Nutritional support in acute pancreatitis

Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence

The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.

Nil per os or Enteral Nutrition in Mild and Moderately Severe Acute Pancreatitis: A Case Series

BACKGROUND: There are controversies regarding the treatment of mild-to-moderate pancreatitis, especially when comparing the efficacy of nil per os regime versus the nasogastric feeding. While some sources suggest the benefits of the nasogastric feeding, there are meager data available toward the impact of the selected treatment vis-à-vis the length of hospital stay, and as of the final outcome. AIM: Authors collected data from two subgroups (treated with nil per os regime or nasogastric feeding, respectively) with the aim to define a safe and more efficacious regime. METHODS: This case series collection was carried out in the University Hospital Center in Tirana (UHC) at the Service of Gastroenterology. The period of the study was January 1, 2018–December 31, 2019. The patients were divided into two subgroups (the control group had a nil per os regime and patients in the intervention group received a nasogastric feeding) according to approved inclusion and exclusion criteria. RESULTS: Twenty subjects were allocated to the control group and 21 subjects were allocated to the intervention group. The length of hospital stay in the control group was 10.2 days compared with 8.4 days in the intervention group (p < 0.05). The days’ average spent with pain was 4.5 in the control group and 3.14 in the intervention group (p < 0.05). Oral feeding begun approximately 5.45 days since the admission in the control group and 3.14 days in the intervention group (p < 0.05). Oral food intolerance occurred in 6 patients (30%) in the control group and in one patient in the intervention group (4.8%) (p < 0.05). CONCLUSIONS: Nasogastric feeding seems to have significant benefits in the treatment of mild to moderate acute pancreatitis, when compared with the nil per os regime. Nasogastric feeding reduces length of stay in hospital and improves early the clinical outcomes.

Nutrition Management in Acute Pancreatitis

Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.

Necrotizing Pancreatitis: Current Management and Therapies

Acute necrotizing pancreatitis accounts for 10% of acute pancreatitis (AP) cases and is associated with a higher mortality and morbidity. Necrosis within the first 4 weeks of disease onset is defined as an acute necrotic collection (ANC), while walled off pancreatic necrosis (WOPN) develops after 4 weeks of disease onset. An infected or symptomatic WOPN requires drainage. The management of pancreatic necrosis has shifted away from open necrosectomy, as it is associated with a high morbidity, to less invasive techniques. In this review, we summarize the current management and therapies for acute necrotizing pancreatitis.

Enteral nutrition formulations for acute pancreatitis

BACKGROUND

Acute pancreatitis is a common and potentially lethal disease with increasing incidence. Severe cases are characterised by high mortality, and despite improvements in intensive care management, no specific treatment relevantly improves clinical outcomes of the disease. Meta-analyses suggest that enteral nutrition is more effective than conventional treatment consisting of discontinuation of oral intake with use of total parenteral nutrition. However, no systematic review has compared different enteral nutrition formulations for the treatment of patients with acute pancreatitis.

OBJECTIVES

To assess the beneficial and harmful effects of different enteral nutrition formulations in patients with acute pancreatitis.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Specialised Register of Clinical Trials, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 7), MEDLINE (from inception to 20 August 2013), EMBASE (from inception to 2013, week 33) and Science Citation Index-Expanded (from 1990 to August 2013); we conducted full-text searches and applied no restrictions by language or publication status.

SELECTION CRITERIA

We considered randomised clinical trials assessing enteral nutrition in patients with acute pancreatitis. We allowed concomitant interventions if they were received equally by all treatment groups within a trial.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and extracted data. We performed the analysis using Review Manager 5 (Review Manager 2013) and both fixed-effect and random-effects models. We expressed results as risk ratios (RRs) for dichotomous data, and as mean differences (MDs) for continuous data, both with 95% confidence intervals (CIs). Analysis was based on an intention-to-treat principle.

