Enteral and parenteral nutrition in acute pancreatitis

Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease

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 In acute pancreatitis, the former recommendation of fasting is obsolete.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.

Classification of Acute Pancreatitis in the Pediatric Population: Clinical Report From the NASPGHAN Pancreas Committee

INTRODUCTION

Acute pancreatitis (AP) is an emerging problem in pediatrics, with most cases resolving spontaneously. Approximately 10% to 30%, however, are believed to develop "severe acute pancreatitis" (SAP).

METHODS

This consensus statement on the classification of AP in pediatrics was developed through a working group that performed an evidence-based search for classification of AP in adult pancreatitis, definitions and criteria of systemic inflammatory response syndrome, and organ failure in pediatrics.

RESULTS AND DISCUSSION

Severity in pediatric AP is classified as mild, moderately severe, or severe. Mild AP is defined by AP without organ failure, local or systemic complications, and usually resolves in the first week. Moderately SAP is defined by the presence of transient organ failure that resolves in no >48 hours, or local complications or exacerbation of co-morbid disease. SAP is defined by persistent organ failure that lasts <48 hours. The presence of systemic inflammatory response syndrome is associated with increased risk for persistent organ dysfunction. Criteria to define organ failure must be pediatric- and age-based.

CONCLUSIONS

Classifying AP in pediatrics in a uniform fashion will help define outcomes and encourage the development of future studies in the field of pediatric pancreatitis.

Noninvasive Verification of Nasogastric Tube Placement Using a Magnet-Tracking System: A Pilot Study in Healthy Subjects

BACKGROUND

Fluoroscopic verification of nasogastric (NG) feeding tube placement is inconvenient and involves radiation exposure. We tested whether the position of an NG tube can be assessed reliably by a recently introduced magnet-tracking system.

METHODS

A small permanent magnet was attached at the end of an NG tube and its position was monitored using an external sensor array connected to a computer. NG tube trajectory, spontaneous movements of the magnet, and its position relative to the lower esophageal sphincter (LES) and xiphisternum were assessed in 22 healthy subjects and compared with esophageal manometry. In 12 subjects, localization of the magnet was also compared with fluoroscopy.

RESULTS

Magnet-tracking displayed NG tube tip movement reproducibly as it moved vertically in the esophagus and then laterally into the stomach. Compared with manometry, the accuracy and sensitivity of magnet tracking for localization of the NG tube tip, above or below the diaphragm, were 100%. Compared with fluoroscopy, the accuracy of NG tube localization by magnet tracking was 100%. With the magnet in the stomach, but not in the esophagus or LES, low amplitude displacements at a frequency of 3 per minute, consistent with gastric slow wave activity, were observed.

CONCLUSIONS

Magnet tracking allows accurate, real-time, 3-dimensional localization of an NG tube with respect to anatomic landmarks. Recorded motor patterns are indicative of the position of the NG tube. Magnet tracking may be a useful tool for bedside placement of nasogastric and enteral feeding tubes.

The Effects of Total Colectomy on Bacterial Translocation in a Model of Acute Pancreatitis

Prevention of secondary infection is currently the main goal of treatment for acute necrotizing pancreatitis. Colon was considered as the main origin of secondary infection. Our aim was to investigate whether prophylactic total colectomy would reduce the rate of bacterial translocation and infection of pancreatic necrosis. Forty-two Sprague-Dawley rats were used. Pancreatitis was created by ductal infusion of sodium taurocholate. Rats were divided into four groups: group-1, laparotomy + pancreatic ductal infusion of saline; group-2, laparotomy + pancreatic ductal infusion of sodium taurocholate; group-3, total colectomy + pancreatic ductal infusion of saline; and group-4, total colectomy + pancreatic ductal infusion of sodium taurocholate. Forty-eight hours later, tissue and blood samples were collected for microbiological and histopathological analysis. Total colectomy caused small bowel bacterial overgrowth with gram-negative and gram-positive microorganisms. Bacterial count of gram-negative rods in the small intestine and pancreatic tissue in rats with colectomy and acute pancreatitis were significantly higher than in rats with acute pancreatitis only (group-2 versus group-4; small bowel, p = <0.001; pancreas, p = 0.002). Significant correlation was found between proximal small bowel bacterial overgrowth and pancreatic infection (r = 0,836, p = 0.001). In acute pancreatitis, prophylactic total colectomy (which can mimic colonic cleansing and reduction of colonic flora) induces small bowel bacterial overgrowth, which is associated with increased bacterial translocation to the pancreas.

