Clinical nutrition in pancreatitis

Contemporary management of acute pancreatitis: What you need to know

ABSTRACT

Acute pancreatitis and management of its complications is a common consult for the acute care surgeon. With the ongoing development of both operative and endoscopic treatment modalities, management recommendations continue to evolve. We describe the current diagnostic and treatment guidelines for acute pancreatitis through the lens of acute care surgery. Topics, including optimal nutrition, timing of cholecystectomy in gallstone pancreatitis, and the management of peripancreatic fluid collections, are discussed. Although the management severe acute pancreatitis can include advanced interventional modalities including endoscopic, percutaneous, and surgical debridement, the initial management of acute pancreatitis includes fluid resuscitation, early enteral nutrition, and close monitoring with consideration of cross-sectional imaging and antibiotics in the setting of suspected superimposed infection. Several scoring systems including the Revised Atlanta Criteria, the Bedside Index for Severity in Acute Pancreatitis score, and the American Association for the Surgery of Trauma grade have been devised to classify and predict the development of the severe acute pancreatitis. In biliary pancreatitis, cholecystectomy prior to discharge is recommended in mild disease and within 8 weeks of necrotizing pancreatitis, while early peripancreatic fluid collections should be managed without intervention. Underlying infection or ongoing symptoms warrant delayed intervention with technique selection dependent on local expertise, anatomic location of the fluid collection, and the specific clinical scenario. Landmark trials have shifted therapy from maximally invasive necrosectomy to more minimally invasive step-up approaches. The acute care surgeon should maintain a skill set that includes these minimally invasive techniques to successfully manage these patients. Overall, the management of acute pancreatitis for the acute care surgeon requires a strong understanding of both the clinical decisions and the options for intervention should this be necessary.

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.

Impact of Nasojejunal Feeding on Outcome of Patients with Walled Off Pancreatic Necrosis (WOPN) Presenting with Pain: a Pilot Study

BACKGROUND

Drainage is usually recommended in symptomatic walled off pancreatic necrosis (WOPN). WOPN presenting with pain may get symptomatic relief if the pancreas is given rest by initiating nasojejunal (NJ) feed.

AIM

The aim of this was to prospectively study the efficacy of nasojejunal (NJ) feeding in patients of WOPN presenting with abdominal pain.

METHODS

Twenty-one patients (15 M; 35 ± 12 years) with WOPN (size 7-16 cm) presenting with pain underwent NJ tube placement under endoscopic guidance. Following this, pain relief and long-term outcome were studied.

RESULTS

Etiology of pancreatitis was alcohol in 12, gall stones in 6, and idiopathic in 3 patients. NJ tube was successfully placed in all patients and 17/21 (81%) patients had symptomatic relief in 1-4 days (mean 2 ± 1 days) following NJ feeding. NJ tube was removed after 7-10 days (mean 7 ± 1 days), and 14 (61%) patients remained pain free and follow-up imaging (1-8 months) revealed complete resolution or decrease in size of WOPN. Three patients had recurrence of pain and were successfully treated with endoscopic drainage.

CONCLUSIONS

NJ feeding improves pain in the majority of patients with WOPN and thus obviates or delays drainage. Majority of nonresponders had disconnected pancreatic duct syndrome (DPDS).

Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis

INTRODUCTION

Enteral feeding can be given either through the nasogastric or the nasojejunal route. Studies have shown that nasojejunal tube placement is cumbersome and that nasogastric feeding is an effective means of providing enteral nutrition. However, the concern that nasogastric feeding increases the chance of aspiration pneumonitis and exacerbates acute pancreatitis by stimulating pancreatic secretion has prevented it being established as a standard of care. We aimed to evaluate the differences in safety and tolerance between nasogastric and nasojejunal feeding by assessing the impact of the two approaches on the incidence of mortality, tracheal aspiration, diarrhea, exacerbation of pain, and meeting the energy balance in patients with severe acute pancreatitis.

METHOD

We searched the electronic databases of the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE. We included prospective randomized controlled trials comparing nasogastric and nasojejunal feeding in patients with predicted severe acute pancreatitis. Two reviewers assessed the quality of each study and collected data independently. Disagreements were resolved by discussion among the two reviewers and any of the other authors of the paper. We performed a meta-analysis and reported summary estimates of outcomes as Risk Ratio (RR) with 95% confidence intervals (CIs).

RESULTS

We included three randomized controlled trials involving a total of 157 patients. The demographics of the patients in the nasogastric and nasojejunal feeding groups were comparable. There were no significant differences in the incidence of mortality (RR=0.69, 95% CI: 0.37 to 1.29, P=0.25); tracheal aspiration (RR=0.46, 95% CI: 0.14 to 1.53, P=0.20); diarrhea (RR=1.43, 95% CI: 0.59 to 3.45, P=0.43); exacerbation of pain (RR=0.94, 95% CI: 0.32 to 2.70, P=0.90); and meeting energy balance (RR=1.00, 95% CI: 0.92 to 1.09, P=0.97) between the two groups. Nasogastric feeding was not inferior to nasojejunal feeding.

