ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease primarily caused by a complex interplay of environmental and genetic risk factors. It might result in pancreatic exocrine and endocrine insufficiency, chronic pain, reduced quality of life, and increased mortality. The diagnosis is based on the presence of typical symptoms and multiple morphological manifestations of the pancreas, including pancreatic duct stones and strictures, parenchymal calcifications, and pseudocysts. Management of chronic pancreatitis consists of prevention and treatment of complications, requiring a multidisciplinary approach focusing on lifestyle modifications, exocrine insufficiency, nutritional status, bone health, endocrine insufficiency, pain management, and psychological care. To optimise clinical outcomes, screening for complications and evaluation of treatment efficacy are indicated in all patients with chronic pancreatitis.

Significant Published Articles in 2024 for Pharmacy Nutrition Support Practice

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several board-certified nutrition support pharmacists aggregated a list of articles relevant to pharmacy nutrition support that was published in 2024. The list was compiled into a spreadsheet whereby the authors were asked to assess whether the article was considered important. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important for pharmacists practicing in nutrition support. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 160 articles were identified; 7 from the primary literature were voted by the group as being of high importance. Twelve guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as they pertain to their practice.

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.

Effect of plasmapheresis versus standard medical treatment in patients with hypertriglyceridemia-associated acute pancreatitis complicated by early organ failure (PERFORM-R): Study design and rationale of a multicenter, pragmatic, registry-based randomized controlled trial

BACKGROUND

The prevalence of hypertriglyceridemia-associated acute pancreatitis (HTG-AP) is increasing. Studies have demonstrated the association between higher initial plasma triglyceride (TG) levels and worse clinical prognosis; therefore, lowering plasma TG has been the mainstay when managing HTG-AP. For TG-lowering therapy, plasmapheresis, which is costly and of potential complications, is currently widely used to clear TG from plasma, but whether it confers clinical benefits is unclear. In this trial, we aimed to evaluate the effect of plasmapheresis versus standard medical treatment on the duration of organ failure in HTG-AP patients with early organ failure.

METHODS

This is a multicenter, pragmatic, registry-based, randomized controlled trial. Based on previous studies, up to 236 HTG-AP patients with early organ failure are projected to be randomly assigned to either the plasmapheresis group or the standard medical treatment group (insulin plus low molecular weight heparin therapy). The PERFORM registry will be used as the platform for patient enrollment. The primary outcome is organ failure-free days to 14 days of enrollment. Organ failure in this trial is defined as an individual sequential organ failure assessment (SOFA) score of two or more for the respiratory, cardiovascular, or renal system. Patients who died before day 14 will be assigned zero organ failure-free days.

DISCUSSION

This trial will provide top-class evidence regarding the clinical impact of plasmapheresis in HTG-AP patients with early organ failure. The findings of this trial will have a direct influence on the current clinical practice concerning the management of HTG-AP.

Updates in the Management of Chronic Pancreatitis: Navigating Through Recent Advances

This article provides an up-to-date review of the management of chronic pancreatitis, highlighting advancements in medical therapy, nutritional support, endoscopic and surgical approaches, and emerging treatments. Nutritional management accentuates addressing malabsorption and nutrient deficiencies. Advances in endoscopy and parenchyma-sparing surgical techniques have opened new avenues for improved patient outcomes, with total pancreatectomy and islet autotransplantation offering the only definitive solution for selected patients. Additionally, emerging therapies, including anti-inflammatory and immune-modulating agents, show promise for future treatment options. Emphasizing a multidisciplinary approach, this review aims to equip health care professionals with a comprehensive overview of current management strategies and future directions.

Initial Management of Acute Pancreatitis

The initial management of acute pancreatitis (AP) is continually evolving. Goal-directed moderate fluid resuscitation is now preferred over more aggressive strategies. Antibiotics should be administered only when there is a proven or highly probable infection rather than for prophylactic purposes. Urgent endoscopic retrograde cholangiopancreatography would be beneficial for patients with acute cholangitis. Same-admission cholecystectomy for mild biliary PA is safe, efficiently prevents relapse, and is associated with lower costs compared with interval cholecystectomy. Ongoing research into novel pharmacologic treatments and strategies is essential for further advancements in AP management.