Parenteral nutrition versus enteral nutrition in severe acute pancreatitis

PURPOSE

To compare the effect of parenteral versus enteral nutritional support in severe acute pancreatitis, with respect to efficacy, safety, morbidity, mortality and length of hospitalization.

METHODS

The study was comprised of 31 patients, divided into a parenteral group (n=16) and an enteral group (n=15), who met severity criteria for abdominal tomography (Balthazar classes C, D, and E). The patients were compared by demographics, disease etiology, antibiotic prophylaxis, use or not of somatostatin, nutritional support, complications and disease progression.

RESULTS

There was no statistical difference in the average duration of nutritional support, somatostatin, or antibiotics in the two groups. Imipenem was the drug of choice for prophylaxis of pancreatic infections in both groups. More complications occurred in the parenteral group, although the difference was not statistically significant (p=0.10). Infectious complications, such as catheter sepsis and infections of the pancreatic tissue, were significantly more frequent in the parenteral group (p=0.006). There was no difference in average length of hospitalization in the two groups. There were three deaths in the parenteral group and none in the enteral group.

CONCLUSION

Enteral nutritional support is associated with fewer septic complications compared to parenteral nutritional support.

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.

Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy

Between 5% and 10% of patients with acute pancreatitis will develop infected pancreatic necrosis. Traditional open surgery for this condition carries a mortality rate of up to 50%, and therefore a number of less invasive techniques have been developed, including radiological drainage and a minimal access retroperitoneal approach. No randomised controlled trials have been published which compare these techniques. Indications for minimal access surgery are the same as for open surgery, i.e. infected pancreatic necrosis or failure to improve with extensive sterile necrosis. Access is obtained to the pancreatic necrosis via the left loin and necrosectomy performed using an operating nephroscope, and this often requires several procedures to remove all necrotic tissue. The cavity is continuously irrigated on the ward in between procedures. The results of this approach are encouraging, with less systemic upset to the patient, a lower incidence of post-operative organ failure when compared with open surgery, and a reduced requirement for ITU support. There is also a trend towards a lower mortality rate, although this does not reach statistical significance on the data published so far. Current evidence suggests that a minimal access approach to pancreatic necrosis is feasible, well tolerated and beneficial for the patient when compared with open surgery.

The impact of parenteral nutrition on the body composition of patients with acute pancreatitis

BACKGROUND

Nutrition support by the enteral route is now the preferred modality in patients with severe acute pancreatitis. Parenteral nutrition is now required to supplement enteral nutrition when the latter is not able to provide the full nutritional requirement. We report the changes in body composition, plasma proteins, and resting energy expenditure (REE) during 14 days of parenteral nutrition (PN) in patients with acute pancreatitis.

METHODS

Total body protein (TBP), total body water (TBW), and total body fat (TBF) were measured by neutron activation analysis and tritium dilution before and after PN. Fat-free mass (FFM) was derived as the difference between body weight and TBF. REE was measured by indirect calorimetry. Protein index (PI) was the ratio of measured TBP to TBP, calculated from healthy volunteers.