CONCLUSIONS

Nasogastric feeding is safe and well tolerated compared with nasojejunal feeding. Study limitations included a small total sample size among others. More high-quality large-scale randomized controlled trials are needed to validate the use of nasogastric feeding instead of nasojejunal feeding.

Endoscopist’s approach to nutrition in the patient with pancreatitis

Nutritional therapy has an important role in the management of patient with severe acute pancreatitis. This article reviews the endoscopist’s approach to manage nutrition in such cases. Enteral feeding has been clearly validated as the preferred route of feeding, and should be started early on admission. Parenteral nutrition should be reserved for patients with contraindications to enteral feeding such as small bowel obstruction. Moreover, nasogastric feeding is safe and as effective as nasojejunal feeding. If a prolonged course of enteral feeding (> 30 d) is required, endoscopic placement of feeding gastrostomy or jejunostomy tubes should be considered.

Nutritional support in acute pancreatitis

Acute pancreatitis can present as a mild or severe disease. Most patients have a mild disease and recover without requiring nutritional support. Patients with severe acute pancreatitis may develop systemic inflammatory response syndrome and progress to multi-organ failure. These ill patients have high metabolism and protein catabolism. Hence, the nutritional management of these patients can be challenging. The aim of nutritional support is to meet the elevated metabolic demands as far as possible without stimulating pancreatic secretion and yet maintaining the gut integrity. The concept of pancreatic rest has evolved over the years. To date, there is a substantial scientific proof that enteral nutrition (EN) in comparison to parenteral nutrition significantly reduces infectious complications, surgical interventions and mortality in predicted severe acute pancreatitis. EN may be able to improve outcome in these patients if given early. In this review, we summarized the current knowledge on nutrition in acute pancreatitis and shared our local experience.

Meta-analysis: total parenteral nutrition versus total enteral nutrition in predicted severe acute pancreatitis

BACKGROUND

Total parenteral nutrition (TPN) as a traditional mode of treatment in severe acute pancreatitis was still used widely in clinical work. In addition, enteral nutrition treatment methods have developed; early enteral nutrition has already been highlighted for severe acute pancreatitis, but the therapeutic risks versus benefits need to be studied.

AIMS AND OBJECTIVE

To compare total parenteral nutrition with total enteral nutrition (TEN) in patients with severe acute pancreatitis by performing a meta-analysis.

MATERIALS AND METHODS

Electronic databases including PubMed, EMBASE, Science Citation Index, were searched to find relevant randomized controlled trials. Two reviewers independently identified relevant trials evaluating the effect of total parenteral nutrition and early enteral nutrion. Outcome measures were the mortality, hospital length of stay, infectious complications, duration of nutrition, organ failure and surgical intervention.

RESULTS

Eight randomized controlled trials (RCTs) including 381 patients were identified. Meta-analysis demonstrated that TEN was significantly superior to TPN when considering mortality [p=0.001, 95%CI 0.37(0.21-0.68)], infectious complications [p=0.004, 95%CI 0.46(0.27-0.78)], organ failure [p=0.02, 95%CI 0.44(0.22-0.88)] and surgical intervention [p=0.003, 95%CI 0.41(0.23-0.74)].While no difference between TEN and TPN when considering the hospital length of stay [p=0.22, 95%CI -14.10(-36.48-8.26)] and as for duration of nutrition [p=0.72, 95%CI -1.50(-9.56-6.56)] there was not enough data to compare the differences.

CONCLUSION

Total enteral nutritional support is associated with lower mortality, fewer infectious complications, decreased organ failure and surgical intervention rate compared to parenteral nutritional support.

Enteral nutrition and acute pancreatitis: a review

Introduction. In patients with acute pancreatitis (AP), nutritional support is required if normal food cannot be tolerated within several days. Enteral nutrition is preferred over parenteral nutrition. We reviewed the literature about enteral nutrition in AP. Methods. A MEDLINE search of the English language literature between 1999-2009. Results. Nasogastric tube feeding appears to be safe and well tolerated in the majority of patients with severe AP, rendering the concept of pancreatic rest less probable. Enteral nutrition has a beneficial influence on the outcome of AP and should probably be initiated as early as possible (within 48 hours). Supplementation of enteral formulas with glutamine or prebiotics and probiotics cannot routinely be recommended. Conclusions. Nutrition therapy in patients with AP emerged from supportive adjunctive therapy to a proactive primary intervention. Large multicentre studies are needed to confirm the safety and effectiveness of nasogastric feeding and to investigate the role of early nutrition support.

A safe, effective, and cheap method of achieving pancreatic rest in patients with chronic pancreatitis with refractory symptoms and malnutrition

OBJECTIVES

Chronic pancreatitis (CP) is common. It is associated with a substantial morbidity, including malnutrition, malabsorption, pseudocysts, metabolic disturbances, and intractable abdominal pain. Approximately 5% of patients with CP are refractory to nutritional support and opiate analgesia, making management challenging.Pancreatic rest can provide symptomatic relief. However, achieving simultaneous pancreatic rest and adequate nutritional support in these patients is difficult. We describe a technique for providing nutritional support and pancreatic rest in patients with intractable symptomatic CP.

