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

Managing complicated pancreatitis with more knowledge and a bigger toolbox!

Acute pancreatitis (AP) is a heterogeneous inflammation of the pancreas, most frequently attributable to gallstones or alcohol. AP accounts for an estimated 300 000 patients admitted each year in the USA, and an estimated US$2.6 billion/year in hospitalization costs. Disease severity is classified as mild, moderate, or severe, dependent on the presence or degree of concomitant organ failure. Locally, pancreatitis may be complicated by fluid collections, necrosis, infection, and hemorrhage. Infection of necrotizing pancreatitis (NP) is associated with a doubling of mortality risk. The modern management of AP is evolving. Recent data suggest a shift from normal saline to lactated Ringer's solution, and from aggressive to more judicious volume resuscitation. Similarly, while historical wisdom advocated keeping patients nothing by mouth to 'rest the pancreas', recent data convincingly show fewer complications and reduced mortality with early enteral nutrition, when tolerated by the patient. The use of antibiotics in NP is controversial. Current recommendations suggest reserving antibiotics for cases with highly suspected or confirmed infected necrosis, as well as in patients with biliary pancreatitis complicated by acute cholecystitis or cholangitis. Regarding the management of local complications, control of acute hemorrhage can be attained either endovascularly or via laparotomy. Abdominal compartment syndrome is associated with a mortality risk of 50%-75%. Routine monitoring of intra-abdominal pressure is recommended in patients at high risk. Pancreatic pseudocysts require intervention in symptomatic patients or those with infection or other complications. Endoscopic transmural drainage may be considered as the first step when technically feasible. Necrotizing pancreatitis without suspicion of infection is often managed medically, while the delay, drain, debride approach remains the standard of care for the vast majority of infected pancreatic necrosis. Robotic surgery, in appropriately selected patients, allows for a one-step approach, and merits further study to explore its initially promising results.

Exploring the Role of Gut Microbiota and Probiotics in Acute Pancreatitis: A Comprehensive Review

Acute pancreatitis (AP) is a common and potentially severe gastrointestinal condition characterized by acute inflammation of the pancreas. The pathophysiology of AP is multifactorial and intricate, involving a cascade of events that lead to pancreatic injury and systemic inflammation. The progression of AP is influenced by many factors, including genetic predispositions, environmental triggers, and immune dysregulation. Recent studies showed a critical involvement of the gut microbiota in shaping the immune response and modulating inflammatory processes during AP. This review aims to provide a comprehensive overview of the emerging role of gut microbiota and probiotics in AP. We analyzed the implication of gut microbiota in pathogenesis of AP and the modification during an acute attack. The primary goals of microbiome-based therapies, which include probiotics, prebiotics, antibiotics, fecal microbiota transplantation, and enteral nutrition, are to alter the composition of the gut microbial community and the amount of metabolites derived from the microbiota. By resetting the entire flora or supplementing it with certain beneficial organisms and their byproducts, these therapeutic approaches aim to eradicate harmful microorganisms, reducing inflammation and avoiding bacterial translocation and the potential microbiota-based therapeutic target for AP from nutrition to pre- and probiotic supplementation to fecal transplantation.

Ability of the modified NUTRIC score to predict all-cause mortality among ICU patients with acute pancreatitis: A retrospective analysis using the MIMIC-IV database

BACKGROUND

Acute pancreatitis (AP) is a common acute abdominal condition that can lead to severe complications. Malnutrition significantly impacts the prognosis of patients with AP, so effective tools are needed to identify those at high nutritional risk. This study validated the ability of the modified NUTRIC score to predict all-cause mortality and identify nutritional risk in patients with acute pancreatitis in the ICU.

METHODS

This retrospective study analyzed data from the MIMIC-IV (v2.2) database, which included patients admitted to the ICU with AP between 2008 and 2019. Patients were categorized into high (mNUTRIC score ≥ 5) and low (mNUTRIC score < 5) nutritional risk groups. The findings were analyzed using Cox regression, ROC curve, and Kaplan-Meier survival analyses.

