Nutritional strategies in severe acute pancreatitis: a systematic review of the evidence

Progress in research of acute pancreatitis in pregnancy

Acute pancreatitis in pregnancy (APIP) is a rare and severe complication of pregnancy, which is characterized by rapid onset, rapid progression, many complications, and high mortality. According to previous studies, the incidence of APIP is about 1/10000-1/1000 and increases with gestational age. Due to the differences in genetic background and dietary habits between Asian and European populations, the incidence of APIP in China is as high as 1.14‰-2.27‰, significantly higher than that in Western countries. The lack of specific clinical symptoms of APIP often leads to misdiagnosis or missed diagnosis, which greatly increases the difficulty of diagnosis and treatment. Despite the deepening of the research on APIP, its pathogenesis is still unclear. This paper will give a systematical review of APIP.

Infection rate among nutritional therapies for acute pancreatitis: A systematic review with network meta-analysis of randomized controlled trials

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.

Application of semi-automated ultrasonography on nutritional support for severe acute pancreatitis

OBJECTIVE

To evaluate the application value of semi-automated ultrasound on the guidance of nasogastrojejunal tube replacement for patients with acute severe pancreatitis (ASP), as well as the value of the nutritional support for standardized treatment in clinical practice.

METHODS

The retrospective research was performed in our hospital, and 34 patients suffering from ASP were enrolled into this study. All these identified participants ever received CT scans in order to make definitive diagnoses. Following, these patients received semi-automated ultrasound examinations within 1 days after their onset, in order to provide enteral nutrititon treatment via nasogastrojejunal tube, or freehand nasogastrojejunal tube replacement. In terms of statistical analysis, the application value of semi-automated ultrasound guidance on nasogastrojejunal tube replacement was evaluated, and was compared with tube replacement of no guidance. After cathetering, the additional enteral nutrition was provided, and its therapeutic effect on SAP was analyzed in further.

RESULTS

A total of 34 patients with pancreatitis were identified in this research, 29 cases with necrosis of pancreas parenchyma. After further examinations, 32 cases were SAP, 2 cases were mild acute pancreatitis. When the firm diagnosis was made, additional enteral nutrition (EN) was given, all the patient conditions appeared good, and they all were satisfied with this kind of nutritional support. According to our clinical experience, when there was 200-250 ml liquid in the stomach, the successful rate of intubation appeared higher. Additionally, the comparison between ultrasound-guided and freehand nasogastrojejunal tube replacement was made. According to the statistical results, in terms of the utilization ratio of nutritional support, it was better in ultrasound-guided group, when compared with it in freehand group, within 1 day, after 3 days and after 7 days (7/20 versus 2/14; P < 0.05; 14/20 versus 6/14; P < 0.05; 20/20 versus 12/14; P < 0.05). Besides, the complications caused by cathetering between two groups was not statistically different (P > 0.05).

CONCLUSIONS

It can be indicated that semi-automated ultrasound guidance is a reliable method for nasogastrojejunal tube replacement, and should be substituted for no guidance of cathetering. In terms of therapeutic effect of EN, additional nutritional support contributed to significantly improve the prognosis of SAP patients, and should be widely recommended in clinical practice. Surely, this conclusion should be evaluated in further, by means of randomized controlled trials and economic evaluation.

Nutrition in acute pancreatitis: a critical review

Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.

Ghrelin and gastroparesis as early predictors of clinical outcomes in acute pancreatitis

BACKGROUND

Impaired motor and hormonal gastrointestinal functions have been implicated in the pathogenesis of acute pancreatitis. The aim of the present study was to investigate the predictive value of the Gastroparesis Cardinal Symptom Index and serum ghrelin in the development of clinically meaningful outcomes in patients with acute pancreatitis.

METHODS

This was a prospective clinical study. The Gastroparesis Cardinal Symptom Index and serum ghrelin were measured for 48 h after hospitalization. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

The Gastroparesis Cardinal Symptom Index total score alone on day 2 was a significant predictor of oral feeding intolerance in both unadjusted (odds ratio 1.21 (1.01-1.46), P = 0.04) and adjusted (odds ratio 1.30 (1.01-1.69), P = 0.05) analyses. Adding ghrelin to Gastroparesis Cardinal Symptom Index further improved prediction in both unadjusted (odds ratio 1.26 (1.02-1.56), P = 0.03) and adjusted (odds ratio 1.53 (1.00-2.35), P = 0.05) analyses.

CONCLUSION

This pilot study demonstrates that the Gastroparesis Cardinal Symptom Index has a potential to be used as a predictor of oral feeding intolerance. Ghrelin, when combined with the Gastroparesis Cardinal Symptom Index, may further improve the predictive accuracy. These findings need to be confirmed in larger studies.

