Nutritional Management of Acute Pancreatitis

Nutritional Support in Pancreatic Diseases

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.

Fighting Fire with Fire: Exosomes and Acute Pancreatitis-Associated Acute Lung Injury

Acute pancreatitis (AP) is a prevalent clinical condition of the digestive system, with a growing frequency each year. Approximately 20% of patients suffer from severe acute pancreatitis (SAP) with local consequences and multi-organ failure, putting a significant strain on patients' health insurance. According to reports, the lungs are particularly susceptible to SAP. Acute respiratory distress syndrome, a severe type of acute lung injury (ALI), is the primary cause of mortality among AP patients. Controlling the mortality associated with SAP requires an understanding of the etiology of AP-associated ALI, the discovery of biomarkers for the early detection of ALI, and the identification of potentially effective drug treatments. Exosomes are a class of extracellular vesicles with a diameter of 30-150 nm that are actively released into tissue fluids to mediate biological functions. Exosomes are laden with bioactive cargo, such as lipids, proteins, DNA, and RNA. During the initial stages of AP, acinar cell-derived exosomes suppress forkhead box protein O1 expression, resulting in M1 macrophage polarization. Similarly, macrophage-derived exosomes activate inflammatory pathways within endothelium or epithelial cells, promoting an inflammatory cascade response. On the other hand, a part of exosome cargo performs tissue repair and anti-inflammatory actions and inhibits the cytokine storm during AP. Other reviews have detailed the function of exosomes in the development of AP, chronic pancreatitis, and autoimmune pancreatitis. The discoveries involving exosomes at the intersection of AP and acute lung injury (ALI) are reviewed here. Furthermore, we discuss the therapeutic potential of exosomes in AP and associated ALI. With the continuous improvement of technological tools, the research on exosomes has gradually shifted from basic to clinical applications. Several exosome-specific non-coding RNAs and proteins can be used as novel molecular markers to assist in the diagnosis and prognosis of AP and associated ALI.

Nutrition in acute pancreatitis: when, what and how

PURPOSE OF REVIEW

This review intends to discuss recently available evidence in three topics related to nutrition in patients with acute pancreatitis, namely timing of refeeding, type of nutritional therapy and its route of administration.

RECENT FINDINGS

Recent lines of research confirm that early oral feeding leads to shorter length of stay, fewer complications and lower costs in patients with acute pancreatitis. Moreover, early (<48 h) enteral nutrition led to decreased hospital mortality in patients with mild and severe acute pancreatitis; thus, in case of intolerance to oral feeding or severe disease, nutritional therapy should be offered within 24-72 h. Furthermore, enteral nutrition should be preferred against parenteral nutrition, as it is related to shorter length of stay and less complications, while initial data bring to light the potential role of the soluble dietary fibre polydextrose as an agent that could lead to faster achievement of energy goal with concomitant lower rates of feeding intolerance. Finally, enteral nutrition can be administered through gastric or jejunal feeding, depending on digestive tolerance, whereas latest data also address the safety of percutaneous gastrostomy with a jejunal extension for enteral nutrition administration. However, more data about its real benefit are warranted.

SUMMARY

Accumulating evidence confirms the importance of early oral refeeding or early administration of enteral nutrition as vital parts of the armamentarium for the management of patients with acute pancreatitis.

Nutrition in acute pancreatitis

PURPOSE OF REVIEW

This review aims to discuss recent developments in different topics regarding nutrition and acute pancreatitis (AP), including oral refeeding, nutritional therapy, and implications of gut microbiota.

RECENT FINDINGS

Obesity increases the risk for severe AP and mortality. Considering the worldwide obesity rates, this finding could have major implications in the global outcomes of patients admitted with AP. Recent research confirms that early oral feeding leads to shorter length of stay, fewer complications, and lower costs. In case of intolerance to oral feeding or severe disease, nutritional therapy should be offered within 24-72 h, whereas enteral nutrition (EN) has been shown superior to parenteral nutrition. EN can be administered through gastric or jejunal feeding, depending on digestive tolerance and the presence of ileus. Nevertheless, modalities of EN in patients undergoing endoscopic drainage of pancreatitis-related collections are still undetermined. Weight-loss after discharge occurs frequently and could reflect post-AP pancreatic exocrine failure. Finally, novel research regarding gut microbiota could open new therapeutic opportunities to prevent bacterial translocation and pancreatic necrosis' infection.

SUMMARY

Despite available evidence many questions regarding nutritional management in patients with AP remain open. Modulation of gut microbiota could play an important role in further therapeutic management.

Acute pancreatitis secondary to cocaine use: a case-based systematic literature review

Cocaine use continues to be an important global public health problem. As the use of cocaine remains pervasive so have a myriad of adverse events associated with this drug. These deleterious effects are well-studied, but gastrointestinal complications remain esoteric and the existing clinical evidence is scarce. Ischemia of the esophagus and small bowel, perforation, peptic ulceration, gastrointestinal bleeding, and ischemic colitis are among the reported complications. In specific, acute pancreatitis secondary to cocaine use is an exceedingly rare clinicopathologic entity. To date, only 7 cases of this condition have been reported in the English-language literature. We hereby delineate a rare case of a 29-year-old female who developed her first episode of cocaine-associated pancreatitis. The diagnosis was made based on a standard battery of investigations and meticulous exclusion of common etiologies of acute pancreatitis. To our knowledge, this case represents the first report of re-occurrence of acute pancreatitis upon subsequent crack cocaine insufflation, adding a higher level of evidence to a fallible association. We also present a systematic review of the existing literature on acute pancreatitis following cocaine use. An updated knowledge regarding this rare association is of paramount importance for early diagnosis and astute management.

Nutritional Support in Patients with Severe Acute Pancreatitis-Current Standards

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.