MAIN RESULTS

We included 15 trials (1376 participants) in this review. We downgraded the quality of evidence for many of our outcomes on the basis of high risk of bias. Low-quality evidence suggests that immunonutrition decreases all-cause mortality (RR 0.49, 95% CI 0.29 to 0.80). The effect of immunonutrition on other outcomes from a subset of the included trials was uncertain. Subgrouping trials by type of enteral nutrition did not explain any variation in effect. We found mainly very low-quality evidence for the effects of probiotics on the main outcomes. One eligible trial in this comparison reported a higher rate of serious adverse events leading to increased organ failure and mortality due to low numbers of events and low risk of bias. When we excluded this study as a post hoc sensitivity analysis, risks of mortality (RR 0.30, 95% CI 0.10 to 0.84), organ failure (RR 0.74, 95% CI 0.59 to 0.92) and local septic complications (RR 0.40, 95% CI 0.22 to 0.72) were lower with probiotics. In one trial assessing immunonutrition with probiotics and fibres, no deaths occurred, but hospital stay was shorter with immunonutrition (MD -5.20 days, 95% CI -8.73 to -1.67). No deaths were reported following semi-elemental enteral nutrition (EN), and the effect on length of hospital stay was small (MD 0.30 days, 95% CI -0.82 to 1.42). Fibre-enriched formulations reduced the number of other local complications (RR 0.52, 95% CI 0.32 to 0.87) and length of hospital stay (MD -9.28 days, 95% CI -13.21 to -5.35) but did not significantly affect all-cause mortality (RR 0.23, 95% CI 0.03 to 1.84) and other outcomes. Very low-quality evidence from the subgroup of trials comparing EN versus no intervention showed a decrease in all-cause mortality with EN (RR 0.50, 95% CI 0.29 to 0.86).

AUTHORS' CONCLUSIONS

We found evidence of low or very low quality for the effects of immunonutrition on efficacy and safety outcomes. The role of supplementation of enteral nutrition with potential immunomodulatory agents remains in question, and further research is required in this area. Studies assessing probiotics yielded inconsistent and almost contrary results, especially regarding safety and adverse events, and their findings do not support the routine use of EN enriched with probiotics in routine clinical practice. However, further research should be carried out to try to determine the potential efficacy or harms of probiotics. Lack of trials reporting on other types of EN assessed and lack of firm evidence regarding their effects suggest that additional randomised clinical trials are needed. The quality of evidence for the effects of any kind of EN on mortality was low, and further studies are likely to have an impact on the finding of improved survival with EN versus no nutritional support. Evidence remains insufficient to support the use of a specific EN formulation.

Gastric feeding and "gut rousing" in acute pancreatitis

The "pancreatic rest" concept is entrenched in the management of acute pancreatitis. As a result, "nonstimulatory" feeding has been widely advocated in patients with this disease, being parenteral nutrition 2-3 decades ago and jejunal tube feeding in the past decade. However, accumulating clinical evidence from the fields of acute pancreatitis and critical care medicine suggests that gastric feeding is as safe and effective as jejunal feeding in most patients. This has paved the way for a new conceptual framework called "gut rousing." Acute pancreatitis management now requires consideration of gut function. Enteral nutrition is a gut-directed therapy, and avoiding stimulation of the pancreas in patients with acute pancreatitis need not overshadow the main goal of maintaining or restoring gut function.

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.

Parenteral nutrition combined with enteral nutrition for severe acute pancreatitis

Background and Aims. Nutritional support in severe acute pancreatitis (SAP) is controversial concerning the merits of enteral or parenteral nutrition in the management of patients with severe acute pancreatitis. Here, we assess the therapeutic efficacy of gradually combined treatment of parenteral nutrition (PN) with enteral nutrition (EN) for SAP. Methods. The clinical data of 130 cases of SAP were analyzed retrospectively. Of them, 59 cases were treated by general method of nutritional support (Group I) and the other 71 cases were treated by PN gradually combined with EN (Group II). Results. The APACHE II score and the level of IL-6 in Group II were significantly lower than Group I (P < 0.05). Complications, mortality, mean hospital stay, and the cost of hospitalization in Group II were 39.4 percent, 12.7 percent, 32 ± 9 days, and 30869.4 ± 12794.6 Chinese Yuan, respectively, which were significantly lower than those in Group I. The cure rate of Group II was 81.7 percent which is obviously higher than that of 59.3% in Group I (P < 0.05). Conclusions. This study indicates that the combination of PN with EN not only can improve the natural history of pancreatitis but also can reduce the incidence of complication and mortality.

[Intravenous glutamine and early nasojejunal nutrition in severe acute pancreatitis -- a prospective randomized clinical study]

INTRODUCTION

Severe acute pancreatitis (SAP) is still one of the great challenges in gastro-intestinal surgery. According to recent studies, intravenously administered glutamine with total parenteral nutrition may be beneficial in the prevention of infectious complications and may reduce mortality rate. However, it has not been investigated yet, whether i.v. glutamine is able to achieve the same effect with early enteral nutrition as well.

OBJECTIVES

The objective of our prospective randomized double-blind study was to explore the effects of intravenously administered glutamine with early nasojejunal nutrition in severe acute pancreatitis.