Successful Plasma Exchange for Acute Pancreatitis Complicated With Hypertriglyceridemia: A Case Report

A 33-year-old male with acute pancreatitis induced by hypertriglyceridemia had problems during treatment with plasma exchange. The hypercoagulable state was prevented by introducing innovative methods for cleaning and warming of the circuit and dialyzer. This enabled successful therapy, and the patient fully recovered from life-threatening acute pancreatitis.

Local complications of acute pancreatitis

Acute pancreatitis is seen commonly on the surgical take. It can be complicated by the development of pseudocysts and necrosis. This review discusses each of these in turn and outlines the different management strategies now on offer.

Efficacy of Glutamine-Enriched Nutrition Support for Patients With Severe Acute Pancreatitis: A Meta-Analysis

BACKGROUND

Plasma glutamine (Gln) level has been negatively correlated with the severity of severe acute pancreatitis (SAP). Although Gln is widely used today, the results of individual randomized controlled trials of Gln-enriched nutrition support for patients with SAP are conflicting.

METHODS

PubMed, EMBASE, HighWire, Cochrane Central Register of Controlled Trials, Wanfang, China Journals Full-Text Database, and the Chinese Biomedical Literature Database were searched. Literature published before June 2014 was searched. Randomized controlled trials investigating the comparison of conventional and Gln-enriched nutrition support were included; a random effect model using Rev Man 5.2 software was chosen to complete this meta-analysis. The count data were analyzed using the risk ratio (RR) and 95% confidence interval (CI), and the measurement data were analyzed using the standard mean difference or weighted mean difference and 95% CI. Heterogeneity analyses were conducted by I(2) test; publication bias analyses were conducted by Begg test.

RESULTS

Ten studies were eventually chosen for analysis, including 218 patients who received conventional methods (control group) and 215 patients who received Gln-enriched nutrition support (experimental group). Compared with the control group, Gln is helpful in elevating the albumin level, decreasing C-reaction protein (standard mean difference = 1.01, -1.89; 95% CI: 0.50 to 1.51, -3.23 to -0.56; P < .05), decreasing the incidence of infectious complication and mortality (RR = 0.62, 0.36; 95% CI: 0.46 to 0.83, 0.16 to 0.83; P < .05), and shortening the hospital stay length (weighted mean difference [WMD] = -3.89; 95% CI: -4.98 to -2.81; P < .05) without increasing expenses (WMD = -0.16; 95% CI: -1.34 to 1.02; P > .05). Intravenous infusion manifested more advantages by decreasing the incidence of infectious complications and mortality.

CONCLUSIONS

Gln-enriched nutrition support is superior to conventional methods for SAP, and intravenous infusion may be a better choice for drug administration.

Effect of early enteral nutrition with Bifico on levels of inflammatory mediators in plasma of patients with severe acute pancreatitis

AIM: To explore the effect of early enteral nutrition combined with probiotic treatment (Bifico) on the levels of inflammatory mediators in plasma of patients with severe acute pancreatitis (SAP).

METHODS: Eighty patients diagnosed with SAP between January 2006 and October 2013 at our hospital were included. They were given parenteral nutrition (PN group), enteral nutrition (EN group) or EN and probiotics (P + EN group). Plasma levels of interleukin-8 (IL-8), tumor necrosis factor alpha (TNF-α), C-reactive protein (CRP) and lactate dehydrogenase (LDH), white blood cell count, serum amylase, and plasma lipase were measured 1 d before and 7 d and 14 d after treatment. Hospitalization time and gastrointestinal function score were also recorded and compared.

RESULTS: After treatment, white blood cell count, serum amylase, plasma lipase and IL-8, CRP and LDH, and gastrointestinal function score were decreased in all the three groups (P < 0.05), while TNF-α in the PN group had no significant change between before and after treatment (F = 0.793, 0.745; P = 0.854, 0.772). White blood cell count, amylase and lipase levels after treatment in the P + EN group were significantly lower than those in the PN group and EN group (4.9 × 10⁹/L ± 2.4 × 10⁹/L vs 9.6 × 10⁹/L ± 3.0 × 10⁹/L vs 5.3 × 10⁹/L ± 2.7 × 10⁹/L; 197 U/L ± 50 U/L vs 297 U/L ± 77 U/L vs 253 U/L ± 63 U/L; 297 U/L ± 72 U/L vs 724 U/L ± 103 U/L vs 323 U/L ± 74 U/L; F = 5.346, 5.753; P = 0.023, 6.556, 0.022, 0.029). IL-8 and TNF-α levels were also significantly lower than those in the PN group and EN group (27.0 pg/mL ± 7.9 pg/mL vs 47.6 pg/mL ± 8.4 pg/mL vs 31.0 pg/mL ± 8.0 pg/mL; 43.5 pg/mL ± 22.7 pg/mL vs 132.5 pg/mL ± 32.6 pg/mL vs 67.5 pg/mL ± 21.4 pg/mL; F = 8.375, 7.278; P = 0.017, 0.012). Plasma CRP and LDH levels were significantly lower in the P + EN group after treatment than in the PN group and EN group (39.4 mg/L ± 19.7 mg/L vs 102.5 mg/L ± 41.9 mg/L vs 68.3 mg/L ± 32.9 mg/L; 20.3 U/L ± 12.3 U/L vs 79.3 U/L ± 34.4 U/L vs 35.3 U/L ± 10.4 U/L; F = 8.353, 10.354; P = 0.032, 0.013). Gastrointestinal function scores in the PN group, EN group and P + EN group on 14 d were significantly decreased, and the decrease was more significant in the P + EN group than in the PN group and EN group (0.25 ± 0.02 vs 0.71 ± 0.08 vs 0.40 ± 0.04; F = 12.456; P = 0.000). The mortality and incidence of complications were significantly lower and duration of hospitalization was significantly shorter in the combination group than in the EN group (χ² = 4.428, 28.986; P = 0.019, 0.000).