METHODS

Three patients with symptomatic CP refractory to standard treatment were included in the study. All 3 patients had masses associated with the pancreas. Symptom relief and adequate nutritional support were achieved by inserting a long-term nasojejunal (NJ) tube (Flocare Bengmark, Nutricia Clinical Care, United Kingdom) under ambulatory endoscopic guidance. Data were recorded prospectively.

RESULTS

Long-term NJ tube feeding achieved pancreatic rest and significant symptomatic relief while delivering adequate nutritional support. Pseudocyst size decreased substantially in 2 patients. The third patient was found to have pancreatic carcinoma after pancreaticoduodenectomy.

CONCLUSIONS

In patients with symptomatic CP refractory to standard nutritional support and opiate analgesia, long-term NJ tube feeding can be a cheap, well-tolerated, safe, and effective method of providing adequate nutritional support and substantially relieving intractable symptoms.

Combination of endoscopy and enteric nutrition in treatment of acute severe biliary pancreatitis: an analysis of 31 cases

AIM: To evaluate the therapeutic efficacy of endoscopy and enteric nutrition (EN) in acute severe biliary pancreatitis at early stage.

METHODS: The clinical data of patients, who were admitted in our department from January 2005 to July 2008, were collected and the diagnoses were acute severe biliary pancreatitis (ASBP). Those patients were randomly divided into two groups (E-group and R-group): E-group's treatment protocols were ERCP + EST + ERBD and Enteral Nutritional on early stage; R-group's treatment protocol was orthodox treatment and Total Parenteral Nutrition (TPN) + EN. We compared the dates of two groups in subjective symptoms, signs, chemical examinations, endotoxin of plasma, TNF-α, computed tomography grades, cost of hospitalization, length of hospital stay. All of dates showed that E group had an advantage in comparison with R group.

RESULTS: All patients involved completed our therapy, and received the EN at early stage. Endoscopy and enteric nutrition significantly improved subjective symptoms, clinical signs, laboratory examinations, TNF-α, endotoxin, significantly reduced hospital fees, length of hospital stay.

CONCLUSION: Endoscopy and enteric nutrition at early stage is of effectiveness, safy and economic protocol in acute severe biliary pancreatitis.

Nutritional management of patients with acute pancreatitis: a Dutch observational multicentre study

BACKGROUND

Following a nil per os (NPO) regimen, most patients with acute pancreatitis (AP) can resume normal oral intake within 1 week. If not tolerated, it is recommended to initiate artificial feeding, preferably by the enteral route.

AIM

To evaluate the nutritional management of patients with AP in a Dutch cohort (EARL study).

METHODS

Observational study in 18 hospitals. Total days of NPO, tube feeding (TF) with/without oral feeding, total parenteral nutrition (TPN) and total starvation time were analysed.

RESULTS

In mild AP, a majority of cases (80.7%, 117/145) were managed with an NPO regimen only. Twenty-seven patients (18.6%) with mild AP additionally received TF; one received TPN. Of those with severe AP, more than half of the patients (56.2%, nine of 16) were treated with TF besides an NPO regimen; four received TPN. TF was delivered preferably via the jejunal route. The median period of total starvation was 2 days for both mild and severe AP. Only 5.5% (nine of 164) of patients had a prolonged starvation time of more than 5 days.

CONCLUSIONS

The total time of starvation was limited in a majority of patients admitted for AP. According to international guidelines, additional nutritional interventions were quickly undertaken with enteral feeding via the jejunum as the preferred route.

Enteral feeding in acute and chronic pancreatitis

Nutrition support is an essential part of the management of acute and chronic pancreatitis. In the past, parenteral nutrition has been used to allow pancreatic rest while providing nutrition support to patients who have acute pancreatitis. Evidence from randomized, controlled trials, however, suggests that enteral nutrition is as effective as and is safer and cheaper than parenteral nutrition. Observational studies also have demonstrated a benefit in patients who have chronic pancreatitis.

Efficacy of enteral nutrition for the treatment of pancreatitis using standard enteral formula

BACKGROUND AND AIMS

Elemental formula delivered distal to the ligament of Treitz has demonstrated efficacy in patients with pancreatitis, presumably by decreasing pancreatic stimulation. Few data exist on the use of standard enteral formula in such patients. This study describes the outcomes of pancreatitis patients managed with long-term standard enteral nutrition (EN).

METHODS

One hundred twenty-six patients managed at the University of Virginia Health System with pancreatitis requiring nutritional support between August 2000 and June 2004 received a standard formula delivered distal to the ligament of Treitz and were followed prospectively to resolution of their disease process. Predictors of improvement in CT Severity Index, duration of EN, and length of hospital stay were identified. Changes in body weight and serum albumin were determined.

RESULTS

Mean age was 50.8 +/- 15.2 yr (male, 83). Etiology included alcohol (46), gallstones (49), idiopathic (15), post-ERCP (7), drug (5), hyperlipidemia (3), and pancreas divisum (1). EN lasted a median of 18.9 (2.4 to 111.7) wk. Median CT Severity Index decreased from 4 to 2 (p < 0.001). Underweight patients gained 9.8 lbs; overweight and obese patients lost 7.2 and 28.8 lbs, respectively. Albumin concentration increased from 3 to 3.8 g/dL (p < 0.001).

