What is the best way to feed patients with pancreatitis? Curr Opin Crit Care. 2009;15:131-138. [PMID: 19300086 DOI: 10.1097/mcc.0b013e328319910a]

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.

ACVIM consensus statement on pancreatitis in cats

Background

Pancreatitis in cats, although commonly diagnosed, still presents many diagnostic and management challenges.

Objective

To summarize the current literature as it relates to etiology, pathogenesis, diagnosis, and management of pancreatitis in cats and to arrive at clinically relevant suggestions for veterinary clinicians that are based on evidence, and where such evidence is lacking, based on consensus of experts in the field.

Animals

None.

Methods

A panel of 8 experts in the field (5 internists, 1 radiologist, 1 clinical pathologist, and 1 anatomic pathologist), with support from a librarian, was formed to assess and summarize evidence in the peer reviewed literature and complement it with consensus clinical recommendations.

Results

There was little literature on the etiology and pathogenesis of spontaneous pancreatitis in cats, but there was much in the literature about the disease in humans, along with some experimental evidence in cats and nonfeline species. Most evidence was in the area of diagnosis of pancreatitis in cats, which was summarized carefully. In contrast, there was little evidence on the management of pancreatitis in cats.

Conclusions and Clinical Importance

Pancreatitis is amenable to antemortem diagnosis by integrating all clinical and diagnostic information available, and recognizing that acute pancreatitis is far easier to diagnose than chronic pancreatitis. Although both forms of pancreatitis can be managed successfully in many cats, management measures are far less clearly defined for chronic pancreatitis.

Pancreatectomy, Islet Cell Transplantation, and Nutrition Considerations

Pancreatic islet transplantation is a reliable approach for treating insulin-deficient diabetes. This established β-cell replacement approach has shown considerable improvements in the last 2 decades. It has helped achieve metabolic homeostasis and safe outcomes for a subset of patients with type 1 diabetes and severe pancreatitis. Nutrition support, until recently, was considered as a secondary factor, merely identified as a means of providing all the necessary nutrients for such patients. However, new literature suggests that several factors, such as the route, timing, quantity, and composition of all the nutrients administered, have key disease-altering properties and are vital during the perioperative management of such patients. This review will highlight the benefits of performing the clinical islet transplantation on a subgroup of patients with type 1 diabetes and pancreatitis and summarize new data that identify the pivotal role of nutrition support as a critical intervention in their management.

Non-inferiority comparative clinical trial between early oral REFEEDING and usual oral REFEEDING in predicted mild acute biliary pancreatitis

BACKGROUND

The aim of the study was to compare the onset of oral feeding in the first 24 h after hospital admission with usual oral refeeding and determine whether the timing of the onset of oral feeding influences the recurrence of pain or alters the blood levels of pancreatic enzymes in patients with predicted mild acute biliary pancreatitis.

METHODS

This non-inferiority randomized controlled trial was carried out between September 2018 and June 2019 after receiving authorization from the ethics committee for health research. Patients with a diagnosis of predicted mild acute biliary pancreatitis were divided into Group A (early oral refeeding, EOR) and Group B (usual oral refeeding, UOR). Outcome measures included pancreatic lipase levels, the systemic inflammatory response (concentrations of leukocytes), feasibility (evaluated by abdominal pain recurrence), the presence and recurrence of gastrointestinal symptoms and the length of hospital stay.

RESULTS

Two patients in the EOR group experienced pain relapse (3.2%), and four patients in the UOR group experienced pain relapse (6.77%) after oral refeeding (p = 0.379). The presence of nausea or vomiting after the onset of oral refeeding was not different between the two groups (p = 0.293). The onset of oral refeeding was approximately 48 h later in the UOR group. The length of hospital stay was 5 days in the EOR group and 8 days in the UOR group (p = 0.042), and this difference was also manifested in higher hospital costs in the UOR group (p = 0.0235).

CONCLUSION

Compared with usual oral refeeding, early oral refeeding is safe in predicted mild acute biliary pancreatitis patients, does not cause adverse gastrointestinal events, and reduces the length of hospital stay and costs.

