma output <600mL/day yellow, oily; requiring stool every stool every 1-2 colored frequency middle of night >2000mL/day alternating w/ miralax 1-2 days days constipation d/t use of opiates EN Perative® Perative® TwoCal HN® Nutren 2.0® Peptisorb®; Vital 1.5® Vital 1.5® Vital 1.5® Peptisorb® Vital 1.5® Peptamen HN®; Peptamen® Glycemic Poor; insulin Increased insulin Normal Impaired Normal Normal Well- Well-controlled 2-32mmol/L 5-11mmol/L Control requirement variable, requirement with glucose controlled, (36 – 576 (90-198mg/dL) glucoses labile stabilization of glucoses tolerance,
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