CONCLUSIONS

Standard enteral formula is effective in the management of patients with complicated pancreatitis.

Nutritional demands in acute and chronic illness

Common to both acute and chronic disease are disturbances in energy homeostasis, which are evidenced by quantitative and qualitative changes in dietary intake and increased energy expenditure. Negative energy balance results in loss of fat and lean tissue. The management of patients with metabolically-active disease appears to be simple; it would involve the provision of sufficient energy to promote tissue accretion. However, two fundamental issues serve to prevent nutritional demands in disease being met. The determination of appropriate energy requirements relies on predictive formulae. While equations have been developed for critically-ill populations, accurate energy prescribing in the acute setting is uncommon. Only 25-32% of the patients have energy intakes within 10% of their requirements. Clearly, the variation in energy expenditure has led to difficulties in accurately defining the energy needs of the individual. Second, the acute inflammatory response initiated by the host can have profound effects on ingestive behaviour, but this area is poorly understood by practising clinicians. For example, nutritional targets have been set for specific disease states, i.e. pancreatitis 105-147 kJ (25-35 kcal)/kg; chronic liver disease 147-168 kJ (35-40 kcal)/kg, but given the alterations in gut physiology that accompany the acute-phase response, targets are unlikely to be met. In cancer cachexia attenuation of the inflammatory response using eicosapentaenoic acid results in improved nutritional intake and status. This strategy poses an attractive proposition in the quest to define nutritional support as a clinically-effective treatment modality in other disorders.

Management of severe acute pancreatitis

BACKGROUND

Acute pancreatitis is still associated with significant morbidity and mortality. Current management guidelines are sometimes equivocal, particularly in relation to the surgical treatment of severe disease. This review assesses available investigative and treatment strategies to allow the development of a formalized management approach.

METHODS

A literature review of diagnosis, staging and management of acute pancreatitis was performed.

RESULTS AND CONCLUSION

Recent evidence has helped to clarify the roles of computed tomography, endoscopic retrograde cholangiopancreatography, prophylactic antibiotics, enteral feeding and fine-needle aspiration for bacteriology in the management of acute pancreatitis. Despite a relative shortage of prospective randomized trials there has been a significant change in the surgical management of acute pancreatitis over the past 20 years. This change has been away from early aggressive surgical intervention towards more conservative management, except when infected necrosis is confirmed. A formalized approach, with appropriate use of the various non-surgical and surgical options, is feasible in the management of severe acute pancreatitis.

The role of the intestine in the pathophysiology and management of severe acute pancreatitis

BACKGROUND

The outcome of severe acute pancreatitis has scarcely improved in 10 years. Further impact will require new paradigms in pathophysiology and treatment. There is accumulating evidence to support the concept that the intestine has a key role in the pathophysiology of severe acute pancreatitis which goes beyond the notion of secondary pancreatic infection. Intestinal ischaemia and reperfusion and barrier failure are implicated in the development of multiple organ failure.

DISCUSSION

Conventional management of severe acute pancreatitis has tended to ignore the intestine. More recent attempts to rectify this problem have included 1) resuscitation aimed at restoring intestinal blood flow through the use of appropriate fluids and splanchnic-sparing vasoconstrictors or inotropes; 2) enteral nutrition to help maintain the integrity of the intestinal barrier; 3) selective gut decontamination and prophylactic antibiotics to reduce bacterial translocation and secondary infection. Novel therapies are being developed to limit intestinal injury, and these include antioxidants and anti-cytokine agents. This paper focuses on the role of the intestine in the pathogenesis of severe acute pancreatitis and reviews the implications for management.

Nutrition support during acute pancreatitis

Studies have shown that protein catabolism increases by 80% and energy expenditure by 20% in acute pancreatitis, indicating that nutritional requirements are elevated. Other studies have associated the resolution of negative nitrogen balance by nutrition support with improved outcome. Consequently, the need for effective nutrition is one cornerstone of management of acute pancreatitis. Concerns that feeding may exacerbate the disease process by stimulating the synthesis of proteolytic enzymes in the acinar cell and perpetuating autolysis has led to the widespread use of total parenteral nutrition (TPN) and bowel rest. Unfortunately, the use of TPN in clinical practice has been associated with major metabolic and infective complications, possibly because 1). patients with acute pancreatitis are intolerant of glucose due to coexistent pancreatic endocrine dysfunction and 2). the disease causes immune suppression. This has led to the search for alternatives. Based on physiologic studies, infusion of nutrients into the distal jejunum bypasses the stimulatory effect of feeding on pancreatic secretion. Many controlled trials have compared TPN with jejunal feeding. No study has shown that jejunal feeding exacerbates the disease. Further, jejunal feeding is associated with fewer infectious and metabolic complications. These observations and the fact that enteral feeding is one-tenth the cost of TPN has resulted in the general acceptance of jejunal feeding as the preferred mode for maintaining nutrition in patients with acute pancreatitis.

