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Ockenga J, Fromhold-Treu S, Löser C, Madl C, Martignoni M, Meier R, Rubin D, Schütte K, Stang K, Török HP, Wehle L, Weimann A. S3-Leitlinie Klinische Ernährung bei
Pankreaserkrankungen. AKTUELLE ERNÄHRUNGSMEDIZIN 2024; 49:451-475. [DOI: 10.1055/a-2328-6190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
ZusammenfassungSowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen,
die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine
Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt
eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und
Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer
enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen,
endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte
Säule der multimodalen Therapie darstellt.Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung
der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie
des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von
Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige
Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine
Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer
Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht
und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit
chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet
werden, und entsprechende Präventivmaßnahmen erwogen werden.
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Affiliation(s)
- Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Gesundheit Nord gGmbH,
Bremen, Deutschland
| | - Sophie Fromhold-Treu
- Abteilung für Gastroenterologie, Endokrinologie und
Stoffwechselkrankheiten, Zentrum für Innere Medizin, Universitätsmedizin
Rostock, Rostock, Deutschland
| | - Christian Löser
- Medizinische Klinik, DRK-Kliniken Nordhessen, Kassel,
Deutschland
| | - Christian Madl
- Zentrum für Gastroenterologische und Hepatologische Erkrankungen und
Gastrointestinale Endoskopie, Krankenanstalt Rudolfstiftung, Wien,
Österreich
| | - Marc Martignoni
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar,
Technische Universität München, Deutschland
| | - Rémy Meier
- Arztpraxis MagenDarm Basel AG, Basel, Schweiz
| | - Diana Rubin
- Zentrum für Ernährungsmedizin, Vivantes Klinikum Spandau, Berlin,
Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie,
Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück,
Deutschland
| | | | - Helga Paula Török
- Medizinische Klinik und Poliklinik II, Campus Innenstadt, Klinikum der
Ludwig-Maximilians-Universität München, München, Deutschland
| | - Lena Wehle
- Deutsche Gesellschaft für Ernährungsmedizin e.V., Berlin,
Deutschland
| | - Arved Weimann
- Abteilung für Allgemein-, Viszeral- und Onkologische Chirurgie,
Klinikum St. Georg gGmbH, Leipzig, Deutschland
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Padula D, Mauro A, Maggioni P, Kurihara H, Di Sabatino A, Anderloni A. Practical approach to acute pancreatitis: from diagnosis to the management of complications. Intern Emerg Med 2024; 19:2091-2104. [PMID: 38850357 DOI: 10.1007/s11739-024-03666-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 05/28/2024] [Indexed: 06/10/2024]
Abstract
The purpose of this review is to provide a practical guide for the clinical care of patients with acute pancreatitis (AP) from the management of the early phases of disease to the treatment of local complications. AP is one of the most frequent causes of gastroenterological admission in emergency departments. It is characterized by a dynamic and unpredictable course and in its most severe forms, is associated with organ dysfunction and/or local complications, requiring intensive care with significant morbidity and mortality. Initial therapy includes adequate fluid resuscitation, nutrition, analgesia, and when necessary critical care support. In recent years, the development of minimally invasive tailored treatments for local complications, such as endoscopic drainage, has improved patients' acceptance and outcomes. Despite this, the management of AP remains a challenge for clinicians. The present review was conducted by the authors, who formulated specific questions addressing the most critical and current aspects of the clinical course of AP with the aim of providing key messages.
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Affiliation(s)
- Donatella Padula
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
| | - Aurelio Mauro
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy.
| | - Paolo Maggioni
- Emergency Department and Medicine, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, via F Sforza 35, Milan, Italy
- Scuola di Specializzazione in Medicina di Emergenza-Urgenza, Università Degli Studi Di Milano, Milan, Italy
| | - Hayato Kurihara
- Emergency Surgery Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, Milan, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
- First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19, Pavia, Italy
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González-Haba Ruiz M, Betés Ibáñez MT, Martínez Moreno B, Repiso Ortega A, de la Serna Higuera C, Iglesias García J, Sendino García O, Moris Felgueroso M, Agudo Castillo B, Esteban López-Jamar JM, Lindo Ricce MD, Soria San Teodoro MT, Moya Valverde E, Muñoz López D, Uribarri González L, Sevilla Ribota S, Lariño Noia J, Pérez Miranda M, Aparicio Tormo JR, Vila Costas JJ, Vázquez Sequeiros E, Subtil Íñigo JC, Pérez-Cuadrado-Robles E, Sánchez Yagüe A, Núñez Otero JA, Foruny Olcina JR. Endoscopic management of pancreatic collections. Endoscopic Ultrasound Group, Spanish Society of Digestive Endoscopy (GSEED-USE) Clinical Guidelines. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:423-437. [PMID: 38305682 DOI: 10.17235/reed.2024.10276/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Acute pancreatitis is associated with significant morbidity and mortality. It can develop complications such as fluid collections and necrosis. Infection of necrosis occurs in about 20-40 % of patients with severe acute pancreatitis, and is associated with organ failure and worse prognosis. In the past few years the treatment of pancreatic collections has shifted from open surgery to minimally invasive techniques such as endoscopic ultrasound-guided drainage. These guidelines from a selection of experts among the Endoscopic Ultrasound Group, Spanish Society of Gastrointestinal Endoscopy (GSEED-USE) are intended to provide advice on the management of pancreatic collections based on a thorough review of the available scientific evidence. It also reflects the experience and clinical practice of the authors, who are advanced endoscopists or clinical pancreatologists with extensive experience in managing patients with acute pancreatitis.
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Li Y, Li J, Li S, Zhou S, Yang J, Xu K, Chen Y. Exploring the gut microbiota's crucial role in acute pancreatitis and the novel therapeutic potential of derived extracellular vesicles. Front Pharmacol 2024; 15:1437894. [PMID: 39130638 PMCID: PMC11310017 DOI: 10.3389/fphar.2024.1437894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 07/15/2024] [Indexed: 08/13/2024] Open
Abstract
During acute pancreatitis, intestinal permeability increases due to intestinal motility dysfunction, microcirculatory disorders, and ischemia-reperfusion injury, and disturbances in the intestinal flora make bacterial translocation easier, which consequently leads to local or systemic complications such as pancreatic and peripancreatic necrotic infections, acute lung injury, systemic inflammatory response syndrome, and multiple organ dysfunction syndrome. Therefore, adjusting intestinal ecosystem balance may be a promising approach to control local and systemic complications of acute pancreatitis. In this paper, we reviewed the causes and manifestations of intestinal flora disorders during acute pancreatitis and their complications, focused on the reduction of acute pancreatitis and its complications by adjusting the intestinal microbial balance, and innovatively proposed the treatment of acute pancreatitis and its complications by gut microbiota-derived extracellular vesicles.
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Affiliation(s)
- Yijie Li
- Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Li
- Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Sen Li
- Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Shumin Zhou
- Wenzhou Institute of Shanghai University, Wenzhou, China
| | - Jiahua Yang
- Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ke Xu
- Wenzhou Institute of Shanghai University, Wenzhou, China
- Institute of Translational Medicine, Shanghai University, Shanghai, China
| | - Yafeng Chen
- Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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5
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Assimakopoulos SF, Bhagani S, Aggeletopoulou I, Tsounis EP, Tsochatzis EA. The role of gut barrier dysfunction in postoperative complications in liver transplantation: pathophysiological and therapeutic considerations. Infection 2024; 52:723-736. [PMID: 38324146 PMCID: PMC11143052 DOI: 10.1007/s15010-024-02182-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/11/2024] [Indexed: 02/08/2024]
Abstract
PURPOSE Gut barrier dysfunction is a pivotal pathophysiological alteration in cirrhosis and end-stage liver disease, which is further aggravated during and after the operational procedures for liver transplantation (LT). In this review, we analyze the multifactorial disruption of all major levels of defense of the gut barrier (biological, mechanical, and immunological) and correlate with clinical implications. METHODS A narrative review of the literature was performed using PubMed, PubMed Central and Google from inception until November 29th, 2023. RESULTS Systemic translocation of indigenous bacteria through this dysfunctional barrier contributes to the early post-LT infectious complications, while endotoxin translocation, through activation of the systemic inflammatory response, is implicated in non-infectious complications including renal dysfunction and graft rejection. Bacterial infections are the main cause of early in-hospital mortality of LT patients and unraveling the pathophysiology of gut barrier failure is of outmost importance. CONCLUSION A pathophysiology-based approach to prophylactic or therapeutic interventions may lead to enhancement of gut barrier function eliminating its detrimental consequences and leading to better outcomes for LT patients.
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Affiliation(s)
- Stelios F Assimakopoulos
- Division of Infectious Diseases, Department of Internal Medicine, Medical School, University of Patras, University Hospital of Patras, Rion, 26504, Patras, Greece.
| | - Sanjay Bhagani
- Department of Infectious Diseases/HIV Medicine, Royal Free Hospital, London, UK
| | - Ioanna Aggeletopoulou
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Efthymios P Tsounis
- Division of Gastroenterology, Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | - Emmanuel A Tsochatzis
- UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, UK
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Sivkov OG, Sivkov AO. Early nasogastric and nasojejunal feeding in patients with predictors of severe acute pancreatitis: а randomized controlled trial. ANNALS OF CRITICAL CARE 2024:107-116. [DOI: 10.21320/1818-474x-2024-2-107-116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2025]
Abstract
OBJECTIVE: Studying the influence of early nasogastric (NG) and nasojejunal (NJ) probe feeding in patients with predictors of severe acute pancreatitis on the course and outcome of the disease. MATERIALS AND METHODS: An open randomized controlled study was performed in Neftyanik Occupational Healthcare Facility ICU. 64 patients with predictors of severe acute pancreatitis (APACHE II > 8, CRP > 150 mg/l, SOFA > 2) randomized by the envelope method for early (the first 24 hrs.) nasogastic or nasojejunal feeding. The standard polymer feeding formula enriched with dietary fibers was administered during the first 5 (five) days taking into account its tolerability. Raw data were statistically processed using SPSS-26 software. RESULTS: Comparison of the NG (n = 33) vs. NJ (n = 31) groups produced the following results: the duration (days) of treatment in the hospital was 21 (12; 42) vs. 24 (11; 35), p = 0.715; in ICU — 4 (2; 20) vs. 4 (3; 13), p = 0.803; mechanical ventilation (MV) — 1 (1; 3) vs. 1 (1; 1), p = 0.124; mortality — OR 0.830 (95 % CI 0.201–3.422), p = 0.796; severity (moderately severe or severe) — OR 1.29 (95 % CI 0.483–3.448), p = 0.611; number of patients subjected to surgery during the first period of the disease — OR 0.774 (95 % CI 0.243–2.467), p = 0.665; and second period of the disease — OR 1.682 (95 % CI 0.623–4.546), p = 0.305. CONCLUSIONS: No difference has been found between the groups of patients with severe disease predictors, who received early nasogastric or nasojejunal tube feeding using standard polymer formula with dietary fibers during early acute pancreatitis, as regards duration of treatment in the hospital, in ICU, numbers of mechanically ventilated patients, patients operated during the first and second disease periods, disease severity or mortality.