Global and regional burden of pancreatitis: epidemiological trends, risk factors, and projections to 2050 from the global burden of disease study 2021

BACKGROUND

Pancreatitis is a significant global health concern with rising incidence, complex management, and substantial mortality. This study aimed to assess global and regional trends in pancreatitis from 1990 to 2021 and project future trends to 2050 using data from the Global Burden of Disease (GBD) Study 2021.

METHODS

We analyzed GBD 2021 data to evaluate age-standardized incidence (ASIR), mortality (ASMR), and disability-adjusted life years (DALYs) rates of pancreatitis. Regional trends, gender disparities, and correlations with the Socio-demographic Index (SDI) were examined. Key risk factors, including alcohol consumption, smoking, and metabolic disorders such as hyperlipidemia, were extracted and evaluated. A Bayesian age-period-cohort model (BAPC) was used for future projections.

RESULTS

From 1990 to 2021, global pancreatitis cases increased from 1.73 million to 2.75 million, representing a rise of 59%. Despite this, ASIR decreased slightly from 37.62 to 32.81 per 100,000, a 12.8% reduction. Deaths rose from 68,490 to 122,416, an increase of 78.7%, while ASMR decreased from 1.69 to 1.45 per 100,000, a reduction of 14.2%. DALYs increased from 2.58 million to 4.10 million (59%). Significant regional variations were found, with Eastern Europe showing the highest ASIR, ASMR, and DALY rates. Projections indicate continued declines in ASIR, ASMR, and DALYs through 2050.

CONCLUSIONS

While global age-standardized rates of pancreatitis have declined, significant regional and socioeconomic disparities persist. Targeted prevention efforts, particularly in high-burden areas like Eastern Europe, and addressing modifiable risk factors such as alcohol use are crucial for reducing the future burden of pancreatitis.

Feeding Intolerance-A Key Factor in the Management of Acute Pancreatitis: A Review

Acute pancreatitis (AP) is one of the most common diseases of the gastrointestinal tract, which in 20% of cases can turn into a severe form, with mortality reaching up to 30%. One of the cornerstones of AP treatment is early nutritional treatment. Feeding intolerance (FI) occurs in up to 25% of patients with AP and is associated with a more severe disease course and poorer clinical outcome. Feeding intolerance can have a multifaceted clinical presentation. The early identification of FI risk factors and appropriately conducted nutritional treatment are critical to the course of the disease. In this review, we summarize the current knowledge of feeding intolerance in AP, its pathomechanisms and risk factors, and its impact on disease progression. We also present suggestions for the management of feeding intolerance.

Current clinical and pathogenetic characteristics of patients with chronic pancreatitis depending on biological age and smoking

OBJECTIVE

Aim: To investigate the relationships between age, smoking status, inflammatory markers, and endotoxicosis in patients with chronic pancreatitis, focusing on C-reactive protein (CRP) and middle molecular peptides, specifically MMP254 and MMP280..

PATIENTS AND METHODS

Materials and Methods: The study involved the examination of 108 patients diagnosed with chronic pancreatitis. These patients were categorized by age according to the World Health Organization (WHO) guidelines. Additionally, patients were stratified based on smoking status. Key biochemical markers were assessed, including fecal α-elastase, medium molecular weight peptides, and C-reactive protein levels. This approach allows for a comprehensive evaluation of how age and smoking may influence the course of chronic pancreatitis, while also considering the diagnostic value of these specific biomarkers in monitoring pancreatic function and inflammatory responses in these patients.

RESULTS

Results: A statistically significant impact of age on fecal α-elastase, C-reactive protein, and medium molecular peptides levels has been identified. Additionally, smoking has been shown to exacerbate pathological changes in these markers.

CONCLUSION

Conclusions: these findings underscore the necessity for individualized treatment approaches that consider age and smoking history, particularly in older patients. Future research should further explore the underlying mechanisms linking these variables to chronic pancreatitis, with an emphasis on the long-term effects of smoking cessation and interventions targeting inflammatory markers and endotoxicosis. This understanding is crucial for enhancing management strategies and improving the quality of life for patients suffering from chronic pancreatitis.