Nutritional management of acute pancreatitis

Most patients with acute pancreatitis have mild to moderate disease and require no specialized nutritional support. Twenty percent to 30% have severe cases, resulting in a catabolic hypermetabolic state, and these patients may require early aggressive nutritional support. Traditionally, this support has been in the form of total parenteral nutrition. However, recent data suggest that enteral nutrition infused into the jejunum is feasible, well tolerated, associated with fewer complications, and significantly less expensive than parenteral nutrition. The pathophysiology of gut function in acute pancreatitis and the rationale and evidence for parenteral and enteral nutritional support are reviewed herein. An algorithm on the nutritional management of acute pancreatitis is suggested.

Stimulated gastrointestinal hormone release and gallbladder contraction during continuous jejunal feeding in patients with pancreatic pseudocyst is inhibited by octreotide

BACKGROUND

Continuous enteral feeding, the old-new therapeutic modality in the treatment of patients with acute pancreatitis and those with complications is considered to bypass the cephalic, the gastric, and (at least in part) the intestinal phase of pancreatic secretion. The aim of this study was to test the GI hormonal changes and gallbladder motility during CJF in patients with pancreatic pseudocysts following acute pancreatitis, with or without octreotide pretreatment.

PATIENTS AND METHODS

In 15 patients with pancreatic pseudocysts, an 8-French (8F) nasojejunal catheter was positioned into the jejunum distal to the ligament of Treitz during duodenoscopy. On test d 1, blood samples were taken for CCK, gastrin, insulin-like immunoreactivity (IRI), glucagon, and glucose measurements prior to and at 20, 40, 60, and 120 min following jejunal saline infusion at a rate of 2 mL/min. The gallbladder volumes were determined simultaneously by ultrasonography. On test d 2, CJF (175 kcal/h) was started by the same route and at the same infusion rate. Analogous measurements were performed as indicated above. On test d 3, 100 microg of octreotide was administered subcutaneously and the previous procedure was repeated. The plasma level of CCK and glucagon and the serum levels of IRI and gastrin were determined by bioassay and radioimmunoassay (RIA), respectively.

RESULTS

Significant changes in hormone levels were not observed during jejunal saline perfusion. However, the levels of CCK (5.7+/-0.9 pmol), gastrin (10.6+/-1.3 pmol/L), IRI (27.2+/-5.8 microIU/mL), glucagon (322.8+/-32.4 pg/mL), and glucose (5.8+/-1.0 mmol/L) were significantly increased at 20 min during CJF vs the saline controls (2.0+/-0.3 pmol, 6.8+/-1.1 pmol/L, 7.8+/-0.4 microIU/mL, 172.8+/-33.4 pg/mL, and 4.5+/-0.5 mmol/L, respectively) and remained elevated at 40, 60, and 120 min. Octreotide pretreatment eliminated the increases in CCK, gastrin, IRI, and glucagon levels observed during CJF alone. The significant decrease in gallbladder volume during CJF was also prevented by octreotide pretreatment.

CONCLUSION

Continuous jejunal feeding (CJF) elicited significant increases in gastrointestinal (GI) regulatory hormone (cholecystokinin [CCK], gastrin, IRI, and glucagon) levels and evoked a consecutive gallbladder contraction. These biological responses are eliminated by octreotide pretreatment. Further clinical studies are needed to assess the eventual therapeutic effect of octreotide during CJF in patients with pancreatic pseudocyst.

Acute and chronic pancreatitis

Acute pancreatitis has multiple causes, an unpredictable course, and myriad complications. The diagnosis relies on a combination of history, physical examination, serologic markers, and radiologic findings. The mainstay of therapy includes aggressive hydration, maintenance of NPO, and adequate analgesia with narcotics. Antibiotic and nutritional support with total parenteral nutrition should be used when appropriate.

Update on the management of acute severe pancreatitis

Acute severe pancreatitis is an aggressive disease with a mortality rate of up to 30 percent. In recent years therapy has shifted away from early surgery to intensive medical care. This article focuses on several issues of the management of acute severe pancreatitis emphasising evidence from recent clinical trials and recommendations from recent consensus conferences. Since a correct assessment of the severity of the disease is mandatory as early as possible in the treatment, several multiple scoring factor systems and individual risk factors are explained. The indications and the optimal timing of ERCP are discussed. Prophylactic administration of antibiotics, intravenously or by means of a selective digestive decontamination scheme, seems to be beneficial in decreasing morbidity but not mortality. Adequate nutritional support, preferably achieved by enteral feeding, is an important component in the supportive therapy. Protease inhibitors and anti-secretory drugs have not proven to be of benefit in improving outcome. Immunomodulating substances like platelet activating antagonists are promising but further studies are necessary to confirm the results of the early studies. Finally, indications for surgery are discussed.