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Affiliation(s)
- Oleg G. Sivkov
- Diagnostics and Cardiovascular Surgery Center (cardiology clinic), Surgut, Russia; Surgut State University, Surgut, Russia
| | - A. O. Sivkov
- Medical and Sanitary Unit «Neftyanik», Tyumen, Russia
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7
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Grover I, Gunjan D, Singh N, Gopi S, Sati HC, Sachdev V, Saraya A. Kitchen-based diet versus commercial polymeric formulation in acute pancreatitis: a pilot randomized comparative study. Eur J Clin Nutr 2024; 78:328-334. [PMID: 38243059 DOI: 10.1038/s41430-024-01400-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 12/14/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024]
Abstract
INTRODUCTION Nutrition plays an important role in management of acute pancreatitis (AP) and decreases its severity and infectious complications. Various formulations of enteral nutrition (EN) are available and are costly. For developing countries, cost and availability is a major issue and kitchen-based diet should be explored in patients with AP. AIM Comparison of kitchen-based diet with a commercially available polymeric formulation in terms of various outcomes in patients with AP within 14 days after the onset of pain. METHODS Sixty patients (39 male, mean age 36.1 ± 12.7 years) of moderately severe and severe AP of any etiology were randomized (30 in each group) to either kitchen-based diet or commercial polymeric formulation group. Outcome measures were refeeding pain, tolerability, infectious complications, mortality, total hospital/intensive care unit stay; and change in serum C-reactive protein (CRP), transferrin and pre albumin. RESULTS There was no significant difference in baseline demographic and biochemical parameters in both groups. No difference was observed in refeeding pain (7.1% vs 8%, p = 0.99), tolerability (28.6% vs 12%, p = 0.17), infectious complications (57.14% vs 36%, p = 0.12), mortality (31.7% vs 20%, p = 0.69), hospital stay (19.5 vs 23.5 days, p = 0.86), CRP (74.4 vs 59 mg/L, p = 0.97), transferrin levels (23.6 vs 25.6 mg/dL, p = 0.75) and pre albumin (9.45 vs 13.09 mg/dL, p = 0.68) in both groups. CONCLUSION Kitchen-based diet is comparable to commercial polymeric formulation for the early initiation of enteral nutrition in patients with severe or moderately severe acute pancreatitis. CLINICAL TRIAL REGISTRATION Trial registered with the Clinical Trials registry-India (CTRI/2018/01/011188).
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Affiliation(s)
- Indu Grover
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Namrata Singh
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Srikanth Gopi
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Hem Chandra Sati
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Sachdev
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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Villaverde C, Hervera M. Nutritional Management of Exocrine Pancreatic Diseases. APPLIED VETERINARY CLINICAL NUTRITION 2023:299-318. [DOI: 10.1002/9781119375241.ch12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Cho IR, Do MY, Han SY, Jang SI, Cho JH. Comparison of Interleukin-6, C-Reactive Protein, Procalcitonin, and the Computed Tomography Severity Index for Early Prediction of Severity of Acute Pancreatitis. Gut Liver 2023; 17:629-637. [PMID: 36789576 PMCID: PMC10352050 DOI: 10.5009/gnl220356] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 02/16/2023] Open
Abstract
Background/Aims Acute pancreatitis (AP) is a common gastrointestinal disease associated with hospitalization. With the increase in its incidence, AP has become a greater burden on healthcare resources. Early identification of patients with mild AP can facilitate the appropriate use of resources. We aimed to investigate the ability of inflammatory markers, including interleukin-6 (IL-6), procalcitonin, and C-reactive protein (CRP), as well as various scoring systems to differentiate mild AP from more severe diseases. Methods We retrospectively investigated patients hospitalized with AP, for whom severity assessment and clinical course confirmation were possible. Inflammatory markers were measured at admission, and CRP levels were measured 24 hours after admission (CRP2). Predictive values were calculated using the area under the receiver operating characteristic curve (AUROC) and logistic regression model analysis. Results Of 103 patients with AP, 42 (40.8%) were diagnosed with mild AP according to the revised Atlanta classification. Based on the AUROC, IL-6 (0.755, p<0.001), CRP2 (0.787, p<0.001), and computed tomography severity index (CTSI) (0.851, p<0.001) were useful predictors of mild AP. With standard cutoff values, the diagnostic sensitivity, specificity, and accuracy were 83.3%, 62.3%, and 70.9% for IL-6 (<50 pg/mL), and 78.6%, 63.9%, and 69.9% for CRP2 (<50 mg/L), respectively. The AUROC of IL-6 and CRP2 were significantly higher than those of other inflammatory markers and were not significantly different from that of CTSI. Conclusions IL-6, CRP2, and CTSI are helpful for early differentiation of AP severity. Among inflammatory markers, IL-6 has the advantage of early prediction of mild pancreatitis at the time of admission.
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Affiliation(s)
- In Rae Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, and
| | - Min Young Do
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - So Young Han
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Gopi S, Saraya A, Gunjan D. Nutrition in acute pancreatitis. World J Gastrointest Surg 2023; 15:534-543. [PMID: 37206070 PMCID: PMC10190733 DOI: 10.4240/wjgs.v15.i4.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/10/2023] [Accepted: 03/21/2023] [Indexed: 04/22/2023] Open
Abstract
Acute pancreatitis (AP) has varying severity, and moderately severe and severe AP has prolonged hospitalization and requires multiple interventions. These patients are at risk of malnutrition. There is no proven pharmacotherapy for AP, however, apart from fluid resuscitation, analgesics, and organ support, nutrition plays an important role in the management of AP. Oral or enteral nutrition (EN) is the preferred route of nutrition in AP, however, in a subset of patients, parenteral nutrition is required. EN has various physiological benefits and decreases the risk of infection, intervention, and mortality. There is no proven role of probiotics, glutamine supplementation, antioxidants, and pancreatic enzyme replacement therapy in patients with AP.
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Affiliation(s)
- Srikanth Gopi
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anoop Saraya
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Deepak Gunjan
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India
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11
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He K, Yan X, Yang Z, Zhang Y, Shu H, Wu D. Neostigmine for the treatment of acute pancreatitis: a protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e070289. [PMID: 36958784 PMCID: PMC10040008 DOI: 10.1136/bmjopen-2022-070289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is a common disease with substantial mortality. Gut dysfunction may result in abdominal compartment syndrome (ACS) and delay enteral nutrition, worsening AP condition. Neostigmine is used as a prokinetic drug for the treatment of AP. But there are no recommendations from guidelines due to the lack of evidence. Therefore, we plan to conduct a systematic review and meta-analysis to explore the efficacy and safety of neostigmine for AP, aiming to provide current evidence for clinical practice. METHODS AND ANALYSIS We prepared this protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. We will search the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, Wanfang, conference proceedings and ongoing trials registers for eligible studies comparing neostigmine plus conventional therapy with conventional therapy. Primary outcomes include new-onset ACS and serious adverse events caused by neostigmine. Evaluation of the risk of bias, heterogeneity and quality of evidence will follow recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. Trial sequential analysis will be used to control the risk of random errors and assess conclusions in the meta-analysis. ETHICS AND DISSEMINATION Ethics approval is unnecessary as the systematic review is based on published studies. Study findings will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022369536.
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Affiliation(s)
- Kun He
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaxiao Yan
- Eight-year Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zihan Yang
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijun Shu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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He K, Wang Y, Li J, Bai X, Yang Z, Han X, Wu D. Neostigmine for non-mild acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials. Front Pharmacol 2023; 14:1131974. [PMID: 36925642 PMCID: PMC10011075 DOI: 10.3389/fphar.2023.1131974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
Background: The therapeutic value of neostigmine as a prokinetic drug in acute pancreatitis (AP), especially in non-mild AP, including moderately severe and severe AP remains controversial. This meta-analysis aimed to investigate the efficacy of neostigmine treatment in patients with non-mild AP. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang databases up to 24 December 2022 for RCTs comparing neostigmine plus conventional treatment versus the conventional treatment alone in patients with non-mild AP. Trial sequential analyses (TSA) were used to assess the risk of random errors and the results. Results: Six RCTs with 318 participants were included. Compared with conventional treatment, patients who received neostigmine plus conventional treatment had a shorter time duration for their first defecation (MD: -1.74; 95% CI: -2.10 to -1.38; p < 0.00001; n = 205; RCTs = 4; low quality of evidence) and better relief time of abdominal symptoms (MD: -1.59, 95% CI: -2.07 to -1.11; p < 0.00001; n = 155; RCTs = 3; low quality of evidence) as primary outcomes, and a faster percentage decrease of IAP at 24 h (p = 0.0005; moderate quality of evidence) and a shorter length of ICU stay (p < 0.00001; moderate quality of evidence) as partial secondary outcomes. TSA suggested the sample size was limited, but the cumulative Z curves of the primary outcomes crossed the conventional boundary and the trial sequential monitoring boundary. Conclusion: For patients with non-mild AP, neostigmine promotes the recovery of gastrointestinal motility and may have positive effects on the improvement of a clinical prognosis. Further large-sample studies are needed for a definite conclusion. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/; Identifier: CRD 42022381417.
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Affiliation(s)
- Kun He
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yabing Wang
- Department of Endocrinology, Beijing Friendship Hospital, Capital Medical College, Beijing, China
| | - Jianing Li
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyin Bai
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zihan Yang
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Dong Wu
- Department of Gastroenterology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Clinical Epidemiology Unit, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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13
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Liu J, Qiu H, Yuan Y, Liu C, Mo S, He F, Fu X. Efficacy and safety of early enteral and intravenous fluid resuscitation in severe acute pancreatitis: a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:36. [PMID: 36781508 DOI: 10.1007/s00384-023-04335-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of enteral fluid resuscitation (via nasointestinal tube or colorectal tube) and intravenous fluid resuscitation (via intravenous route) in the early treatment of severe acute pancreatitis. METHODS In this study, 8 electronic databases (PubMed, Web of Science, Embase, Cochrane Library, Scopus, China HowNet database, Wanfang database, and VIP database) were searched to collect clinical studies from inception to June 12, 2022. After the quality evaluation and data extraction of the included studies, the RevMan 5.3 software was used for analysis. RESULTS A total of seven studies including 580 patients were studied in this meta-analysis, in which 291 cases were treated with enteral fluid resuscitation and 289 cases were treated with intravenous fluid resuscitation. Compared with the intravenous route group, the enteral route resuscitation group reduced the incidence of new organ failure (OR = 0.23, 95% CI: 0.12-0.43, P < 0.00001), the incidence of persistent organ failure (OR = 0.38, 95% CI: 0.22-0.64, P = 0.0003), the incidence of mechanical ventilation (OR = 0.15, 95% CI: 0.03-0.69, P = 0.01), the incidence of ICU care (OR = 0.49, 95% CI: 0.27-0.88, P = 0.02), and the incidence of pancreatic infection (OR = 0.38, 95% CI: 0.17-0.83, P = 0.02). There were no statistically significant differences in mortality (OR = 0.77, 95% CI: 0.35-1.66, P = 0.50), surgical intervention rate (OR = 0.47, 95% CI: 0.19-1.18, P = 0.11), and incidence of localized ascites (OR = 0.65, 95% CI: 0.25-1.73, P = 0.39). CONCLUSION Early enteral fluid resuscitation is safe and effective for in severe pancreatitis. But this conclusion needs to be verified by more additional multi-centre randomized controlled trials with large samples.