RESULTS

Fifteen patients with acute pancreatitis (11 men, 4 women; median age 56, range 30-80 years) were studied. Thirteen patients had severe acute pancreatitis (Atlanta criteria), and 1 patient died. The gains in body weight (1.05 +/- 0.77 kg), TBW (0.49 +/- 0.87 kg), TBP (0.20 +/- 0.22 kg), FFM (0.73 +/- 0.92 kg), TBF (0.32 +/- 0.95 kg), and REE (146 +/- 90 kcal/d) after 14 days of PN were not significant. Plasma prealbumin increased by 46.5% (p = .020). When patients (n = 6) with intercurrent sepsis and recent surgery were excluded, there were significant increases in TBP (0.65 +/- 0.17 kg, p = .005) and PI (0.060 +/- 0.011, p = .0006).

CONCLUSIONS

Body composition is preserved in acute pancreatitis during 14 days of PN. In patients without sepsis or recent surgery, PN is able to significantly increase body protein stores.

Severe acute pancreatitis: case-oriented discussion of interdisciplinary management

The clinical course of an episode of acute pancreatitis varies from a mild, transitory illness to a severe often necrotizing form with distant organ failure and a mortality rate of 20-40%. Patients with severe pancreatitis, representing about 15-20% of all patients with acute pancreatitis, need to be identified as early as possible after onset of symptoms allowing starting intensive care treatment early in the disease process. An episode of severe acute pancreatitis progresses in two phases. The first 10-14 days are characterized by a systemic inflammatory response syndrome maintained by the release of various inflammatory mediators. The second phase, beginning about 10-14 days after the onset of the disease is dominated by sepsis-related morbidity due to infected peripancreatic and pancreatic necrosis. This state is associated with septic multiple organ systemic failure. The importance of infection on the outcome of necrotizing pancreatitis has been clearly delineated and the pre-emptive use of broad-spectrum antibiotics that achieve effective tissue concentrations is considered standard management of patients with severe necrotizing pancreatitis, especially if associated with organ failure or extended necrosis. Patients with infected necrosis should undergo a surgical intervention. The standard open technique consisting of an organ preserving necrosectomy followed by a postoperative concept of lavage and/or drainage to evacuate necrotic debris occurring during the further course has recently been challenged by various minimally invasive approaches.

Medical treatment of acute pancreatitis

Eighty percent of all cases of acute pancreatitis are linked etiologically to gallstone disease or caused by immoderate alcohol consumption. No specific causal treatment for acute pancreatitis exists. Early prognostic factors that indicate severe disease are three or more signs on organ failure scores according to Ranson, Imrie, or Acute Physiology and Chronic Health Evaluation (APACHE) 11, extrapancreatic complications of the disease, or the detection of pancreatic necrosis on CT scans. Elevated CRP levels above 130 mg/L can also predict a severe course of acute pancreatitis. The essential medical treatment for acute pancreatitis is the correction of hypovolemia. Moreover, relief of often severe visceral pain is a high priority. Prophylactic antibiotics should be restricted to patients with necrotizing pancreatitis, infected necrosis, or other infectious complications. Enteral nutrition has no adverse effect compared with parenteral nutrition during the course of acute pancreatitis, and is probably beneficial in regard to outcome.

Acute pancreatitis and organ failure: pathophysiology, natural history, and management strategies

Acute pancreatitis is a common condition that carries a significant risk of morbidity and mortality. It is characterized by intra-acinar cell activation of digestive enzymes and a subsequent systemic inflammatory response governed by the release of proinflammatory cytokines. In 80% of patients the disease runs a self-limiting course, but in the rest, pancreatic necrosis and systemic organ failure carry a mortality rate of up to 40%. The key to management is early identification of the patients liable to have a severe attack and require treatment in a high-dependency or critical-care setting by a specialist team. In gallstone-induced pancreatitis, early removal of ductal calculi by endoscopic sphincterotomy is indicated. The use of prophylactic antibiotics to prevent the infection of pancreatic necrosis remains controversial, but once established, infected necrosis must be removed. Although a number of techniques to accomplish this end have been described, minimally invasive techniques are gaining in popularity.