TRIAL REGISTRATION

Early oral refeeding in mild acute pancreatitis (EORVsUOR). NCT04168801 , retrospectively registered (November 19, 2019).

Current status of diagnosis and Mesenchymal stem cells therapy for acute pancreatitis

Acute pancreatitis (AP) is an acute gastrointestinal disorder that is the most common and requiring emergency hospitalization. Its incidence is increasing worldwide, thus increasing the burden of medical services. Approximately 20% of the patients develop moderate to severe necrotizing pancreatitis associated with pancreatic or peri-pancreatic tissue necrosis and multiple organ failure. There are many reports about the anti-inflammatory effect of mesenchymal stem cells (MSCs) on pancreatitis and the repair of tissue damage. MSCs cells come from a wide range of sources, autologous MSCs come from bone marrow and allogeneic MSCs such as umbilical cord blood MSCs, placenta-derived MSCs, etc. The wide source is not only an advantage of MSCs but also a disadvantage of MSCs. Because of different cell sources and different methods of collection and preparation, it is impossible to establish a unified standard method for evaluation of efficacy. The biggest advantage of iMSCs is that it can be prepared by a standardized process, and can be prepared on a large scale, which makes it easier to commercialize. This paper reviews the present status of diagnosis and progress of MSCs therapy for AP.

Prediction of Self-Limited Acute Pancreatitis Cases at Admission to Emergency Unit

Background

While acute pancreatitis (AP) resolves spontaneously with supportive treatment in most patients, it may be life-threatening. Predicting the disease severity at onset dictates the management strategy. We aimed to define the patients with mild pancreatitis who may be considered for outpatient management with significant cost-savings.

Materials and Methods

This prospective observational study included 180 patients with mild AP according to the harmless acute pancreatitis score (HAPS) and Imrie score. The relationships of biochemical parameters with the changes in the Balthazar score and clinical course were examined.

Results

The study included 180 patients (111 females, 69 males; mean age: 53.9 ± 17.2 years; range: 17-92 years). The etiology was biliary in 118 (65%) patients and remained undetermined in 38 (21.1%) patients. Computed tomography (CT) performed within the first 12 h revealed mild and moderate AP in 159 (88.3%) and 21 (11.7%) patients, respectively. CT repeated at 72 h revealed mild, moderate, and severe AP in 155 (86.1%), 24 (13.3%), and 1 (0.6%) patients, respectively. Comparisons between stages A + B + C and D + E showed significant differences in the amylase levels on day 1 and 3, and in C-reactive protein on day 3. Also, in stage D and E disease, narcotic analgesic intake, oral intake onset time, and pain were significantly higher.

Conclusion

There were no significant changes in the CT findings of patients with mild AP at 12 and 72 h. Most patients (n = 179; 99.4%) recovered uneventfully. Patients with mild pancreatitis according to the HAPS and Imrie scores can be considered for outpatient management. The recovery is longer in stage D and E disease.

Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

BACKGROUND

Although the incidence of acute pancreatitis (AP) in children is increasing, management recommendations rely on adult published guidelines. Pediatric-specific recommendations are needed.

METHODS

The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas committee performed a MEDLINE review using several preselected key terms relating to management considerations in adult and pediatric AP. The literature was summarized, quality of evidence reviewed, and statements of recommendations developed. The authorship met to discuss the evidence, statements, and voted on recommendations. A consensus of at least 75% was required to approve a recommendation.

RESULTS

The diagnosis of pediatric AP should follow the published INternational Study Group of Pediatric Pancreatitis: In Search for a CuRE definitions (by meeting at least 2 out of 3 criteria: (1) abdominal pain compatible with AP, (2) serum amylase and/or lipase values ≥3 times upper limits of normal, (3) imaging findings consistent with AP). Adequate fluid resuscitation with crystalloid appears key especially within the first 24 hours. Analgesia may include opioid medications when opioid-sparing measures are inadequate. Pulmonary, cardiovascular, and renal status should be closely monitored particularly within the first 48 hours. Enteral nutrition should be started as early as tolerated, whether through oral, gastric, or jejunal route. Little evidence supports the use of prophylactic antibiotics, antioxidants, probiotics, and protease inhibitors. Esophago-gastro-duodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography have limited roles in diagnosis and management. Children should be carefully followed for development of early or late complications and recurrent attacks of AP.