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Affiliation(s)
- Jiao Liu
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
- General Surgery Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Huifang Qiu
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
- General Surgery Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yanfang Yuan
- Nursing Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
- Nursing Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Chengjiang Liu
- Department of General Medicine, Affiliated Anqing First People's Hospital of Anhui Medical University, Anqing, 246000, China
| | - Shaojian Mo
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
- General Surgery Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Fang He
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China.
- General Surgery Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Xifeng Fu
- General Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030032, China
- General Surgery Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
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14
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Lee SH, Choe JW, Cheon YK, Choi M, Jung MK, Jang DK, Jo JH, Lee JM, Kim EJ, Han SY, Choi YH, Seo HI, Lee DH, Lee HS. Revised Clinical Practice Guidelines of the Korean Pancreatobiliary Association for Acute Pancreatitis. Gut Liver 2023; 17:34-48. [PMID: 35975642 PMCID: PMC9840919 DOI: 10.5009/gnl220108] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 02/01/2023] Open
Abstract
Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.
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Affiliation(s)
- Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Young Koog Cheon
- Department of Internal Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Miyoung Choi
- Division of Health Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Min Kyu Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Hyun Jo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Min Lee
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Eui Joo Kim
- Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Sung Yong Han
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Young Hoon Choi
- Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung-Il Seo
- Department of Surgery, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Dong Ho Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Sik Lee
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea,Corresponding AuthorHong Sik Lee, ORCIDhttps://orcid.org/0000-0001-9726-5416, E-mail
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Chen D, Zhao B, Wang L, Qiu Y, Mao E, Sheng H, Jing F, Ge W, Bian X, Chen E, He J. Prognostic performance of the NRS2002, NUTRIC, and modified NUTRIC to identify high nutritional risk in severe acute pancreatitis patients. Front Nutr 2023; 10:1101555. [PMID: 36937348 PMCID: PMC10017740 DOI: 10.3389/fnut.2023.1101555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Background Acute pancreatitis (AP) is the most common gastrointestinal disease requiring hospital admission. AP patients are categorized as mild, moderately severe, and severe AP (SAP). For SAP patients, malnutrition increases susceptibility to infection and mortality. The Nutritional Risk Screening 2002 (NRS 2002), the Nutrition Risk in Critically Ill (NUTRIC) score and modified Nutrition Risk in Critically Ill (mNUTRIC) are nutritional risk screening tools of critically ill patients and have not been validated in patients with SAP. It is essential to evaluate the prognostic performance of these nutritional risk screening tools. Materials and methods A retrospective study was designed to validate the NRS 2002, NUTRIC, and mNUTRIC when applied to SAP patients. Receiver operating characteristic curves were plotted to investigate the predictive ability of clinical outcomes by comparing areas under the curve (AUC). Appropriate cut-offs were calculated by using Youden's index. Patients were identified as being at high nutritional risk according to the calculated cut-off values. The effects of different scoring systems on mortalities were calculated using the Cox proportional hazards model. Logistic regression was used to assess the association between the energy provision and 28-day mortality. Results From January 2013 to December 2019, 234 SAP patients were included and analyzed. Patients categorized as high nutritional risk by the NRS 2002 (12.6% versus 1.9% for 28-day and 20.5% versus 3.7% for 90-day), NUTRIC (16.2% versus 0.0% for 28-day and 27.0% versus 0.0% for 90-day), and mNUTRIC (16.4% versus 0.0% for 28-day and 26.4% versus 0.8% for 90-day) had significant higher mortality than those categorized as low nutritional risk. The NUTRIC (AUC: 0.861 for 28-day mortality and 0.871 for 90-day mortality, both cut-off value ≥3) and mNUTRIC (AUC: 0.838 for 28-day and 0.828 for 90-day mortality, both cut-off value ≥3) showed better predictive ability of the 28- and 90-day mortality than the NRS 2002 (AUC: 0.706 for 28-day mortality and 0.695 for 90-day mortality, both cut-off value ≥5). Conclusion The NRS 2002, NUTRIC, and mNUTRIC scores were predictors for the 28- and 90-day mortalities. The NUTRIC and mNUTRIC showed better predictive ability compared with the NRS 2002 when applied to SAP patients.
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Affiliation(s)
- Dayu Chen
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Nanjing Medical Center for Clinical Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Bing Zhao
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Linyu Wang
- Department of Pharmacy, The Affiliated Cancer Hospital of Guangxi Medical University, Nanning, China
| | - Yusi Qiu
- Department of Pharmacy, Guigang People’s Hospital, Guigang, China
| | - Enqiang Mao
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiqiu Sheng
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Jing
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihong Ge
- Department of Pharmacy, Nanjing Drum Tower Hospital the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaolan Bian
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erzhen Chen
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- *Correspondence: Erzhen Chen,
| | - Juan He
- Department of Pharmacy, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Emergency Department, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Juan He,
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Cañamares-Orbís P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients 2022; 14:4570. [PMID: 36364832 PMCID: PMC9656643 DOI: 10.3390/nu14214570] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 08/13/2023] Open
Abstract
This review summarizes the main pancreatic diseases from a nutritional approach. Nutrition is a cornerstone of pancreatic disease and is sometimes undervalued. An early identification of malnutrition is the first step in maintaining an adequate nutritional status in acute pancreatitis, chronic pancreatitis and pancreatic cancer. Following a proper diet is a pillar in the treatment of pancreatic diseases and, often, nutritional counseling becomes essential. In addition, some patients will require oral nutritional supplements and fat-soluble vitamins to combat certain deficiencies. Other patients will require enteral nutrition by nasoenteric tube or total parenteral nutrition in order to maintain the requirements, depending on the pathology and its consequences. Pancreatic exocrine insufficiency, defined as a significant decrease in pancreatic enzymes or bicarbonate until the digestive function is impaired, is common in pancreatic diseases and is the main cause of malnutrition. Pancreatic enzymes therapy allows for the management of these patients. Nutrition can improve the nutritional status and quality of life of these patients and may even improve life expectancy in patients with pancreatic cancer. For this reason, nutrition must maintain the importance it deserves.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, Martínez de Velasco Avenue 36, 22004 Huesca, Spain
| | - Guillermo García-Rayado
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
| | - Enrique Alfaro-Almajano
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
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17
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Berlana D. Parenteral Nutrition Overview. Nutrients 2022; 14:4480. [PMID: 36364743 PMCID: PMC9659055 DOI: 10.3390/nu14214480] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/17/2022] [Accepted: 10/22/2022] [Indexed: 09/10/2023] Open
Abstract
Parenteral nutrition (PN) is a life-saving intervention for patients where oral or enteral nutrition (EN) cannot be achieved or is not acceptable. The essential components of PN are carbohydrates, lipids, amino acids, vitamins, trace elements, electrolytes and water. PN should be provided via a central line because of its hypertonicity. However, peripheral PN (with lower nutrient content and larger volume) can be administered via an appropriate non-central line. There are alternatives for the compounding process also, including hospital pharmacy compounded bags and commercial multichamber bags. PN is a costly therapy and has been associated with complications. Metabolic complications related to macro and micronutrient disturbances, such as hyperglycemia, hypertriglyceridemia, and electrolyte imbalance, may occur at any time during PN therapy, as well as infectious complications, mostly related to venous access. Long-term complications, such as hepatobiliary and bone disease are associated with longer PN therapy and home-PN. To prevent and mitigate potential complications, the optimal monitoring and early management of imbalances is required. PN should be prescribed for malnourished patients or high-risk patients with malnutrition where the feasibility of full EN is in question. Several factors should be considered when providing PN, including timing of initiation, clinical status, and risk of complications.
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Affiliation(s)
- David Berlana
- Pharmacy Department, Vall Hebron Barcelona Campus Hospital, 08035 Barcelona, Spain;
- Pharmacology, Toxicology and Therapeutic Chemistry Department, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
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18
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Bukowski JS, Dembiński Ł, Dziekiewicz M, Banaszkiewicz A. Early Enteral Nutrition in Paediatric Acute Pancreatitis-A Review of Published Studies. Nutrients 2022; 14:3441. [PMID: 36014947 PMCID: PMC9416066 DOI: 10.3390/nu14163441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Nowadays, nutrition is said to be an integral aspect of acute pancreatitis (AP) treatment. Early enteral nutrition (EEN) is safe and beneficial for patients. This was confirmed by clinical experience and can be found in guidelines on managing adults with AP. Furthermore, paediatric recommendations encourage EEN use in AP. However, paediatric guidelines are based exclusively on studies in adults. Therefore, we present a review of published studies on the time of nutritional interventions in children with AP. A search was independently conducted in April 2022 by two of the authors. Only full-text papers published in English involving children between 0-21 were considered. Only four papers met our inclusion criteria: one randomised-control trial (RCT), one prospective study with retrospective chart review, and two retrospective chart reviews. All studies supported EEN and there was no recommendation of any delay in its initiation. The results of all four papers suggested EEN with a regular, normal-fat diet. EEN is safe in children with mild or moderately severe AP and may decrease the length of hospitalisation. Unfortunately, all the conclusions are based on a small amount of heterogeneous data that are mostly retrospective. Future prospective RCTs are needed.
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Affiliation(s)
- Jan Stanisław Bukowski
- Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warszawa, Poland
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19
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Kurti F, Xinxo S, Babameto A, Vyshka G. Nil per os or Enteral Nutrition in Mild and Moderately Severe Acute Pancreatitis: A Case Series. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.10653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: There are controversies regarding the treatment of mild-to-moderate pancreatitis, especially when comparing the efficacy of nil per os regime versus the nasogastric feeding. While some sources suggest the benefits of the nasogastric feeding, there are meager data available toward the impact of the selected treatment vis-à-vis the length of hospital stay, and as of the final outcome.
AIM: Authors collected data from two subgroups (treated with nil per os regime or nasogastric feeding, respectively) with the aim to define a safe and more efficacious regime.