RESULTS

A total of 670 AP patients were included in the study. Patients at high nutritional risk had significantly worse clinical outcomes, including higher 28-day (30.0 % vs. 5.4 %) and 90-day (39.41 % vs. 10.2 %) mortality rates, compared to patients with low nutritional risk. The mNUTRIC score demonstrated stronger predictive ability for the 28-day (AUC: 0.797) and 90-day (AUC: 0.772) mortality compared to other nutritional risk tools used in the ICU, including the SOFA, APACHE II, and OASIS scores. A Cox regression analysis revealed that higher mNUTRIC scores were independently associated with increased mortality risk. Kaplan-Meier analyses confirmed that patients at high nutritional risk had significantly lower survival probabilities than those at low risk (P < 0.001). Patients with high nutritional risk who received nutrition intervention had a higher survival probability compared to those who did not (P < 0.001).

CONCLUSION

The mNUTRIC score is an effective tool for predicting the mortality in patients with AP. The mNUTRIC score stratifies patients with AP into different risk groups and predicts their all-cause mortality, highlighting the importance of nutritional interventions in improving survival outcomes, especially for patients at high risk.

Advances in the Management of Fluid Resuscitation in Acute Pancreatitis: A Systematic Review

Background/Objectives: Acute pancreatitis (AP) is an inflammatory condition with diverse origins, often resulting in significant morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiorgan failure. Fluid resuscitation is pivotal in early management, and it is aimed at preventing hypovolemia-induced ischemia and necrosis. This review evaluates fluid therapy strategies in AP, including fluid types, resuscitation rates, and clinical outcomes. Methods: This systematic review was conducted in January 2025 using databases such as PubMed, Medline, and Google Scholar, focusing on studies published between 2010 and 2024. Search terms included "acute pancreatitis", "fluid resuscitation", and related keywords. Studies involving adults with AP were analyzed to compare the outcomes of crystalloid and colloid use, aggressive vs. moderate fluid resuscitation, and administration timings. The primary outcomes were mortality and severe complications, while secondary outcomes included organ failure, SIRS, and length of hospital stay. Results: Crystalloids, particularly Ringer's lactate (RL), are superior to normal saline in reducing SIRS, organ failure, and intensive care unit stays without significantly affecting mortality rates. Colloids were associated with adverse events such as renal impairment and coagulopathy, limiting their use. Aggressive fluid resuscitation increased the risk of fluid overload, respiratory failure, and acute kidney injury, particularly in severe AP, while moderate hydration protocols achieved comparable clinical outcomes with fewer complications. Conclusions: Moderate fluid resuscitation using RL is recommended for managing AP, balancing efficacy with safety. Further research is needed to establish optimal endpoints and protocols for fluid therapy, ensuring improved patient outcomes while minimizing complications.

Clinical significance of perioperative probiotic intervention on recovery following intestinal surgery

Restoring the balance of gut microbiota has emerged as a critical strategy in treating intestinal disorders, with probiotics playing a pivotal role in maintaining bacterial equilibrium. Surgical preparations, trauma, and digestive tract reconstruction associated with intestinal surgeries often disrupt the intestinal flora, prompting interest in the potential role of probiotics in postoperative recovery. Lan et al conducted a prospective randomized study on 60 patients with acute appendicitis, revealing that postoperative administration of Bacillus licheniformis capsules facilitated early resolution of inflammation and restoration of gastrointestinal motility, offering a novel therapeutic avenue for accelerated postoperative recovery. This editorial delves into the effects of perioperative probiotic supplementation on physical and intestinal recovery following surgery. Within the framework of enhanced recovery after surgery, the exploration of new probiotic supplementation strategies to mitigate surgical complications and reshape gut microbiota is particularly intriguing.

Antioxidant Potential of Xanthohumol in Disease Prevention: Evidence from Human and Animal Studies

Xanthohumol (XN) is a phenolic compound found in the largest amount in the flowers of the hop plant, but also in the leaves and possibly in the stalks, which is successfully added to dietary supplements and cosmetics. XN is known as a potent antioxidant compound, which, according to current research, has the potential to prevent and inhibit the development of diseases, i.e., cancer and neurodegenerative diseases. The review aims to examine the antioxidant role of XN in disease prevention, with an emphasis on the benefits and risks associated with its supplementation. The regulation by XN of the Nrf2/NF-kB/mTOR/AKT (Nuclear factor erythroid 2-related factor 2/Nuclear factor kappa-light-chain-enhancer of activated B cells/Mammalian target of rapamycin/Protein Kinase B) pathways induce a strong antioxidant and anti-inflammatory effect, among others the acceleration of autophagy through increased synthesis of Bcl-2 (B-cell lymphoma 2) proteins, inhibition of the synthesis of VEGF (Vascular-endothelial growth factor) responsible for angiogenesis and phosphorylation of HKII (Hexokinase II). It is the key function of XN to ameliorate inflammation and to promote the healing process in organs. However, existing data also indicate that XN may have adverse effects in certain diseases, such as advanced prostate cancer, where it activates the AMPK (activated protein kinase) pathway responsible for restoring cellular energy balance. This potential risk may explain why XN has not been classified as a therapeutic drug so far and proves that further research is needed to determine the effectiveness of XN against selected disease entities at a given stage of the disease.

