GeriatricS- Nutritional Support

Pancreatic Cancer: Prognosis, Pathophysiology, and Diagnostics

  • Prognosis and Survival Rates

    • Survival chances for pancreatic cancer are generally very low.
    • The typical survival rate is approximately 3%−5%3\% - 5\%.
    • The maximum life expectancy is usually between 22 to 55 years.
    • Prognosis varies by tumor location: a tumor located in the ampulla has a better prognosis compared to one located in the head of the pancreas.

  • Clinical Presentation and Symptomatology

    • Patients often present with "painless jaundice" and significant weight loss.
    • Belly pain that radiates to the back is common.
    • Diarrhea may be present.
    • Patients may exhibit signs of hyperglycemia or glycosuria.
    • Acute pancreatitis may be visible on imaging with no clear cause (idiopathic presentation).

  • The Link to Acute Pancreatitis

    • Pancreatitis is rarely idiopathic; it usually has a specific etiology.
    • The two most common causes of pancreatitis are alcohol use and obstructing gallstones.
    • If a patient has acute pancreatitis with an unknown origin (no risk factors), it should raise clinical suspicion for underlying pancreatic cancer.

  • Hepatobiliary Indicators

    • Jaundice: Whenever jaundice is observed in either pediatric or adult patients, it should immediately trigger an investigation of the hepatobiliary tract as a primary differential.
    • Hyperbilirubinemia: This usually occurs in the later stages of pancreatic cancer due to biliary obstruction caused by the tumor.

  • Laboratory Investigations: Lipase vs. Amylase

    • Amylase: This enzyme is not specific to the pancreas. It is also secreted by the salivary glands and other sources. An elevated amylase level alone is not specific to pancreatic disease.
    • Lipase: This is the preferred marker because it is much more specific to pancreatic etiology. In acute settings, clinicians prefer to send lipase; an elevated lipase level is highly concerning for pancreatic disease.

  • Tumor Markers and Imaging

    • CA 19-9: This is a cancer tumor marker positive in pancreatic cancer. However, it is not exclusive; it can also be positive in biliary disease, hepatocellular disease, and simple conditions like cholangitis (Common Bile Duct [CBD] obstruction).
    • Imaging Modalities: Diagnostics include CAT scans, MRIs, and endoscopic ultrasound.
    • ERCP (Endoscopic Retrograde Cholangiopancreatography): This imaging technique captures the ducts and is used to clarify ambiguous cases, such as determining the exact location of a stone.

  • Surgical and Medical Management

    • Differentiating Care: Issues involving biliary disorders often require coordination. Cholecystitis is typically handled by General Surgery (cholecystectomy), while cholangitis is managed by the GI team (ERCP).
    • Adenocarcinoma: This is the most common histological type of pancreatic cancer.
    • Whipple Procedure: A major resection surgery performed for certain stages of the disease.
    • Chemoradiation: This can downstage tumors in up to 30%30\% of cases for stages past T1T1.
    • Metastatic Care: Once the cancer has metastasized, treatment shifts to palliative chemotherapy.

Geriatric Nutrition and Specialized Diets

  • Significance of Diet Orders

    • Diet orders are mandatory for admitted patients in internal medicine or geriatric wards.
    • Diets must be tailored based on medical history, religious requirements, or acute conditions.
    • Geriatric patients may be admitted for weeks or months, making the diet order a critical long-standing part of their care.

  • Types of Medical Diets

    • Renal Diet: Specifically for patients with Chronic Kidney Disease (CKD) or those on dialysis.
    • Hepatic Diet: For patients with hepatitis; typically involves moderate protein and low sodium.
    • Cardiac Diet: The most common diet seen in hospitals. It is used for patients with hypertension or hyperlipidemia, focusing on low sodium and moderate protein.
    • Diabetic Diet: Based on ADA (American Diabetes Association) guidelines to manage blood sugar.
    • Puree Diet: Ordered for patients post-CVA (stroke) who suffer from dysphagia (difficulty swallowing).

  • ADA Diet Recommendations

    • These serve as the national guidelines for what geriatric patients should consume.
    • Supplementation may include protein, caloric, and fiber supplements, along with strict hydration protocols.

Percutaneous Endoscopic Gastrostomy (PEG) Tubes

  • Indications for PEG Tubes

    • PEG tubes are used for patients unable to consume nutrition orally due to motility or swallowing disorders.
    • Common in geriatric populations, post-stroke patients, or those with Parkinson's and dementia.
    • Head or neck cancer patients often require PEG tubes even in remission because radiation or surgery may have permanently impaired swallowing function.
    • Used in cases of extreme malnutrition, weight loss, or dehydration.

  • Insertion and Confirmation Procedures

    • Initial insertion is performed by GI or Surgery via an anastomosis.
    • Confirmatory Site Check: You must never start a feeding until the site is confirmed. Inserting a feed into a false tract can cause necrotic bowel.
    • X-ray Confirmation Protocol:
      1. Inject oral contrast into the PEG tube site.
      2. Obtain an X-ray within the next 6060 seconds.
      3. Observe the contrast flowing through to ensure it is in the correct location.

  • Maintenance and Complications

    • Care of the PEG tube site often falls to PA/ER staff once the main site is established.
    • Clogging: A common issue frequently managed with saline flushes.
    • Dislodgment: Tubes can fall out or balloons may deflate; replacement is common in Urgent Care settings.
    • Infection: The site must be cleaned regularly to prevent cellulitis or bacterial colonization from the external environment into the abdomen.

Total Parenteral Nutrition (TPN)

  • Definition and Usage

    • TPN is intravenous (IV) nutrition therapy.
    • It is used for patients who cannot meet their nutritional needs orally or enterally (via PEG tube).

  • Indications and Contraindications

    • TPN is used when PEG tubes are contraindicated, such as in cases of certain carcinomas that prevent tube insertion.
    • It is used when a patient's family refuses a PEG tube (end-of-life/palliative care).
    • Indicated for inability to digest normally or inadequate oral intake.

  • Administration

    • TPN runs over a very long period, usually requiring slower feed rates to ensure patient tolerance.
    • It consists of a complete formula of nutrients injected directly into the bloodstream.

Questions & Discussion

  • Question: What are the two most common causes of pancreatitis?

  • Response: Alcohol use and gallstones.

  • Question: How do you confirm the site of a PEG tube after replacement?

  • Response: You inject contrast and get an X-ray within 6060 seconds to ensure the contrast is flowing through the correct spot. You must confirm this before starting any feeding.

  • Question: Which is more specific for pancreatic disease, amylase or lipase?

  • Response: Lipase is more specific. Amylase can be elevated due to issues with salivary glands or other etiologies.