METHODS: This case series collection was carried out in the University Hospital Center in Tirana (UHC) at the Service of Gastroenterology. The period of the study was January 1, 2018–December 31, 2019. The patients were divided into two subgroups (the control group had a nil per os regime and patients in the intervention group received a nasogastric feeding) according to approved inclusion and exclusion criteria.
RESULTS: Twenty subjects were allocated to the control group and 21 subjects were allocated to the intervention group. The length of hospital stay in the control group was 10.2 days compared with 8.4 days in the intervention group (p < 0.05). The days’ average spent with pain was 4.5 in the control group and 3.14 in the intervention group (p < 0.05). Oral feeding begun approximately 5.45 days since the admission in the control group and 3.14 days in the intervention group (p < 0.05). Oral food intolerance occurred in 6 patients (30%) in the control group and in one patient in the intervention group (4.8%) (p < 0.05).
CONCLUSIONS: Nasogastric feeding seems to have significant benefits in the treatment of mild to moderate acute pancreatitis, when compared with the nil per os regime. Nasogastric feeding reduces length of stay in hospital and improves early the clinical outcomes.
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20
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Dong S, Zhao Z, Li X, Chen Z, Jiang W, Zhou W. Efficacy of Glutamine in Treating Severe Acute Pancreatitis: A Systematic Review and Meta-Analysis. Front Nutr 2022; 9:865102. [PMID: 35774540 PMCID: PMC9237617 DOI: 10.3389/fnut.2022.865102] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 05/09/2022] [Indexed: 01/30/2023] Open
Abstract
Objectives The prognosis of severe acute pancreatitis (SAP) patients is closely related to early nutritional support. It is well-established that changes in glutamine (Gln), an important amino acid and nutritional supplement, can reflect disease severity. However, no consensus has been reached on the role of Gln nutrition therapy for SAP patients. We conducted this systematic review and meta-analysis to summarize and evaluate the advantages of Gln supplementation in SAP. Methods PubMed, Web of Science, the Embase, Cochrane Library, and Chinese databases (CNKI, SinoMed, Wanfang, and VIP) were systematically searched for eligible studies that included glutamine supplementation in SAP patients from inception to October 31 2021, excluding non-SAP studies. Primary outcome measures included mortality, APACHE II score, complications, and length of hospital stay. The meta-analysis was registered with PROSPERO (CRD42021288371) and was conducted using Review Manager and Stata softwares. Results This meta-analysis included 30 randomized controlled trials (RCTs) with a total of 1,201 patients. Six primary outcomes and six secondary outcomes were analyzed. For the primary outcomes, Gln supplementation was associated with lower mortality (OR = 0.38, 95% CI: 0.21-0.69, P = 0.001), total hospital stay (MD = -3.41, 95% CI: -4.93 to -1.88, P < 0.0001) and complications (OR = 0.45, 95% CI: 0.31-0.66, P < 0.0001) compared with conventional nutrition. Further subgroup analysis found that parenteral glutamine was more effective in reducing mortality. In terms of secondary outcomes, Gln supplementation helped restore liver, kidney and immune function, with significantly increased serum albumin (SMD = 1.02, 95% CI: 0.74-1.31, P < 0.00001) and IgG levels (MD = 1.24, 95% CI: 0.82-1.67, P < 0.00001), and decreased serum creatinine (Scr) (MD = -12.60, 95% CI: -21.97 to -3.24, P = 0.008), and inflammatory indicators such as C-reaction protein (CRP) (SMD = -1.67, 95% CI: -2.43 to -0.90, P < 0.0001). Conclusion Although Gln supplementation is not routinely recommended, it is beneficial for SAP patients. Indeed, glutamine nutrition has little effect on some indicator outcomes but contributes to improving the prognosis of this patient population.Systematic Review Registration: PROSPERO (york.ac.uk). Unique Identifier: CRD42021288371.
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Affiliation(s)
- Shi Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Zhenjie Zhao
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xin Li
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Zhou Chen
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Wenkai Jiang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Wence Zhou
- Department of General Surgery, Lanzhou University Second Hospital, Lanzhou, China
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21
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Ejaz A, Ahmad K, Khan ZI, Akhtar S, Sultana R, Nadeem M, Hussain MI, Elshikh MS. Assessment of cobalt in wheat grains as affected by diverse fertilizers: implications for public health. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:34558-34574. [PMID: 35041165 DOI: 10.1007/s11356-022-18528-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/02/2022] [Indexed: 06/14/2023]
Abstract
Present study was conducted to check the heavy metal content in wheat treated with municipal solid waste, Although municipal solid waste was enriched with organic nutrient, micronutrients, and macro-nutrients, considerable amount of cobalt was also witnessed in municipal solid waste that s why pot experiment was executed. The concentration of cobalt in different parts of wheat (root, shoot, and grain) was analyzed by atomic absorption spectrophotometer (AA-6300 Shimadzu Japan). Highest concentration of cobalt in root, shoot, and grain of wheat was observed in the range of 0.91-1.02 mg/kg, 0.92-1.04 mg/kg, and 0.93-1.00 mg/kg, respectively, under the influence of different fertilizer's used, while in field experiment, level of Co was greater in roots followed by shoots and grain. The metal concentration in wheat grown in field was ranged from 0.67 to 0.72 mg/kg for roots, 0.64 to 0.71 mg/kg for shoots, and 0.66 to 1.71 mg/kg for grains. Concentrations of cobalt were found below the permissible limits suggested by FAO/WHO. Various indices (PLI, BCF, DIM, HRI) were calculated and results showed that PLI was above 1 indicating that metal was causing pollution in treatments while value of BCF, DIM, and HRI was within the permissible range. Higher Co content in wheat may cause damage to the pancreatic cells of animals, cause respiratory problems, and effects their kidney, liver, and lungs, if exposure is for long period through feed.
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Affiliation(s)
- Abid Ejaz
- Department of Botany, University of Sargodha, Sargodha, Pakistan
| | - Kafeel Ahmad
- Department of Botany, University of Sargodha, Sargodha, Pakistan
| | - Zafar Iqbal Khan
- Department of Botany, University of Sargodha, Sargodha, Pakistan.
| | - Shahzad Akhtar
- Department of Botany, University of Sargodha, Sargodha, Pakistan
| | - Razia Sultana
- Department of Botany, University of Sargodha, Sargodha, Pakistan
| | - Muhammad Nadeem
- Instituteof Food Science and Nutrition, University of Sargodha, Sargodha, Pakistan
| | | | - Mohamed S Elshikh
- Department of Botany and Microbiology, College of Science, King Saud University, Riyadh, 11451, Saudi Arabia
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22
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Rai A, Anandhi A, Sureshkumar S, Kate V. Hunger-Based Versus Conventional Oral Feeding in Moderate and Severe Acute Pancreatitis: A Randomized Controlled Trial. Dig Dis Sci 2022; 67:2535-2542. [PMID: 33939143 PMCID: PMC8090517 DOI: 10.1007/s10620-021-06992-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/07/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The length of hospitalization is prolonged in patients with acute pancreatitis due to delay in feeding. The present study aimed at evaluating hunger-based early feeding for its efficacy in reducing length of hospitalisation. AIMS AND METHODS This was a parallel arm superiority randomized control trial. Patients with moderate and severe acute pancreatitis were randomised into hunger-based feeding and conventional feeding groups. Patients in hunger-based feeding group commenced feeding once they felt hungry and in conventional feeding group after normalization of biochemical parameters and resolution of symptoms. Patients were followed up till their discharge and were analyzed for length of hospitalisation, fasting duration, feed intolerance, incidence of infective morbidities and invasive procedures. RESULTS Hunger-based feeding and conventional feeding group included 56 and 54 patients, respectively. Hunger-based feeding led to a decrease in length of hospitalization (6.3 days in hunger-based feeding vs 7.3 days in conventional feeding group, P = 0.041) and fasting duration (1.6 days in hunger-based feeding vs 2.7 days in conventional feeding group, P = 0.001).The incidence of feed intolerance (P = 0.098), infective morbidities and invasive non-surgical procedures were similar in both the groups. CONCLUSION Hunger-based feeding significantly reduces length of hospitalization and fasting duration in cases of moderate and severe acute pancreatitis without any significant rise in the incidence of complications. Registration number of Clinical Trails Registry India CTRI/2019/01/017,144.
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Affiliation(s)
- Ashwin Rai
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Amaranathan Anandhi
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Sathasivam Sureshkumar
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Vikram Kate
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
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Ultrasound-Assisted versus Endoscopic Nasojejunal Tube Placement for Acute Pancreatitis: A Retrospective Feasibility Study. Gastroenterol Res Pract 2021; 2021:4903241. [PMID: 34650607 PMCID: PMC8510840 DOI: 10.1155/2021/4903241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 12/14/2022] Open
Abstract
Objective The optimal technique for nasojejunal tube (NJT) placement in terms of facilitating early enteral nutrition (EN) in patients with acute pancreatitis (AP) is unclear. In this study, we aimed to evaluate the impact of two common techniques on EN implementation and clinical outcomes in a group of AP patients. Methods This is a retrospective study. All the data were extracted from an electronic database from August 2015 to October 2017. Patients with a diagnosis of AP requiring NJT placement were retrospectively analyzed. The primary outcome was the successful procedural rate. Results A total of 53 eligible patients were enrolled, of whom 30 received an ultrasound-assisted technique and the rest received the endoscopy method (n = 23). There was no difference in success rates of initial placement procedures between the two groups (93.3% and 95.7% in the ultrasound-assisted group and endoscopy group, respectively). The mean amount of EN delivery within the first three days after NJT placement was significantly higher in the ultrasound-assisted group (841.4 kcal (95% CI: 738.8, 944 kcal) vs. 652.5 kcal (95% CI: 562.5, 742.6 kcal), P = 0.018). Moreover, a slight increased postprocedural intra-abdominal pressure (IAP) was observed in patients undergoing endoscopic procedures, but not in the ultrasound-assisted group, especially at 6 hours after NJT placement (0.35 vs. -2.01 from baseline, P < 0.05). For clinical outcomes, we observed no difference between groups. Conclusion Compared with endoscopic procedures, ultrasound-assisted NJT placement possesses the acceptable success rates of initial placement procedures.