CONCLUSION: Early application of EN combined with Bifico can reduce the levels of enzymes and mediators of inflammation, pancreatic secretion, complications, hospitalization time, and mortality in SAP patients.

High-dose versus low-dose octreotide in the treatment of acute pancreatitis: a randomized controlled trial

To evaluate the therapeutic efficacy of high-dose octreotide in patients with predicted severe acute pancreatitis (SAP) or SAP, two hundred and thirty-six patients with predicted SAP and 136 patients with SAP were randomized into control, high-dose octreotide (High-O) and low-dose octreotide (Low-O) groups. In addition to the conventional managements administrated in control group, High-O group received an intravenous infusion of octreotide at 50 μg/h × 3d + 25 μg/h × 4d, and Low-O group received octreotide at 25 μg/h × 7d. The major primary outcomes included the numbers of predicted SAP patients which developed SAP after intervention and the number of patients with SAP amelioration. Secondary outcomes included APACHE II, SIRS scores, plasma levels of somatostatin (SST), tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6). There were no significant differences between the control and Low-O groups in terms of prevention and treatment for SAP. The incidence of SAP in patients with predicted SAP who received High-O was significantly lower than the Low-O group: 37.5% vs. 59.8%, p=0.005. Compared with Low-O group, the number of SAP patients in the SAP arm in the High-O group was reduced by 29.8%. Plasma levels of SST in both predicted SAP and the SAP patients were efficiently recovered (from 132.71±31.40 pg/ml to 180.00±23.50 pg/ml, p<0.05) after high-dose octreotide supplementation, which concomitantly reduced TNF-α and IL-6 levels. High-dose octreotide administration within 48h after AP onset may efficiently reduce the risk of SAP developing and partly attenuate SAP through raising plasma SST to a normal level and decreasing IL-6 and TNF-α.

Nutritional support in acute and chronic pancreatitis

Nutritional support can have a significant beneficial impact on the course of moderate to severe acute pancreatitis. Enteral nutrition is preferred, with emphasis on establishment of jejunal access; however, parenteral nutrition can also be of value if intestinal failure is present. Early initiation of nutritional support is critical, with benefits decreasing rapidly if begun after 48 hours from admission. Severe malnutrition in chronic pancreatitis can be avoided or treated with dietary modifications or enteral nutrition.

Acute pancreatitis in pregnancy: an overview

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

A meta-analysis of enteral nutrition and total parenteral nutrition in patients with acute pancreatitis

Objective. To analyze the effect of total parenteral nutrition (TPN) and enteral nutrition (EN) in patients with acute pancreatitis. Methods. Randomized controlled trials of TPN and EN in patients with acute pancreatitis were searched in NCBI and CBM databases and The Cochrane Controlled Trials Register. Six studies were enrolled into the analysis, and the details about the trial designs, characters of the subjects, results of the studies were reviewed by two independent authors and analyzed by STATA 11.0 software. Results. Compared with TPN, EN was associated with a significantly lower incidence of pancreatic infection complications (RR = 0.556, 95% CI 0.436∼0.709, P = .000), MOF (RR = 0.395, 95% CI 0.272∼0.573, P = .003), surgical interventions (RR = 0.556, 95% CI 0.436∼0.709, P = .000), and mortality (RR = 0.426, 95% CI 0.238∼0.764, P = .167). There was no statistic significance in non-pancreatitis-related complications (RR = 0.853, 95% CI 0.490∼1.483, P = .017). However, EN had a significantly higher incidence of non-infection-related complications (RR = 2.697, 95% CI 1.947∼3.735, P = .994). Conclusion. EN could be the preferred nutrition feeding method in patients with acute pancreatitis.