Medical and Endoscopic Treatment of Acute Pancreatitis

Accurate diagnosis of acute pancreatitis and assessment of disease severity is crucial. Multiorgan failure predicts a poorer prognosis. Treatment of acute biliary pancreatitis by endoscopic retrograde cholangiopancreatography (ERCP) may improve overall prognosis. Referral of seriously ill or unstable patients to a specialized center is recommended. Managing teams must be vigilant regarding the avoidance of iatrogenic complications, such as endoscopic misadventure or inadvertent line sepsis. Large, multicenter endoscopic outcome trials for prevention of ERCP-related pancreatitis, and to determine efficacy of treatment of acute gallstone pancreatitis, are needed.

Clinical study on nutrition support in patients with severe acute pancreatitis

AIM: To investigate the effect of nutritional support therapy on severe acute pancreatitis (SAP).

METHODS: A total of 96 patients with severe acute pancreatitis were divided randomly into control and treatment groups. The former group received total parenteral nutrition (TPN) via central venous infusion, while parenteral nutrition (PN) and enteral nutrition (EN) therapies were applied in different phases for the latter group. The nutrition status, acute phase responses, pancreas lesions, enteric mucosa penetrability and immune functions were monitored.

RESULTS: Body weight and prealbumin concentration were increased in treatment group, compared to those in the control group, but albumin concentration did not change significantly. Acute physiology and chronic health evaluation II (APACHE II) scores decreased after 7 d of treatment, whereas the scores of the control group decreased on the 11^th day. Concentrations of tumor necrosis factor-α (TNF-α), interleukine-6 (IL-6) and serum C reactive protein (CRP) dropped earlier in the treatment group (on the 4^th day) than that in the control group (on the 7^th day). No difference was observed in pancreatic lesions between the control and treatment groups. Concentration of endotoxin and lactulose/manicol (L:M) ratio of urine did not change in treatment group, but those in the control group were elevated markedly. Compared with the treatment group, CD4:CD8 T cells ratio and immunoglobulin G (IgG) concentration in the control group decreased significantly.

CONCLUSION: Compared to TPN, the combined therapy of EN and PN could improve the nutrition status and moderate the acute phase response obviously. Moreover, the integrity of enteric mucosa and immune function were protected more effectively in treatment group than in the control one. On the other hand, EN did not simulate the excretion of pancreas and avoid exaggerating the inflammation of pancreas. Thus, appropriate application of PN and EN appears to be more effective for patients with SAP.

Acute pancreatitis: treatment strategies

Acute pancreatitis is an acute painful abdominal disease of sudden onset that ranges from a mild and self-limited illness to a severe and severe life-threatening condition. In spite of decades of intensive research, there are no causal therapeutic options. Treatment relies on supportive treatment principles based on adequate volume replacement to compensate for fluid loss in the intraperitoneal space and analgesics for pain relief. In cases with acute pancreatitis predicted to have a severe course of the disease, antibiotic therapy is recommended to avoid infection of pancreatic necrosis. Despite a substantial set of clinical trials in favor of antibiotic treatment to reduce morbidity, there is no general consensus on the prophylactic antibiotic treatment. Adequate nutritional support is required for patients with severe acute pancreatitis and a protracted course of the disease. Enteral nutrition appears to be superior to enteral nutrition.

[Acute pancreatitis]

While interstitial acute pancreatitis usually takes a benign course, necrotizing acute pancreatitis takes a severe course, mainly because of severe local and systemic complications. After a quick diagnosis it is necessary to rapidly assess a degree of severity of the disease and thus the prognosis. The clinical picture and the result of imaging procedures do not always correspond. The management basically includes to treat pain as well as to administer fluid, electrolyte, protein and calories. In addition, systemic treatment of complications such as shock or respiratory and renal insufficiency--if occurring--is necessary. In case of pancreatic necrosis, prophylactic administration of pancreas-penetrable antibiotics is recommended to avoid infection. In the severely ill with infected pancreatic necrosis, surgery is the treatment of choice. In approximately 10% of all patients with alcohol-induced pancreatitis, there is a gradual transition to chronic pancreatitis.