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Early Enteral Nutrition is Related to Decreased In-hospital Mortality and Hospitalization in Patients with Acute Pancreatitis: Data from the Japanese Diagnosis Procedure Combination Database. J UOEH 2021; 43:313-321. [PMID: 34483190 DOI: 10.7888/juoeh.43.313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Management of early nutrition plays an important role in the treatment of acute pancreatitis patients, but the sample sizes of randomized control trials that have compared enteral and parental nutrition were small. From the data of Diagnostic Procedure Combination, we identified patients who had been diagnosed with acute pancreatitis and discharged from the hospital between 2014 and 2015. We compared the length of hospital stay and hospital mortality among patients with acute pancreatitis that was managed with and without enteral nutrition within 7 days from hospitalization. The results showed a significant decrease in the in-hospital mortality rate of 56% (odds ratio 0.444, 95% confidence interval [CI] 0.358 - 0.551, P < 0.001) and length of hospital stay by 8.6 days (95% CI -9.05 - -8.13, P < 0.001) when enteral nutrition was administered within 7 days. According to multivariate analysis, early enteral nutrition was independently associated with in-hospital mortality rate and length of hospitalization. Enteral nutrition is an important management method for the treatment of acute pancreatitis patients.
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Jabłońska B, Mrowiec S. Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards. Nutrients 2021; 13:1498. [PMID: 33925138 PMCID: PMC8145288 DOI: 10.3390/nu13051498] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/20/2021] [Accepted: 04/25/2021] [Indexed: 12/14/2022] Open
Abstract
Severe acute pancreatitis (SAP) leads to numerous inflammatory and nutritional disturbances. All SAP patients are at a high nutritional risk. It has been proven that proper nutrition significantly reduces mortality rate and the incidence of the infectious complications in SAP patients. According to the literature, early (started within 24-48 h) enteral nutrition (EN) is optimal in most patients. EN protects gut barrier function because it decreases gastrointestinal dysmotility secondary to pancreatic inflammation. Currently, the role of parenteral nutrition (PN) in SAP patients is limited to patients in whom EN is not possible or contraindicated. Early versus delayed EN, nasogastric versus nasojejunal tube for EN, EN versus PN in SAP patients and the role of immunonutrition (IN) in SAP patients are discussed in this review.
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Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, Medyków 14 St., 40752 Katowice, Poland;
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Yang AL. Nutrition and Acute Pancreatitis. J Clin Med 2021; 10:jcm10040836. [PMID: 33670647 PMCID: PMC7922255 DOI: 10.3390/jcm10040836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis (AP) is an acute inflammatory process of the pancreas that is characterized by severe abdominal pain, elevated pancreatic enzymes, and pancreatic changes on abdominal imaging. AP is, by nature, an inflammatory process that leads to protein catabolism and an increased metabolic rate, highlighting the strong need for early nutritional support in the initial management of the disease process. The goal of nutritional support in acute pancreatitis is to correct the negative nitrogen balance to reduce inflammation and improve outcomes. Many trials and multiple systemic reviews and meta-analyses have examined the best modality, timing, and composition of nutritional support for acute pancreatitis. Early enteral nutrition has emerged as an important aspect of the clinical management of AP. This narrative review aimed to provide an overview of the clinical management of nutrition in acute pancreatitis based on the currently available data.
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Affiliation(s)
- Allison L Yang
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY 10065, USA
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Pagliari D, Rinninella E, Cianci R, Attili F, Franza L, Luciano R, Mancarella FA, Rizzatti G, Musso M, Cintoni M, Gasbarrini A, Mele MC. Early oral vs parenteral nutrition in acute pancreatitis: a retrospective analysis of clinical outcomes and hospital costs from a tertiary care referral center. Intern Emerg Med 2020; 15:613-619. [PMID: 31620978 DOI: 10.1007/s11739-019-02210-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/01/2019] [Indexed: 12/22/2022]
Abstract
Nutritional support is a crucial issue in Acute Pancreatitis (AP) management. Recommendations on nutrition in AP are still not completely translated in the clinical practice. We aimed to compare and evaluate the effects of parenteral nutrition (PN) vs oral/enteral nutrition (EN) on several clinical and economic outcomes in AP. This is a retrospective monocentric study conducted in a tertiary care center for pancreatic diseases. The primary outcomes were length of hospital stay (LOS) and associated costs. The secondary outcomes were the use and cost of antibiotics and fluid therapy, and the complication's rates. One hundred seventy-one patients were included from January 2015 to January 2018. Patients were 69 (40.4%) in PN group and 102 (59.6%) in EN group. There was a significant reduction in LOS in EN vs PN group in both mild AP (p < 0.0001), and moderate-severe AP (p < 0.005). There was a significant reduction in the total hospitalization costs in EN group vs PN group in both mild AP (p < 0.0001), and moderate-severe AP (p < 0.005). There was a significant reduction in the total costs of antibiotics and pain therapy in EN vs PN group (p < 0.0001 and p = 0.05, respectively). Finally, a significant reduction in the infected peri-pancreatic fluid collections rate (p = 0.04) was observed in EN vs PN group. The use of EN in AP is associated with substantial clinical and economic benefits. Thus, the application of the standard of care in nutrition and following AP guidelines is the best way to cure patients and improve healthcare system costs.
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Affiliation(s)
- Danilo Pagliari
- Division of Internal Medicine and Gastroenterology and Pancreatic Unit, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Emanuele Rinninella
- Clinical Nutrition Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
| | - Rossella Cianci
- General Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Fabia Attili
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Laura Franza
- General Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Rosamaria Luciano
- Division of Internal Medicine and Gastroenterology and Pancreatic Unit, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Francesco A Mancarella
- Division of Internal Medicine and Gastroenterology and Pancreatic Unit, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Gianenrico Rizzatti
- Division of Internal Medicine and Gastroenterology and Pancreatic Unit, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Massimiliano Musso
- Division of Internal Medicine and Gastroenterology and Pancreatic Unit, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Marco Cintoni
- Clinical Nutrition Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
| | - Antonio Gasbarrini
- Division of Internal Medicine and Gastroenterology and Pancreatic Unit, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy
- Università Cattolica del Sacro Cuore, Roma, Italia
| | - Maria C Mele
- Clinical Nutrition Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
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Lakananurak N, Gramlich L. Nutrition management in acute pancreatitis: Clinical practice consideration. World J Clin Cases 2020; 8:1561-1573. [PMID: 32432134 PMCID: PMC7211526 DOI: 10.12998/wjcc.v8.i9.1561] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/06/2020] [Accepted: 04/20/2020] [Indexed: 02/05/2023] Open
Abstract
Acute pancreatitis (AP) is a common gastrointestinal disease and the leading cause of hospital admission and healthcare burden among gastrointestinal disorders in many countries. Patients can present with varying degrees of inflammation and disease severity, ranging from self-limiting mild AP to devastating and fatal severe AP. Many factors contribute to malnutrition in AP, especially abnormal metabolism and catabolism related to inflammation. The concept of “pancreatic rest” is not evidence-based. There is however, emerging evidence that supports the use of oral or enteral nutrition to improve nutrition status and to reduce local and systemic inflammation, complications, and death. In mild disease, patients are generally able to initiate solid oral diet and do not require specialized nutrition care such as enteral or parenteral nutrition. In contrast, nutrition interventions are imperative in moderately severe and severe AP. The current article aims to review the latest evidence and suggest practical nutrition interventions in patients with AP, including nutrition requirements, routes of nutrition treatment, types of formula, and the role of nutritional supplements, such as glutamine, probiotics, omega-3 fatty acids, and antioxidants.
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Affiliation(s)
- Narisorn Lakananurak
- Department of Medicine, University of Alberta, Edmonton T6G 2R3, Alberta, Canada
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton T6G 2R3, Alberta, Canada
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Dutta AK, Goel A, Kirubakaran R, Chacko A, Tharyan P. Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis. Cochrane Database Syst Rev 2020; 3:CD010582. [PMID: 32216139 PMCID: PMC7098540 DOI: 10.1002/14651858.cd010582.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Nutrition is an important aspect of management in severe acute pancreatitis. Enteral nutrition has advantages over parenteral nutrition and is the preferred method of feeding. Enteral feeding via nasojejunal tube is often recommended, but its benefits over nasogastric feeding are unclear. The placement of a nasogastric tube is technically simpler than the placement of a nasojejunal tube. OBJECTIVES To compare the mortality, morbidity, and nutritional status outcomes of people with severe acute pancreatitis fed via nasogastric tube versus nasojejunal tube. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS on 17 October 2019 without using any language restrictions. We also searched reference lists and conference proceedings for relevant studies and clinical trial registries for ongoing trials. We contacted authors for additional information. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing enteral feeding by nasogastric and nasojejunal tubes in participants with severe acute pancreatitis. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, assessed risk of bias of the included studies, and extracted data. This information was independently verified by the other review authors. We used standard methods expected by Cochrane to assess the risk of bias and perform data synthesis. We rated the certainty of evidence according to GRADE. MAIN RESULTS We included five RCTs that randomised a total of 220 adult participants from India, Scotland, and the USA. Two of the trial reports were available only as abstracts. The trials differed in the criteria used to rate the severity of acute pancreatitis, and three trials excluded those who presented in severe shock. The duration of onset of symptoms before presentation in the trials ranged from within one week to four weeks. The trials also differed in the methods used to confirm the placement of the tubes and in what was considered to be nasojejunal placement. We assessed none of the trials as at high risk of bias, though reporting of methods in four trials was insufficient to judge the risk of bias for one or more of the domains assessed. There was no evdence of effect with nasogastric or nasojejunal placement on the primary outcome of mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.36 to 1.17; I2 = 0%; 5 trials, 220 participants; very low-certainty evidence due to indirectness and imprecision). Similarly, there was no evidence of effect on the secondary outcomes for which data were available. These included organ failure (3 trials, 145 participants), rate of infection (2 trials, 108 participants), success rate (3 trials, 159 participants), complications associated with the procedure (2 trials, 80 participants), need for surgical intervention (3 trials, 145 participants), requirement of parenteral nutrition (2 trials, 80 participants), complications associated with feeds (4 trials, 195 participants), and exacerbation of pain (4 trials, 195 participants). However, the certainty of the evidence for these secondary outcomes was also very low due to indirectness and imprecision. Three trials (117 participants) reported on length of hospital stay, but the data were not suitable for meta-analysis. None of the trials reported data suitable for meta-analysis for the other secondary outcomes of this review, which included days taken to achieve full nutrition requirement, duration of tube feeding, and duration of analgesic requirement after feeding tube placement. AUTHORS' CONCLUSIONS There is insufficient evidence to conclude that there is superiority, inferiority, or equivalence between the nasogastric and nasojejunal mode of enteral tube feeding in people with severe acute pancreatitis.