PATIENTS AND METHODS

Forty-five patients with severe acute pancreatitis (with a Glasgow score at least 3 and/or a CRP level above 150 mg/ml on admission) were randomized into two groups. Group Glutamine (n = 24) was given 0.5 g/kg/die glutamine intravenously, while the control group (n = 21) received normal amino acid solution in the same quantity for 7 days. Nasojejunal nutrition was introduced 48 hours after admission in case of all patients, and their management was the same in every other aspect, too. The primary end-points of the study were the rate of pancreas-specific infectious complications and organ failure, and the secondary end-points were the necessity for radiological and surgical interventions, length of hospital stay and mortality rate.

RESULTS

In group Glutamine, infected acute peripancreatic fluid collections (APFC) were detected in 4 patients, 2 patients had post-necrotic pancreatic/peripancreatic fluid collections (PNPFC), 2 patients had infected pseudocysts and 2 patients had walled-off pancreatic necrosis (WOPN). Ten patients were cured by ultrasound assisted puncture or drainage successfully. No surgical intervention was necessary. In the control group, 4 patients had infected APFC, 2 patients had infected PNPFC, infected pseudocysts and infected WOPN were diagnosed in 3 cases. Radiological intervention was effective in 9 cases, but 3 patients needed surgery. Three patients died of multi-organ failure, thus the mortality rate of the control group was 14%, while the mortality rate of the Glutamine group was zero. The mean hospital stay of the Glutamine group was 10.6 days, which is significantly shorter than the mean hospital stay of the control group, which was 15.9 days (p = 0.00104).

DISCUSSION

The results of the Glutamine group are better in every end-points, however, statistically significant difference was detected in one parameter only, the length of hospital stay.

Ulinastatin in combination with glutamine dipeptide reduces serum levels of TNF-α, endotoxin and IL-6 in patients with severe acute pancreatitis

AIM: To evaluate the impact of protease inhibitor ulinastatin in combination with glutamine dipeptide on serum levels of TNF-α, endotoxin, IL-6 and IL-18 in patients with severe acute pancreatitis (SAP).

METHODS: Sixty-four SAP patients were divided into two groups: treatment group (n = 32) and control group (n = 32). The control group was treated with ulinastatin alone, while the treatment group was treated with ulinastatin in combination with glutamine dipeptide. The treatment lasted for 10 days. The changes in serum levels of TNF-α, endotoxin, IL-6 and IL-18 were determined by ELISA.

RESULTS: Compared to the control group, serum levels of TNF-α and endotoxin on days 7 and 10 (7 d: 38.83 ± 14.71 vs 51.92 ± 18.29; 0.46 ± 0.13 vs 0.71 ± 0.19; 10 d: 31.49 ± 12.65 vs 48.36 ± 15.43; 0.22 ± 0.07 vs 0.43 ± 0.15; all P < 0.05) and that of IL-6 on day 7 (117.68 ± 14.87 vs 163.43 ± 19.76, P < 0.05) were significantly lower in the treatment group. There was no significant difference in serum level of IL-18 between the two groups of patients (P > 0.05).

CONCLUSION: Ulinastatin in combination with glutamine dipeptide can reduce serum levels of TNF-α, endotoxin and IL-6 in SAP patients.

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.

Asymptomatic hyperamylasemia and hyperlipasemia in pediatric patients with toxic epidermal necrolysis

Although pancreatitis is rare in pediatric burn patients, elevated pancreatic enzymes have been recently observed among toxic epidermal necrolysis (TEN) patients. This clinical phenomenon has implications particularly for the nutritional management of patients involved. The objective of this study was to assess the frequency of sustained, elevated amylase, and lipase enzymes among children with TEN or Stevens Johnson Syndrome (SJS) and to evaluate the utilization of enteral nutrition support in this population. Medical records of 24 patients admitted to our hospital between January 1994 and October 2008 with TEN or SJS were retrospectively reviewed. Only patients with > or =4 consecutive measures for both amylase and lipase were included in this study (n = 10). Serial laboratory values were collected during the first 30 days of disease. Four patients (40%) had elevated amylase and lipase values, whereas six patients had values within normal limits. Patients with elevated pancreatic enzymes were significantly younger in age (4.7 +/- 1.7 years) than patients without elevated enzymes (11 +/- 5.9 years) and also had a higher incidence of sepsis. All other characteristics were similar between the groups. Enteral nutrition support was initiated within 4 days of admission in all 10 patients and did not correlate with elevated enzymes. Our findings suggest that hyperlipasemia and hyperamylasemia can occur in the pediatric population with TEN or SJS. Although the sample size in this study makes it difficult to determine the cause, sepsis may have been a contributing factor. In the absence of symptomatic pancreatitis, patients with TEN can safely meet nutritional goals orally or with standard enteral nutrition support.