Nutrition in acute pancreatitis

The majority of patients (80%) admitted with acute pancreatitis recovers after a few days of bowel rest and intravenous fluids. However, some cases progress to a fulminant disease complicated by a severe systemic inflammatory response and multiple organ failure, a condition in which mortality is related to the degree of negative nitrogen balance. The goal of nutrition support in this situation is to cover the increased metabolic demands without stimulating pancreatic secretion and exacerbating the "autodigestion" that characterizes the condition. Although human and animal studies have shown conflicting results regarding the effect of composition and location of feeding on pancreatic enzyme secretion, there is consensus that total parenteral nutrition (TPN), given at moderate infusion rates, does not significantly stimulate secretion in humans and that enteral diets stimulate enzyme secretion unless delivered below the jejunum. Consequently, until recently TPN has been the standard of therapy. The fact that the cost and complications of TPN can often outweigh its benefits (catheter sepsis, hyperglycemia) has led to a series of recent controlled clinical trials of modified enteral diets in which the diet is delivered by nasojejunal tube. Results have demonstrated that enteral nutrition, with either elemental or polymeric formulas, was cheaper, safer, and at the same time more effective in reducing the systemic inflammatory response. The pathophysiologic explanation for these observations needs further investigation.

Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis

This study assessed the feasibility and effectiveness of jejunal feeding (JF) after surgery due to secondary peritonitis or failed conservative therapy of severe pancreatitis. Of 60 patients, 30 were randomly assigned to receive postoperative JF and the remaining 30 constituted the control group. Acute Physiology and Chronic Health Evaluation II, nutritional intake, systemic inflammatory response syndrome, and outcomes were measured. Patients in JF group received the daily mean of 1294.6 (362.6) kcal including 830.6 (372.7.0) kcal enterally, versus 472.8 (155.8) kcal daily in the control group (P < 0.0001). There were fewer complications in the JF patients, with no significant difference; length of stay in the intensive care unit and in the hospital did not differ. The frequency of systemic inflammatory response syndrome was similar in both groups, but outcomes differed. The first surgical intervention resulted in 3.3% of relaparotomies in JF patients, caused by unresolved peritonitis, versus 26.7% in the control subjects (P = 0.03). Recovery of bowel transit took significantly less time in the JF patients (mean: 54.6 h versus 76.8 h in control subjects, P = 0.01). JF resulted in 3.3% mortality as opposed to 23.3% in the control group (P = 0.05). In conclusion, JF is feasible and effective in postoperative treatment of patients due to secondary peritonitis or severe pancreatitis. Improved bowel and peritoneal function could be the main impact of JF.

Whole gut washout ameliorates the progression of acute experimental pancreatitis

BACKGROUND

Septic complications are mainly responsible for deterioration of a patient with acute pancreatitis. Intestinal tract is accepted as the main source of pancreatic or peripancreatic infection.

MATERIAL AND METHODS

Acute pancreatitis was induced in 40 Sprague-Dawley rats by ligation of the main biliopancreatic duct. Animals were divided into two groups. The first group of animals (n = 20) received high volume polyethylene glycol-3500 (GoLYTELY) for 6 hours through a silastic catheter introduced into the proximal part of the jejunum from a puncture gastrostomy during the initial laparotomy. The second group animals (n = 20) did not receive any treatment. Half of the animals from each group were sacrificed 72 hours later and tissue samples were taken from mesenteric lymph nodes, pancreas, spleen, and liver for bacteriologic cultures. Cecum cultures were also prepared. Blood samples at 72 hours were obtained for the measurement of amylase, lactic dehydrogenase (LDH), lactic acid, alanine aminotransferase (ALT), glucose, calcium, arterial pH, base excess, partial oxygen pressure, bicarbonate, leucocyte count, and hematocrit levels. The pancreas was examined histopathologically. The remaining half of the animals from each group were allowed to survive until death.

RESULTS

The levels of amylase, LDH, ALT, lactic acid, pH, pO(2), bicarbonate and base excess for the rats in group I were significantly lower when compared with the rats in group II (P<0.05). Positive mesenteric lymph node cultures were detected in 30% of group I animals whereas they were positive in 90% of group II animals (P = 0.0198). Distant organ cultures were positive in 8 animals (liver 5, spleen 2, pancreas 1) in group II, whereas only one positive distant organ culture (liver) was established in group I (P>0.05). Histopathological scoring observed in the pancreas were less severe for the rats in group I when compared with the rats in group II (P = 0.012). The rats in group I survived longer than the rats in group II (median survival 6.8 days versus 17.3 days, P<0.001).

CONCLUSIONS

Whole gut washout with high-volume polyethylene glycol in pancreatitis reduced the blood levels of enzymes and increased the survival. Whole gut washout for acute pancreatitis appears effective to ameliorate the prognostic factors in blood and this modality may be a promising treatment method in acute pancreatitis.

Evolution of nutritional support in acute pancreatitis

BACKGROUND

Acute pancreatitis is a catabolic illness and patients with the severe form have high metabolic and nutrient demands. Artificial nutritional support should therefore be a logical component of treatment. This review examines the evidence in favour of initiating nutritional support in these patients and the effects of such support on the course of the disease.

METHODS

Medline and Science Citation Index searches were performed to locate English language publications on nutritional support in acute pancreatitis in the 25 years preceding December 1999. Manual cross-referencing was also carried out. Letters, editorials, older review articles and most case reports were excluded.