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Affiliation(s)
- Amit Kumar Dutta
- Christian Medical College and HospitalDepartment of GastroenterologyIda Scudder RoadVelloreTamil NaduIndia632004
| | - Ashish Goel
- Christian Medical CollegeDepartment of Gastrointestinal SciencesIda Scudder RoadVelloreTamil NaduIndia632004
| | - Richard Kirubakaran
- Christian Medical CollegeCochrane South Asia, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreIndia632002
| | - Ashok Chacko
- Christian Medical College and HospitalDepartment of GastroenterologyIda Scudder RoadVelloreTamil NaduIndia632004
| | - Prathap Tharyan
- Christian Medical CollegeClinical Epidemiology Unit, Prof. BV Moses Centre for Evidence‐Informed Healthcare and Health PolicyCarman Block II FloorCMC Campus, BagayamVelloreTamil NaduIndia632002
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García-Rayado G, Cárdenas-Jaén K, de-Madaria E. Towards evidence-based and personalised care of acute pancreatitis. United European Gastroenterol J 2020; 8:403-409. [PMID: 32213025 DOI: 10.1177/2050640620903225] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis is a heterogeneous illness. Most patients experience a mild course of disease, but one third will develop local complications and/or organ failure associated with increased morbidity and risk of mortality. Diagnosis of acute pancreatitis is based on typical epigastric pain, elevation of serum lipase or amylase levels, and/or characteristic findings on imaging. Personalised management is needed in patients with acute pancreatitis. Currently, analgesia, Ringer's lactate solution-based goal-directed fluid resuscitation and early oral refeeding providing enteral nutrition if not tolerated are the cornerstones for early management. Prophylactic antibiotics or endoscopic retrograde cholangiopancreatography in the absence of cholangitis are considered to be futile. Future clinical trials should address optimal fluid resuscitation, the early administration of anti-inflammatory drugs and the exact role of nutritional support in severe acute pancreatitis. Here, we present a patient case and review the diagnosis, treatment and prognosis of acute pancreatitis.
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Affiliation(s)
- Guillermo García-Rayado
- Service of Digestive Diseases, University Clinic Hospital Lozano Blesa, Aragón Health Research Institute (IIS Aragón), Zaragoza, Spain
| | - Karina Cárdenas-Jaén
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Enrique de-Madaria
- Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
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Xu MM, Andalib I, Novikov A, Dawod E, Gabr M, Gaidhane M, Tyberg A, Kahaleh M. Endoscopic Therapy for Pancreatic Fluid Collections: A Definitive Management Using a Dedicated Algorithm. Clin Endosc 2019; 53:355-360. [PMID: 31794655 PMCID: PMC7280836 DOI: 10.5946/ce.2019.113] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic ultrasonography (EUS)-guided drainage is the preferred approach for infected or symptomatic pancreatic fluid collections (PFCs). Here, we developed an algorithm for the management of pancreatitis complicated by PFCs and report on its effcacy and safety. METHODS Between September 2011 and October 2017, patients were prospectively managed according to the algorithm. PFCs were classified as poorly organized fluid collections (POFCs), pancreatic pseudocysts (PPs), or walled-off pancreatic necrosis (WOPN). Clinical success was defined as a decrease in PFC size by ≥50% of the maximal diameter or to ≤2 cm. RESULTS A total of 108 patients (62% male; mean age, 53 years) were included: 13 had POFCs, 43 had PPs, and 52 had WOPN. Seventytwo patients (66%) required a pancreatic duct (PD) stent, whereas 65 (60%) received enteral feeding. A total of 103 (95%) patients achieved clinical success. Eight patients experienced complications including bleeding (n=6) and surgical intervention (n=2). Patients with enteral feeding were 3.4 times more likely to achieve resolution within 60 days (p=0.0421), whereas those with PD stenting was five times more likely to achieve resolution within 90 days (p=0.0069). CONCLUSION A high PFC resolution rate can be achieved when a dedicated algorithm encompassing EUS-guided drainage, PD stenting, and early enteral feeding is adopted.
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Affiliation(s)
- Ming Ming Xu
- Division of Gastroenterology, Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Iman Andalib
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Aleksey Novikov
- Division of Gastroenterology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Enad Dawod
- Division of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Moamen Gabr
- Division of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Monica Gaidhane
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Amy Tyberg
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Michel Kahaleh
- Division of Gastroenterology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Abstract
The risks, measurements of severity, and management of severe acute pancreatitis and its complications have evolved rapidly over the past decade. Evidence suggests that initial goal directed therapy, nutritional support, and vigilance for pancreatic complications are best practice. Patients can develop pancreatic fluid collections including acute pancreatic fluid collections, pancreatic pseudocysts, acute necrotic collections, and walled-off necrosis. Several randomized controlled trials and cohort studies have recently highlighted the advantage of managing these conditions with a progressive approach, with initial draining for infection followed by less invasive techniques. Surgery is no longer an early intervention and may not be needed. Instead, interventional radiologic and endoscopic methods seem to be safer with at least as good survival outcomes. Newly developed evidence based quality indicators are available to assess and improve performance. Development and clinical testing of drugs to target the mechanisms of disease are necessary for further advancements.
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Affiliation(s)
- O Joe Hines
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-6904, USA
| | - Stephen J Pandol
- Department of Medicine, Cedar-Sinai Medical Center, Los Angeles, CA 90048, USA
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Lin Y, He S, Gong J, Ding X, Liu Z, Gong J, Zeng Z, Cheng Y. Continuous veno-venous hemofiltration for severe acute pancreatitis. Cochrane Database Syst Rev 2019; 10:CD012959. [PMID: 31618443 PMCID: PMC6953293 DOI: 10.1002/14651858.cd012959.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Severe acute pancreatitis is associated with high rates of mortality and life-threatening complications. Continuous veno-venous hemofiltration (CVVH) has been used in some centers to reduce mortality and avoid local or systemic complications, however its efficiency and safety is uncertain. OBJECTIVES To assess the benefits and harms of CVVH in patients suffering from severe acute pancreatitis; to compare the effects of different CVVH techniques; and to evaluate the optimal time for delivery of CVVH. SEARCH METHODS We searched the Cochrane Library (2019, Issue 8), MEDLINE (1946 to 13 September 2019), Embase (1974 to 13 September 2019), and Science Citation Index Expanded (1982 to 13 September 2019). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared CVVH versus no CVVH in participants with severe acute pancreatitis. We also included RCTs that compared different types of CVVH and different schedules for CVVH in participants with severe acute pancreatitis. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes, and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included two studies, involving a total of 94 participants, in the review.Continuous veno-venous hemofiltration versus no interventionWe included one study in which 64 participants with severe acute pancreatitis were randomized to undergo CVVH (32 participants) or no intervention (32 participants). There were no deaths in either group (very low-quality evidence). Adverse events, length of stay in the intensive care unit (ICU), length of hospital stay, total hospital cost, and quality of life were not reported in the study.One type of continuous veno-venous hemofiltration versus a different type of continuous veno-venous hemofiltrationWe included one study in which 30 participants with severe acute pancreatitis were randomized to undergo high-volume CVVH (15 participants) or standard CVVH (15 participants). High-volume CVVH may lead to little or no difference in in-hospital mortality rates (20.0% in the high-volume CVVH group versus 33.3% in the standard CVVH group; risk ratio (RR) 0.60, 95% confidence interval (CI) 0.17 to 2.07; 30 participants; 1 study; low-quality evidence). We are uncertain whether high-volume hemofiltration reduces rates of adverse events (13.3% in both groups; RR 1.00, 95% CI 0.16 to 6.20; 30 participants; 1 study; very low-quality evidence). Length of ICU stay, length of hospital stay, total hospital cost, and quality of life were not reported in the study. AUTHORS' CONCLUSIONS The quality of the current evidence is very low or low. For both comparisons addressed in this review, data are sparse. It is unclear whether CVVH has any effect on mortality or complications in patients with severe acute pancreatitis. It is also unclear whether high-volume CVVH is superior, equivalent or inferior to standard CVVH in patients with severe acute pancreatitis.
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Affiliation(s)
- Yanjun Lin
- Department of Urology, The Second Affiliated Hospital, Chongqing Medical University, No. 74, Lin Jiang Road, Chongqing, China, 400010
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Quality of Care Indicators in Patients with Acute Pancreatitis. Dig Dis Sci 2019; 64:2514-2526. [PMID: 31152333 DOI: 10.1007/s10620-019-05674-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 05/15/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP. AIMS To define quality of care in patients with AP by developing explicit QIs using standardized techniques. METHODS We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP. RESULTS We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management. CONCLUSIONS We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.
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Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8081098. [PMID: 31349549 PMCID: PMC6723806 DOI: 10.3390/jcm8081098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/06/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022] Open
Abstract
Liver, pancreatic, and inflammatory bowel diseases are often associated with nutritional difficulties and necessitate an adequate nutritional therapy in order to support the medical treatment. As most patients with non-alcoholic fatty liver disease are overweight or obese, guidelines recommend weight loss and physical activity to improve liver enzymes and avoid liver cirrhosis. In contrast, patients with alcoholic steatohepatitis or liver cirrhosis have a substantial risk for protein depletion, trace elements deficiency, and thus malnutrition. Patients with chronic pancreatitis and patients with inflammatory bowel disease have a similar risk for malnutrition. Therefore, it clearly is important to screen these patients for malnutrition with established tools and initiate adequate nutritional therapy. If energy and protein intake are insufficient with regular meals, oral nutritional supplements or artificial nutrition, i.e., tube feeding or parenteral nutrition, should be used to avoid or treat malnutrition. However, the oral route should be preferred over enteral or parenteral nutrition. Acute liver failure and acute pancreatitis are emergencies, which require close monitoring for the treatment of metabolic disturbances. In most patients, energy and protein requirements are increased. In acute pancreatitis, the former recommendation of fasting is obsolete. Each disease is discussed in this manuscript and special recommendations are given according to the pathophysiology and clinical routine.
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Infection rate among nutritional therapies for acute pancreatitis: A systematic review with network meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0219151. [PMID: 31291306 PMCID: PMC6620007 DOI: 10.1371/journal.pone.0219151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infection in acute pancreatitis (AP) is associated with nutritional therapies including naso-gastric (NG), naso-jejunal (NJ), and total parenteral nutrition (TPN). To examine infections among NG, NJ, TPN, and no nutritional support (NNS) in treating patients with AP. Methods The investigators completed comprehensive search in the Cochrane library, EMBASE, PubMed, Web of Science, and ClinicalTrials.gov without restriction on language and publication date before January 21, 2019. They also searched the reference lists of relevant studies for randomized controlled trials (RCTs) comparing NG, NJ, TPN, and NNS among patients with AP. Quantitative synthesis was conducted in a contrast-based network meta-analysis. To clarify effects, a network meta-analysis was conducted to calculate the surface under the cumulative ranking curve (SUCRA). Beside of overall infections, the event rates of infected pancreatic necrosis, bacteremia, line infection, pneumonia, urinary tract infection, and other types of infections were measured. Results The network meta-analysis of 16 RCTs showed that NJ had significantly lower overall infection rates compared with TPN (risk ratio: 0.59; 95% confidence interval: 0.38, 0.90); and NG had a larger effect size and higher rank probability compared with NJ, TPN, and NNS (mean rank = 1.7; SUCRA = 75.8). TPN was the least preferred (mean rank = 3.2; SUCRA = 26.6). Conclusions NG and NJ may be preferred therapies for treating patients with AP. Clinicians may consider NG as a first-line treatment for patients with AP (including severe AP) and even in patients receiving prophylactic antibiotics. In addition, we found that NNS should be avoided when treating patients with severe AP.