Effects of individualized comprehensive nutritional support on inflammatory markers, serum amylase (AMS), prealbumin (PA), albumin (ALB), calcium ion (Ca2+) in patients with severe pancreatitis

Background

The aim of the paper was to study the effectiveness of individualized comprehensive nutritional support on inflammatory markers, serum amylase (AMS), prealbumin (PA), albumin (ALB), calcium ion (Ca2+) in patients with severe acute pancreatitis (SAP).

Methods

102 participants with SAP treated in our hospital were chosen as the study objects. The participants were randomly split into a control group and an observation group and both groups were given routine treatment. Additionally, the observation group received individualized comprehensive nutrition support. The inflammatory indexes, biochemical indexes and symptom improvement time were observed and analyzed on the day of admission, intervention 1d, intervention 3d, intervention 7d and intervention 14d.

Results

Among the 102 patients included in this study, 3 cases had sudden exacerbation during the intervention, 1 case had clinical data missing >10%, and 1 case voluntarily withdrew due to personal factors, all of which were eliminated. Finally, the effective data for 97 patients were recovered. There were significant differences in the hypersensitive C-reactive protein (hs-CRP), white blood cell count (WBC), procalcitonin (PCT) and interleukin1b (IL-1β) between the two groups. The inter-group, time and interaction differences of AMS, PA, ALB and Ca2+ levels were significantly different. The recovery time of abdominal pain, bowel sound, blood amylase level and urine amylase level in the observation group was inferior to the control group, and the differences were statistically significant (P<0.05).

Conclusions

Individualized comprehensive nutritional support is more conducive to the improvement of inflammatory indexes in SAP patients and can accelerate symptom relief and promote the recovery of nutritional status.

Prediction model establishment and validation for enteral nutrition aspiration during hospitalization in patients with acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) is a disease caused by abnormal activation of pancreatic enzymes and can lead to self-digestion of pancreatic tissues and dysfunction of other organs. Enteral nutrition plays a vital role in the treatment of AP because it can meet the nutritional needs of patients, promote the recovery of intestinal function, and maintain the barrier and immune functions of the intestine. However, the risk of aspiration during enteral nutrition is high; once aspiration occurs, it may cause serious complications, such as aspiration pneumonia, and suffocation, posing a threat to the patient's life. This study aims to establish and validate a prediction model for enteral nutrition aspiration during hospitalization in patients with AP.

AIM

To establish and validate a predictive model for enteral nutrition aspiration during hospitalization in patients with AP.

METHODS

A retrospective review was conducted on 200 patients with AP admitted to Chengdu Shangjin Nanfu Hospital, West China Hospital of Sichuan University from January 2020 to February 2024. Clinical data were collected from the electronic medical record system. Patients were randomly divided into a validation group (n = 40) and a modeling group (n = 160) in a 1:4 ratio, matched with 200 patients from the same time period. The modeling group was further categorized into an aspiration group (n = 25) and a non-aspiration group (n = 175) based on the occurrence of enteral nutrition aspiration during hospitalization. Univariate and multivariate logistic regression analyses were performed to identify factors influencing enteral nutrition aspiration in patients with AP during hospitalization. A prediction model for enteral nutrition aspiration during hospitalization was constructed, and calibration curves were used for validation. Receiver operating characteristic curve analysis was conducted to evaluate the predictive value of the model.