RESULTS AND CONCLUSION

There is no evidence that nutritional support in acute pancreatitis affects the underlying disease process, but it may prevent the associated undernutrition and starvation, supporting the patient while the disease continues and until normal and sufficient eating can be resumed. The safety and feasibility of enteral nutrition in acute pancreatitis have been established; enteral nutrition may even be superior to parenteral nutrition. Some patients, however, cannot tolerate enteral feeding and this route may not be practical in others. Parenteral nutrition still has a role, either on its own or in combination with the oral and enteral routes, depending on the stage of the illness and the clinical situation.

Enteral nutrition support in acute pancreatitis

OBJECTIVE

To review the controversies surrounding the use of nutritional interventions, particularly enteral support, in patients with acute pancreatitis.

DATA SOURCES

Articles were obtained through a MEDLINE search (1966-June 1999). Additionally, several textbooks containing information on the diagnosis and management of acute pancreatitis were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references.

STUDY SELECTION

All original investigations in humans pertaining to the use of enteral nutritional support in acute pancreatitis were reviewed for inclusion. Studies that investigated parenteral nutrition in acute pancreatitis were also reviewed, with preference given to controlled comparisons with enteral regimens or no nutritional support.

DATA EXTRACTION

The primary outcomes extracted from the literature were time to oral feeding tolerance, complications (e.g., infection) associated with nutritional support, and length of stay.

DATA SYNTHESIS

The duration of pancreatitis and time to oral feedings is similar whether patients receive enteral (i.e., jejunal tube feedings) or parenteral nutrition. Additionally, complications, length of stay, and costs are either similar or decreased with enteral versus parenteral nutrition.

CONCLUSIONS

Current evidence suggests that the enteral rather than parenteral route should be used to provide nutrition to patients with acute pancreatitis. Parenteral nutrition should be reserved for patients in whom nasojejunal feeding is not possible.

Artificial nutrition in pancreatic disease: what lessons have we learned from the literature?

Acute pancreatitis is a disease process that begins with an initial injury to the pancreatic acinar cell due to the erroneous premature activation and intracellular release of digestive enzymes. The local injury is amplified through the induction of a systemic inflammatory response, mediated by the generation and release of cytokines and an aggressive inflammatory cell recruitment. Failure to maintain gut integrity may exacerbate the stress response and the systemic inflammatory reaction associated with this process, worsening the overall clinical severity of the pancreatitis and contributing further to complications of organ failure and nosocomial infection. Emphasis in the clinical nutritional management of these patients has shifted from efforts to minimize stimulation of the gland, to attaining enteral access, starting tube feeds low in the gastrointestinal tract, and monitoring tolerance. While clinical guidelines help identify those patients with acute pancreatitis at greatest need for aggressive nutritional support, the proper timing to initiate feeding, the optimal composition of the enteral formula, and whether or not enteral feeding is better than no nutritional therapy is still not clear from the current literature.

Does jejunal feeding with a polymeric immune-enhancing formula increase pancreatic exocrine output as compared with TPN? A case report

This case report compares the pancreatic output with different feeding regimes in a patient who underwent a partial pancreatectomy for carcinoma of the ampulla of Vater. A postoperative secretin stimulation test demonstrated significant pancreatic reserve. There was no difference in pancreatic exocrine secretion when the patient was fed jejunally with a polymeric immune-enhancing formula or supported with two different formulations of total parenteral nutrition. This result suggests that jejunal infusion of a polymeric immune-enhancing formula may be safe to administer in patients with acute pancreatitis.

The impact of oral feeding on the severity of acute pancreatitis

BACKGROUND

In the management of acute pancreatitis, oral feeding is prohibited and either enteral or parenteral feeding is commenced for the patients in an effort to not increase the secretion of the pancreatic enzymes.

PURPOSE

This study was undertaken in an attempt to determine the impact of oral feeding on the severity of acute pancreatitis and to compare this impact with that of parenteral feeding.

MATERIALS AND METHODS

Twenty-four female Sprague-Dawley rats were divided into two groups. In both groups, acute pancreatitis was induced by ligation of the main biliopancreatic duct. The rats in group I were fed orally and the rats in group II were fed parenterally. The rats were sacrificed at 48 hours, and blood samples were obtained from the heart upon exposure of the abdominal and thoracic cavities. The pancreas and the left lung were removed for histopathological examination. The levels of lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT), glucose, calcium and blood urea nitrogen, base deficit, partial oxygen pressure, leukocyte count, and hematocrit level among Ranson criteria and the level of amylase were measured. The pancreas and the lung were examined under a light microscope.

RESULTS

The levels of LDH, SGOT, and calcium for the rats in group I were significantly higher when compared with the rats in group II (P <0.05). Similarly, the levels of amylase for the rats in group I were found to be higher when compared with the rats in group II, but the difference was not significant. Inflammatory changes observed in the pancreas were less severe whereas inflammatory changes observed in the lung were more severe for the rats in group I when compared with the rats in group II.