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Goodchild G, Chouhan M, Johnson GJ. Practical guide to the management of acute pancreatitis. Frontline Gastroenterol 2019; 10:292-299. [PMID: 31288253 PMCID: PMC6583768 DOI: 10.1136/flgastro-2018-101102] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/09/2018] [Indexed: 02/04/2023] Open
Abstract
Acute pancreatitis (AP) is characterised by inflammation of the exocrine pancreas and is associated with acinar cell injury and both a local and systemic inflammatory response. AP may range in severity from self-limiting, characterised by mild pancreatic oedema, to severe systemic inflammation with pancreatic necrosis, organ failure and death. Several international guidelines have been developed including those from the joint International Association of Pancreatology and American Pancreatic Association, American College of Gastroenterology and British Society of Gastroenterology. Here we discuss current diagnostic and management challenges and address the common dilemmas in AP.
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Affiliation(s)
- George Goodchild
- Department of Gastroenterology, University College Hospital, London, UK
| | - Manil Chouhan
- Department of Radiology, University College Hospital, London, UK
| | - Gavin J Johnson
- Department of Gastroenterology, University College Hospital, London, UK
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Choi K, Flynn DE, Karunairajah A, Hughes A, Bhasin A, Devereaux B, Chandrasegaram MD. Management of infected pancreatic necrosis in the setting of concomitant rectal cancer: A case report and review of literature. World J Gastrointest Surg 2019; 11:237-246. [PMID: 31123561 PMCID: PMC6513786 DOI: 10.4240/wjgs.v11.i4.237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/26/2019] [Accepted: 04/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatitis with infected necrosis is a severe complication of acute pancreatitis and carries with it high rates of morbidity and mortality. The management of infected pancreatic necrosis alongside concomitant colorectal cancer has never been described in literature.
CASE SUMMARY A 77 years old gentleman presented to the Emergency Department of our hospital complaining of ongoing abdominal pain for 8 h. The patient had clinical features of pancreatitis with a raised lipase of 3810 U/L, A computed tomography (CT) abdomen confirmed pancreatitis with extensive peri-pancreatic edema. During the course of his admission, the patient had persistent high fevers and delirium thought secondary to infected necrosis, prompting the commencement of broad-spectrum antibiotic therapy with Piperacillin/Tazobactam. Subsequent CT abdomen confirmed extensive pancreatic necrosis (over 70%). Patient was managed with supportive therapy, nutritional support and gut rest initially and improved over the course of his admission and was discharged 42 d post admission. He represented 24 d following his discharge with fever and chills and a repeat CT abdomen scan noted gas bubbles within the necrotic pancreatic tissue thereby confirming infected necrotic pancreatitis. This CT scan also revealed asymmetric thickening of the rectal wall suspicious for malignancy. A rectal cancer was confirmed on flexible sigmoidoscopy. The patient underwent two endoscopic necrosectomies and was treated with intravenous antibiotics and was discharged after 28 d. Within 1 wk post discharge, the patient commenced a course of neoadjuvant radiotherapy and subsequently underwent concomitant chemotherapy prior to undergoing a successful Hartmann’s procedure for treatment of his colorectal cancer.
CONCLUSION This case highlights the efficacy of endoscopic necrosectomy, early enteral feeding and targeted antibiotic therapy for timely management of infected necrotic pancreatitis. The prompt resolution of pancreatitis permitted the patient to undergo neoadjuvant treatment and resection for his concomitant colorectal cancer.
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Affiliation(s)
- Kihoon Choi
- Department of Surgery, Gold Coast University Hospital, Southport, QLD 4215, Australia
| | - David E Flynn
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Anitha Karunairajah
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Andrew Hughes
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Ambika Bhasin
- Department of Radiology, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Benedict Devereaux
- Department of Gastroenterology, Royal Brisbane and Women’s Hospital, Brisbane, QLD 4029, Australia
| | - Manju D Chandrasegaram
- Department of General Surgery, the Prince Charles Hospital, Brisbane, QLD 4032, Australia
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Di Martino M, Madden AM, Gurusamy KS. Nutritional supplementation in enteral and parenteral nutrition for people with acute pancreatitis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Angela M Madden
- University of Hertfordshire; Biological & Environmental Sciences; College Lane Hatfield Hertfordshire UK AL10 9AB
| | - Kurinchi Selvan Gurusamy
- University College London; Division of Surgery and Interventional Science; 9th Floor, Royal Free Hospital Rowland Hill Street London UK NW3 2PF
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van Laarhoven S, Di Martino M, Gurusamy KS. Fluid therapy protocols in people with acute pancreatitis. Hippokratia 2018. [DOI: 10.1002/14651858.cd013159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical School; Department of Surgery; Royal Free Hospital Rowland Hill Street London UK NW3 2PF
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Impact of continuous regional arterial infusion in the treatment of acute necrotizing pancreatitis: analysis of a national administrative database. J Gastroenterol 2018; 53:1098-1106. [PMID: 29564566 DOI: 10.1007/s00535-018-1452-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/16/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although continuous regional arterial infusion (CRAI) of protease inhibitors and broad antibiotics has been suggested as one of the therapeutic option for patients with acute necrotic pancreatitis (ANP), the effectiveness has not been well-corroborated in clinical studies. METHODS We conducted a retrospective cohort study using a Japanese national administrative database. Severe acute pancreatitis patients with a poorly enhanced pancreas region (i.e., definitive or clinically suspected ANP) were identified and dichotomized according to whether CRAI was performed. We compared the outcomes of in-hospital mortality, surgical interventions, hospital-free days, and healthcare costs between groups adjusted by the well-validated case-mix adjustment model using a multivariate mixed-effect regression analysis and a propensity score matching analysis. RESULTS Of 243,312 acute pancreatitis patients, 702 eligible patients were identified, of these 339 patients underwent CRAI. The case-mix adjustment model established had good predictability for in-hospital mortality with an area under the receiver operating characteristics curve of 0.87. CRAI was significantly associated with reduced in-hospital mortality [14.5% in the CRAI group vs. 18.2% in the non-CRAI group, adjusted odds ratio (95% confidence interval; CI) = 0.60 (0.36-0.97)]. Significant associations were not observed for the frequency of surgical interventions and mean hospital-free days; however, significantly higher healthcare costs were observed in the CRAI group. Results of the propensity score matching analysis did not alter these results. CONCLUSIONS Analysis of a nationwide large-scale database suggested that CRAI was significantly associated with reduced in-hospital mortality for patients with ANP. Further randomized controlled trials are warranted.
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Herbers U, Trautwein C, Tacke F, Koch A. [Diagnosis and stage-adapted treatment of acute pancreatitis]. Med Klin Intensivmed Notfmed 2018; 113:593-605. [PMID: 30094503 DOI: 10.1007/s00063-018-0466-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/04/2018] [Indexed: 10/28/2022]
Abstract
Acute pancreatitis is a potentially life-threatening disease, which is morphologically classified into interstitial edematous or necrotizing pancreatitis. According to the revised Atlanta classification, mild, moderate and severe clinical courses are differentiated regarding local and systemic complications as well as concomitant organ failure. In the initial disease phase, the therapeutic measures are focused on (aggressive) volume replacement, early enteral nutrition and adequate analgesia. Characteristic in the course of severe acute pancreatitis are abdominal necroses, which require individualized and interdisciplinary treatment with antibiotic therapy, drainage and definitive necrosectomy. Necrosectomy should be planned as a "step-up approach" using interventional-radiological, endoscopic and minimally invasive surgical procedures.
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Affiliation(s)
- U Herbers
- Medizinische Klinik III (Gastroenterologie, Stoffwechselerkrankungen und Internistische Intensivmedizin), Universitätsklinikum, RWTH-Aachen, Pauwelsstraße 30, 52072, Aachen, Deutschland
| | - C Trautwein
- Medizinische Klinik III (Gastroenterologie, Stoffwechselerkrankungen und Internistische Intensivmedizin), Universitätsklinikum, RWTH-Aachen, Pauwelsstraße 30, 52072, Aachen, Deutschland
| | - F Tacke
- Medizinische Klinik III (Gastroenterologie, Stoffwechselerkrankungen und Internistische Intensivmedizin), Universitätsklinikum, RWTH-Aachen, Pauwelsstraße 30, 52072, Aachen, Deutschland
| | - A Koch
- Medizinische Klinik III (Gastroenterologie, Stoffwechselerkrankungen und Internistische Intensivmedizin), Universitätsklinikum, RWTH-Aachen, Pauwelsstraße 30, 52072, Aachen, Deutschland.
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Gut-origin sepsis in the critically ill patient: pathophysiology and treatment. Infection 2018; 46:751-760. [PMID: 30003491 DOI: 10.1007/s15010-018-1178-5] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/06/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gut permeability is increased in critically ill patients, and associated with the development of the systemic inflammatory response syndrome and multiple organ dysfunction syndrome (MODS). The pathogenetic link(s) and potential therapies are an area of intense research over the last decades. METHODS We thoroughly reviewed the literature on gut-origin sepsis and MODS in critically ill patients, with emphasis on the implicated pathophysiological mechanisms and therapeutic interventions. FINDINGS Intestinal barrier failure leading to systemic bacterial translocation associated with MODS was the predominant pathophysiological theory for several years. However, clinical studies with critically ill patients failed to provide the evidence of systemic spread of gut-derived bacteria and/or their products as a cause of MODS. Newer experimental data highlight the role of the mesenteric lymph as a carrier of gut-derived danger-associated molecular patterns (DAMPs) to the lung and the systemic circulation. These substances are recognized by pattern recognition receptor-bearing cells in diverse tissues and promote proinflammatory pathways and the development MODS. Therefore, the gut becomes a pivotal proinflammatory organ, driving the systemic inflammatory response through DAMPs release in mesenteric lymph, without the need for systemic bacterial translocation. CONCLUSIONS There is an emerging need for application of sensitive non-invasive and easily measured biomarkers of early intestinal injury (e.g., citrulline, intestinal fatty acid protein, and zonulin) in our everyday clinical practice, guiding the early pharmacological intervention in critically ill patients to restore or prevent intestinal injury and improve their outcomes.
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Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group. J Pediatr Gastroenterol Nutr 2018; 67:131-143. [PMID: 29927872 PMCID: PMC6020697 DOI: 10.1097/mpg.0000000000002023] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed. METHODS This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified. RESULTS AND DISCUSSION The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies. CONCLUSIONS This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.