RESULTS

There was no statistically significant difference in general data between the validation and modeling groups (P > 0.05). The comparison of age, gender, body mass index, smoking history, hypertension history, and diabetes history showed no statistically significant difference between the two groups (P > 0.05). However, patient position, consciousness status, nutritional risk, Acute Physiology and Chronic Health Evaluation (APACHE-II) score, and length of nasogastric tube placement showed statistically significant differences (P < 0.05) between the two groups. Multivariate logistic regression analysis showed that patient position, consciousness status, nutritional risk, APACHE-II score, and length of nasogastric tube placement were independent factors influencing enteral nutrition aspiration in patients with AP during hospitalization (P < 0.05). These factors were incorporated into the prediction model, which showed good consistency between the predicted and actual risks, as indicated by calibration curves with slopes close to 1 in the training and validation sets. Receiver operating characteristic analysis revealed an area under the curve (AUC) of 0.926 (95%CI: 0.8889-0.9675) in the training set. The optimal cutoff value is 0.73, with a sensitivity of 88.4 and specificity of 85.2. In the validation set, the AUC of the model for predicting enteral nutrition aspiration in patients with AP patients during hospitalization was 0.902, with a standard error of 0.040 (95%CI: 0.8284-0.9858), and the best cutoff value was 0.73, with a sensitivity of 91.9 and specificity of 81.8.

CONCLUSION

A prediction model for enteral nutrition aspiration during hospitalization in patients with AP was established and demonstrated high predictive value. Further clinical application of the model is warranted.

Preoperative risk factors for skeletal muscle mass loss in patients with biliary tract cancer

BACKGROUND

Endoscopic retrograde cholangiography (ERC)-related procedures, usually performed before biliary tract cancer (BTC) surgery, are associated with increased risk for various complications, which can cause sarcopenia. No study has previously elucidated the relationship between preoperative ERC-related procedures and sarcopenia/skeletal muscle mass loss.

METHODS

Patients with BTC who underwent radical surgical resection following ERC-related procedures were included. Skeletal muscle mass was evaluated using the psoas muscle mass index (PMI), which was determined using computed tomography images, and the change in PMI before the initial pre-ERC and surgery (ΔPMI) was calculated. Risk factors for advanced skeletal muscle mass loss, defined as a large ΔPMI, were evaluated.

RESULTS

The study cohort included 90 patients with a median age of 72 (interquartile range, 65-75) years. The median PMI pre-ERC and surgery was 4.40 and 4.15 cm2/m2, respectively (p < .01). The median ΔPMI was -6.2% (interquartile range, -10.9% to 0.5%). By multivariate analysis, post-ERC pancreatitis and cholangitis before surgery were independent predictive factors for large PMI loss (odds ratio, 4.57 and 3.18, respectively; p = .03 and p = .02, respectively).

CONCLUSIONS

Skeletal muscle mass decreases preoperatively in most patients with BTC undergoing ERC. Post-ERC pancreatitis and cholangitis before surgery were independent risk factors for large skeletal muscle mass loss.

Nutrition therapy in critically ill patients with severe acute pancreatitis

A significant proportion of patients (10%-20%) with acute pancreatitis develop severe acute pancreatitis characterized by pancreatic necrosis, systemic inflammation, and organ failure, commonly requiring intensive care unit (ICU) admission. In this specific population, nutrition therapy is more challenging than that in the general ICU population, primarily because of inevitable gastrointestinal involvement by pancreatic inflammation. In this review, we discussed several key aspects of nutrition therapy in this population, including key pathophysiology that may impede nutrition therapy, the timing and implementation of enteral nutrition and parenteral nutrition, the importance of specific nutrient supplements, and the long-term outcomes that may be addressed by nutrition therapy.

Persistently High Procalcitonin and C-Reactive Protein Are Good Predictors of Infection in Acute Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis

Infected necrotizing pancreatitis (INP) is associated with an increased risk of organ failure and mortality. Its early recognition and timely initiation of antibiotic therapy can save patients' lives. We systematically searched three databases on 27 October 2022. In the eligible studies, the presence of infection in necrotizing pancreatitis was confirmed via a reference test, which involved either the identification of gas within the necrotic collection through computed tomography imaging or the examination of collected samples, which yielded positive results in Gram staining or culture. Laboratory biomarkers compared between sterile necrotizing pancreatitis and INP were used as the index test, and our outcome measures included sensitivity, specificity, the receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). Within the first 72 hours (h) after admission, the AUC of C-reactive protein (CRP) was 0.69 (confidence interval (CI): 0.62-0.76), for procalcitonin (PCT), it was 0.69 (CI: 0.60-0.78), and for white blood cell count, it was 0.61 (CI: 0.47-0.75). After the first 72 h, the pooled AUC of CRP showed an elevated level of 0.88 (CI: 0.75-1.00), and for PCT, it was 0.86 (CI: 0.60-1.11). The predictive value of CRP and PCT for infection is poor within 72 h after hospital admission but seems good after the first 72 h. Based on these results, infection is likely in case of persistently high CRP and PCT, and antibiotic initiation may be recommended.