Protective effect of galactooligosaccharide-supplemented enteral nutrition on intestinal barrier function in rats with severe acute pancreatitis

BACKGROUND & AIMS

Intestinal barrier dysfunction may play an important role in the secondary infectious complications associated with severe acute pancreatitis (SAP). We aimed to investigate the protective effect of enteral nutrition supplemented with prebiotics, namely, galactooligosaccharides (GOS), on intestinal barrier function in SAP rats.

METHODS

We randomly divided 60 Sprague-Dawley (SD) rats into 6 groups: sham operation 4-d and 7-d groups, SAP with standard enteral nutrition (EN) 4-d and 7-d groups, and SAP with GOS-supplemented EN (PRE-EN) 4-d and 7-d groups (n = 10 in each group). The intestinal barrier function was assessed on the basis of several aspects, including the number of colonic bifidobacteria and lactobacilli, sIgA concentration in intestinal mucus, extent of apoptosis in intestinal epithelial cells, and the protein expression and mRNA of the intestinal tight junction protein occludin. The results for groups at the same time points were compared with each other.

RESULTS

We observed that the intestinal barrier function was impaired after the establishment of the SAP model, in comparison with the sham control group. In the PRE-EN groups, the number of fecal bifidobacteria, sIgA level in intestinal mucus, intestinal occludin mRNA level at both day 4 and day 7, and extent of intestinal epithelial apoptosis at day 7 were significantly higher than the corresponding values in the standard EN groups (P < 0.05).

CONCLUSION

Supplementation of the prebiotic GOS in EN can significantly improve intestinal barrier function in SAP rats.

Therapeutic effect of pancreas clearing tablets (Qingyi pian) on severe acute pancreatitis

AIM: To explore the therapeutic effect of pancreatic clearance pills (Qingyi pian) on severe acute pancreatitis.

METHODS: From January 1997 to December 2007, 272 cases of severe acute pancreatitis were randomly divided into traditional Chinese medicine group and control group. Their recurrence and nutritional status were recorded.

RESULTS: The 1-year AP recurrence rate after discharge was 46.3% (126/272). The 1-year AP recurrence rate of the Chinese medicine group was significantly lower than that of the control group (39.9% vs 53.0%, P < 0.05). Nutritional damage score at 6 and 12 mo after discharge was significantly lower in Chinese herb group than in the control group (t = 2.23, 2.77, P < 0.05 or 0.01).

CONCLUSION: Use of pancreatic clearance pills within the first 3 months after discharge reduces long-term AP recurrence rate and improves nutritional status for SAP patients.

Early inhibition of prostaglandin synthesis by n-3 fatty acids determinates histologic severity of necrotizing pancreatitis

OBJECTIVE

Previously, we observed decreased histopathological severity of acute necrotizing pancreatitis (ANP) by parenteral nutrition with n-3 fatty acids. Thus, we now sequentially analyzed the impact of n-3 fatty acids on prostaglandin and leukotriene synthesis in ANP.

METHODS

One hundred ninety-eight Sprague-Dawley rats (11 groups, n = 18) underwent intraductal glycodesoxycholat instillation and 6-hour cerulein infusion. Afterward, saline was infused in groups 2, 4, 6, 8, and 10, whereas groups 3, 5, 7, 9, and 11 received infusion rich in n-3 fatty acids (Omegaven, Fresenius Kabi, Bad Homburg, Germany). Animals were killed after 6 (group 1), 10 (groups 2 and 3), 14 (groups 4 and 5), 18 (groups 6 and 7), 22 (groups 8 and 9), and 26 hours (groups 10 and 11). The pancreas was histopathologically examined, and the pancreatic eicosanoid metabolism (prostaglandin E2, prostaglandin F1alpha [PGF1alpha], and leukotrienes) and lipid peroxidation (thiobarbituric acid-reactive substance, superoxide dismutase, and glutathione peroxidase) were analyzed.

RESULTS

Between the 14th and 26th hours, histopathologic scores (edema, inflammation, bleeding, and necrosis) were reduced in the n-3 fatty acid group compared with the corresponding saline group. Pancreatic prostaglandin E2 and PGF1alpha were decreased between the 10th and 18th hour by n-3 fatty acids; PGF1alpha was reduced after 26 hours compared with the corresponding saline group. Lipid peroxidation was decreased by n-3 fatty acids after 14 hours (thiobarbituric acid-reactive substance); however, there was no difference concerning lipid peroxidation protective enzymes (glutathione peroxidase and superoxide dismutase).

CONCLUSIONS

Parenteral therapy with n-3 fatty acids decreased histopathologic severity in ANP by early inhibition of prostaglandin (E2 and F1alpha) synthesis and reduction of lipid peroxidation.