CONCLUSION

The blood levels of the enzymes were adversely affected for the rats fed orally. In contrast, inflammatory changes observed in the pancreas were more severe for the rats fed parenterally. The study suggests that certain hormones released from the duodenum upon stimulation by oral nutrient intake lessens the severity of pancreatitis through protective effects on the pancreas, whereas the elevated levels of the enzymes cause endothelial damage resulting in destruction in distant organs such as the lung.

Nutritional care of pancreatitis and its complications

This article reviews the current literary data on the role of conservative supportive treatment for acute pancreatitis, with special emphasis on parenteral and enteral nutrition. Despite the fact that the indications for both methods have been discussed, defined and widely accepted in recent years, enteral nutrition is currently the focus of recent clinical investigations for use in acute pancreatitis.

Infusion protocol improves delivery of enteral tube feeding in the critical care unit

BACKGROUND

Numerous factors may impede the delivery of enteral tube feedings (ETF) in the intensive care unit (ICU). We designed a prospective study to determine whether the use of an infusion protocol could improve the delivery of ETF in the ICU.

METHODS

In a prior prospective study, we monitored all patients admitted to the medical intensive care unit (MICU) or cardiac care unit (CCU) who were made nil per os and placed on ETF (control group). We found that critically ill patients received only 52% of their goal calories, primarily due to physician underordering (66% of goal), frequent cessations of ETF (22% of the time), and slow advancement (14% at goal by 72 hours). Based on these findings, we developed an ETF protocol that incorporated standardized physician ordering and nursing procedures, rapid advancement, and limited ETF interruption. After extensive educational sessions, the ETF protocol was begun. Again, all patients admitted to the MICU or CCU who were made nil per os and placed on ETF were prospectively followed (protocol group).

RESULTS

Thirty-one patients in the protocol group were followed during 312 days of ETF and compared with the control group (44 patients with 339 days of ETF). Despite efforts by the nutritional support team, the infusion protocol was used in only 18 patients (58%). The main reasons for noncompliance with the protocol were physician preference and system failure (ETF order sheet not placed in chart). When used, the infusion protocol improved physician ordering (control 66% of goal volume, noncompliant 68%, compliant 82%, p < .05); delivery of calories (control 52% of goal, noncompliant 55%, compliant 68%, p < .05); and advancement of ETF (control 14% at goal by 72 hours, noncompliant 31%, compliant 56%, p < .05). Although significant reduction in ETF cessation due to nursing care was noted, it represented only a fraction of the total time ETF were stopped. Cessation due to residual volumes, patient tolerance, and procedure continued to be a frequent occurrence and was often avoidable.

CONCLUSIONS

An evidence-based infusion protocol improved the delivery of ETF in the ICU, primarily because of better physician ordering and more rapid advancement. The nursing staff rapidly assimilated these changes. However, physicians' reluctance to use the protocol limited its efficacy and will need continued educational efforts.

Nutrition in the intensive care unit

Nutritional support has become a routine part of the care of the critically ill patient. It is an adjunctive therapy, the main goal of which is to attenuate the development of malnutrition, yet the effectiveness of nutritional support is often thwarted by an underlying hostile metabolic milieu. This requires that these metabolic changes be taken into consideration when designing nutritional regimens for such patients. There is also a need to conduct large, multi-center studies to acquire more knowledge of the cost-benefit and cost effectiveness of nutritional support in the critically ill.

Decreased mortality from necrotizing pancreatitis

BACKGROUND

Necrotizing pancreatitis has been associated with mortality rates of 25% to 80%. We reviewed our experience to determine whether aggressive debridement and comprehensive critical care improves survival.

METHODS

The records of 989 patients with the diagnosis of pancreatitis admitted between January 1990 and September 1997 were retrospectively reviewed. Twenty-six patients required surgery for necrotizing pancreatitis and are the subjects of this review.

RESULTS

Five of twenty-six patients (19%) died. For all patients, mean Ranson's score was 4.3 of 11, mean admission APACHE II score was 17.2, and mean Multiple Organ Dysfunction (MOD) score was 9.1. Poor outcome was associated with infected pancreatic necrosis (P = 0.03), elevated APACHE II score on admission (P = 0.04), and progression of MOD during the week after admission (P = 0.02).

CONCLUSIONS

This review demonstrates improved survival in seriously ill patients with necrotizing pancreatitis as a result of comprehensive surgical and critical care.

Nutritional management in acute and chronic pancreatitis

Patients with severe pancreatitis, characterized by multiple organ failure and pancreatic necrosis on CT scan (identified by an Acute Physiology and Chronic Health Evaluation II score of > or = 10 with > or = 3 Ranson criteria), most likely require aggressive nutritional support. Use of the enteral route of feeding may help contain the hypermetabolic stress response, reduce morphologic change and atrophy of the gut, and theoretically decrease late complications of nosocomial infection and organ failure. Evidence that decreasing degrees of stimulation of the pancreas occur as the site of feeding descends in the gastrointestinal tract and evidence from perspective, randomized trials suggest that jejunal feeding appears at least as safe and well tolerated as total parenteral nutrition in acute pancreatitis.