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Li W, Liu J, Zhao S, Li J. Safety and efficacy of total parenteral nutrition versus total enteral nutrition for patients with severe acute pancreatitis: a meta-analysis. J Int Med Res 2018; 46:3948-3958. [PMID: 29962261 PMCID: PMC6136006 DOI: 10.1177/0300060518782070] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective This study was performed to systematically compare the safety and efficacy of
total enteral nutrition (TEN) and total parenteral nutrition (TPN) for
patients with severe acute pancreatitis (SAP). Methods The PubMed database was searched up to January 2017, and nine studies were
retrieved. These studies were selected according to specific eligibility
criteria. The methodological quality of each trial was assessed, and the
study design, interventions, participant characteristics, and final results
were then analyzed by Review Manager 5.3 (The Nordic Cochrane Centre, The
Cochrane Collaboration, Copenhagen, Denmark). Results Nine relevant randomized controlled trials involving 500 patients (244
patients in the TEN group and 256 patients in the TPN group) were included
in the meta-analysis. Pooled analysis showed a significantly lower mortality
rate in the TEN than TPN group [odds ratio (OR), 0.31; 95% confidence
interval (CI), 0.18–0.54]. The duration of hospitalization was significantly
shorter in the TEN than TPN group (mean difference, −0.59; 95% CI,
−2.56–1.38). Compared with TPN, TEN had a lower risk of pancreatic infection
and related complications (OR, 0.41; 95% CI, 0.22–0.77), organ failure (OR,
0.17; 95% CI, 0.06–0.52), and surgical intervention (OR, 0.17; 95% CI,
0.05–0.62). Conclusions This meta-analysis indicates that TEN is safer and more effective than TPN
for patients with SAP. When both TEN and TPN have a role in the management
of SAP, TEN is the preferred option.
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Affiliation(s)
- Wen Li
- 2 Department of Surgical Intensive Care Unit, China-Japan Friendship Hospital, Yinghuadongjie, Chaoyang District, Beijing 100029, China
| | - Jixi Liu
- 1 Department of Gastroenterology, China-Japan Friendship Hospital, Yinghuadongjie, Chaoyang District, Beijing 100029, China
| | - Shuqiao Zhao
- 3 Department of Gastroenterology, The First Hospital of Shijiazhuang, Shijiazhuang, Hebei province 050011, China
| | - Jingtao Li
- 1 Department of Gastroenterology, China-Japan Friendship Hospital, Yinghuadongjie, Chaoyang District, Beijing 100029, China
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Lewis SR, Schofield‐Robinson OJ, Alderson P, Smith AF. Enteral versus parenteral nutrition and enteral versus a combination of enteral and parenteral nutrition for adults in the intensive care unit. Cochrane Database Syst Rev 2018; 6:CD012276. [PMID: 29883514 PMCID: PMC6353207 DOI: 10.1002/14651858.cd012276.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Critically ill people are at increased risk of malnutrition. Acute and chronic illness, trauma and inflammation induce stress-related catabolism, and drug-induced adverse effects may reduce appetite or increase nausea and vomiting. In addition, patient management in the intensive care unit (ICU) may also interrupt feeding routines. Methods to deliver nutritional requirements include provision of enteral nutrition (EN), or parenteral nutrition (PN), or a combination of both (EN and PN). However, each method is problematic. This review aimed to determine the route of delivery that optimizes uptake of nutrition. OBJECTIVES To compare the effects of enteral versus parenteral methods of nutrition, and the effects of enteral versus a combination of enteral and parenteral methods of nutrition, among critically ill adults, in terms of mortality, number of ICU-free days up to day 28, and adverse events. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase on 3 October 2017. We searched clinical trials registries and grey literature, and handsearched reference lists of included studies and related reviews. SELECTION CRITERIA We included randomized controlled studies (RCTs) and quasi-randomized studies comparing EN given to adults in the ICU versus PN or versus EN and PN. We included participants that were trauma, emergency, and postsurgical patients in the ICU. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 25 studies with 8816 participants; 23 studies were RCTs and two were quasi-randomized studies. All included participants were critically ill in the ICU with a wide range of diagnoses; mechanical ventilation status between study participants varied. We identified 11 studies awaiting classification for which we were unable to assess eligibility, and two ongoing studies.Seventeen studies compared EN versus PN, six compared EN versus EN and PN, two were multi-arm studies comparing EN versus PN versus EN and PN. Most studies reported randomization and allocation concealment inadequately. Most studies reported no methods to blind personnel or outcome assessors to nutrition groups; one study used adequate methods to reduce risk of performance bias.Enteral nutrition versus parenteral nutritionWe found that one feeding route rather than the other (EN or PN) may make little or no difference to mortality in hospital (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.80 to 1.77; 361 participants; 6 studies; low-certainty evidence), or mortality within 30 days (RR 1.02, 95% CI 0.92 to 1.13; 3148 participants; 11 studies; low-certainty evidence). It is uncertain whether one feeding route rather than the other reduces mortality within 90 days because the certainty of the evidence is very low (RR 1.06, 95% CI 0.95 to 1.17; 2461 participants; 3 studies). One study reported mortality at one to four months and we did not combine this in the analysis; we reported this data as mortality within 180 days and it is uncertain whether EN or PN affects the number of deaths within 180 days because the certainty of the evidence is very low (RR 0.33, 95% CI 0.04 to 2.97; 46 participants).No studies reported number of ICU-free days up to day 28, and one study reported number of ventilator-free days up to day 28 and it is uncertain whether one feeding route rather than the other reduces the number of ventilator-free days up to day 28 because the certainty of the evidence is very low (mean difference, inverse variance, 0.00, 95% CI -0.97 to 0.97; 2388 participants).We combined data for adverse events reported by more than one study. It is uncertain whether EN or PN affects aspiration because the certainty of the evidence is very low (RR 1.53, 95% CI 0.46 to 5.03; 2437 participants; 2 studies), and we found that one feeding route rather than the other may make little or no difference to pneumonia (RR 1.10, 95% CI 0.82 to 1.48; 415 participants; 7 studies; low-certainty evidence). We found that EN may reduce sepsis (RR 0.59, 95% CI 0.37 to 0.95; 361 participants; 7 studies; low-certainty evidence), and it is uncertain whether PN reduces vomiting because the certainty of the evidence is very low (RR 3.42, 95% CI 1.15 to 10.16; 2525 participants; 3 studies).Enteral nutrition versus enteral nutrition and parenteral nutritionWe found that one feeding regimen rather than another (EN or combined EN or PN) may make little or no difference to mortality in hospital (RR 0.99, 95% CI 0.84 to 1.16; 5111 participants; 5 studies; low-certainty evidence), and at 90 days (RR 1.00, 95% CI 0.86 to 1.18; 4760 participants; 2 studies; low-certainty evidence). It is uncertain whether combined EN and PN leads to fewer deaths at 30 days because the certainty of the evidence is very low (RR 1.64, 95% CI 1.06 to 2.54; 409 participants; 3 studies). It is uncertain whether one feeding regimen rather than another reduces mortality within 180 days because the certainty of the evidence is very low (RR 1.00, 95% CI 0.65 to 1.55; 120 participants; 1 study).No studies reported number of ICU-free days or ventilator-free days up to day 28. It is uncertain whether either feeding method reduces pneumonia because the certainty of the evidence is very low (RR 1.40, 95% CI 0.91 to 2.15; 205 participants; 2 studies). No studies reported aspiration, sepsis, or vomiting. AUTHORS' CONCLUSIONS We found insufficient evidence to determine whether EN is better or worse than PN, or than combined EN and PN for mortality in hospital, at 90 days and at 180 days, and on the number of ventilator-free days and adverse events. We found fewer deaths at 30 days when studies gave combined EN and PN, and reduced sepsis for EN rather than PN. We found no studies that reported number of ICU-free days up to day 28. Certainty of the evidence for all outcomes is either low or very low. The 11 studies awaiting classification may alter the conclusions of the review once assessed.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Shah AP, Mourad MM, Bramhall SR. Acute pancreatitis: current perspectives on diagnosis and management. J Inflamm Res 2018; 11:77-85. [PMID: 29563826 PMCID: PMC5849938 DOI: 10.2147/jir.s135751] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.
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Affiliation(s)
- Adarsh P Shah
- Department of Surgery, Hereford County Hospital, Hereford, UK
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Cheng Y, Gong J, Ding X, Liu Z, Gong J, Zeng Z. Continuous veno‐venous hemofiltration for severe acute pancreatitis. Cochrane Database Syst Rev 2018; 2018:CD012959. [PMCID: PMC6491106 DOI: 10.1002/14651858.cd012959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the benefits and harms of CVVH in people suffering from severe acute pancreatitis, compare the effects of different CVVH techniques, and evaluate the optimal time for delivery of CVVH.
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Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
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Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2018; 66:159-176. [PMID: 29280782 PMCID: PMC5755713 DOI: 10.1097/mpg.0000000000001715] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed. METHODS The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation. RESULTS The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP. CONCLUSIONS This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.
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Pan LL, Li J, Shamoon M, Bhatia M, Sun J. Recent Advances on Nutrition in Treatment of Acute Pancreatitis. Front Immunol 2017; 8:762. [PMID: 28713382 PMCID: PMC5491641 DOI: 10.3389/fimmu.2017.00762] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/16/2017] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis (AP) is a common abdominal acute inflammatory disorder and the leading cause of hospital admission for gastrointestinal disorders in many countries. Clinical manifestations of AP vary from self-limiting local inflammation to devastating systemic pathological conditions causing significant morbidity and mortality. To date, despite extensive efforts in translating promising experimental therapeutic targets in clinical trials, disease-specific effective remedy remains obscure, and supportive care has still been the primary treatment for this disease. Emerging evidence, in light of the current state of pathophysiology of AP, has highlighted that strategic initiation of nutrition with appropriate nutrient supplementation are key to limit local inflammation and to prevent or manage AP-associated complications. The current review focuses on recent advances on nutritional interventions including enteral versus parenteral nutrition strategies, and nutritional supplements such as probiotics, glutamine, omega-3 fatty acids, and vitamins in clinical AP, hoping to advance current knowledge and practice related to nutrition and nutritional supplements in clinical management of AP.
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Affiliation(s)
- Li-Long Pan
- School of Medicine, Jiangnan University, Wuxi, China
| | - Jiahong Li
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China
- Nutrition and Immunology Laboratory, School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Muhammad Shamoon
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China
- Nutrition and Immunology Laboratory, School of Food Science and Technology, Jiangnan University, Wuxi, China
| | - Madhav Bhatia
- Inflammation Research Group, Department of Pathology, University of Otago, Christchurch, New Zealand
| | - Jia Sun
- State Key Laboratory of Food Science and Technology, Jiangnan University, Wuxi, China
- Nutrition and Immunology Laboratory, School of Food Science and Technology, Jiangnan University, Wuxi, China
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