CONCLUSIONS

This clinical report represents the first English-language recommendations for the management of pediatric AP. Future aims should include prospective multicenter pediatric studies to further validate these recommendations and optimize care for children with AP.

Acute pancreatitis: recent advances through randomised trials

Acute pancreatitis is one of the most common GI conditions requiring acute hospitalisation and has a rising incidence. In recent years, important insights on the management of acute pancreatitis have been obtained through numerous randomised controlled trials. Based on this evidence, the treatment of acute pancreatitis has gradually developed towards a tailored, multidisciplinary effort, with distinctive roles for gastroenterologists, radiologists and surgeons. This review summarises how to diagnose, classify and manage patients with acute pancreatitis, emphasising the evidence obtained through randomised controlled trials.

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.

Improving the Outcome of Acute Pancreatitis

Acute pancreatitis (AP) is the most common indication for hospital admission and its incidence is rising. It has a variable prognosis, which is mainly dependent upon the development of persistent organ failure and infected necrotizing pancreatitis. In the past few years, based on large-scale multicenter randomized trials, some novel insights regarding clinical management have emerged. In patients with infected pancreatic necrosis, a step-up approach of percutaneous catheter drainage followed by necrosectomy only when the patient does not improve, reduces new-onset organ failure and prevents the need for necrosectomy in about a third of patients. A randomized pilot study comparing surgical to endoscopic necrosectomy in patients with infected necrotizing pancreatitis showed a striking reduction of the pro-inflammatory response following endoscopic necrosectomy. These promising results have recently been tested in a large multicenter randomized trial whose results are eagerly awaited. Contrary to earlier data from uncontrolled studies, a large multicenter randomized trial comparing early (within 24 h) nasoenteric tube feeding compared with an oral diet after 72 h, did not show that early nasoenteric tube feeding was superior in reducing the rate of infection or death in patients with AP at high risk for complications. Although early ERCP does not have a role in the treatment of predicted mild pancreatitis, except in the case of concomitant cholangitis, it may ameliorate the disease course in patients with predicted severe pancreatitis. Currently, a large-scale randomized study is underway and results are expected in 2017.

Effect of endogenous cholecystokinin on the course of acute pancreatitis in rats

AIM: To examine the effects of pancreatic rest, stimulation and rest/stimulation on the natural course of recovery after acute pancreatitis.

METHODS: Acute hemorrhagic pancreatitis (AP) was induced in male rats by intraductal infusion of 40 μL/100 g body weight of 3% sodium taurocholate. All rats took food ad libitum. At 24 h after induction of AP, rats were divided into four groups: control (AP-C), pancreas rest (AP-R), stimulation (AP-S), and rest/stimulation (AP-R/S). Rats in the AP-C, AP-R and AP-S groups received oral administration of 2 mL/kg body weight saline, cholecystokinin (CCK)-1 receptor antagonist, and endogenous CCK release stimulant, respectively, twice daily for 10 d, while those in the AP-R/S group received twice daily CCK-1 receptor antagonist for the first 5 d followed by twice daily CCK release stimulant for 5 d. Rats without any treatment were used as control group (Control). Biochemical and histological changes in the pancreas, and secretory function were evaluated on day 12 at 24 h after the last treatment.

RESULTS: Feeding ad libitum (AP-C) delayed biochemical, histological and functional recovery from AP. In AP-C rats, bombesin-stimulated pancreatic secretory function and HOMA-β-cell score were significantly lower than those in other groups of rats. In AP-R rats, protein per DNA ratio and pancreatic exocrine secretory function were significantly low compared with those in Control rats. In AP-S and AP-R/S rats, the above parameters recovered to the Control levels. Bombesin-stimulated pancreatic exocrine response in AP-R/S rats was higher than in AP-S rats and almost returned to control levels. In the pancreas of AP-C rats, destruction of pancreatic acini, marked infiltration of inflammatory cells, and strong expression of α-smooth muscle actin, tumor necrosis factor-α and interleukin-1β were seen. Pancreatic rest reversed these histological alterations, but not atrophy of pancreatic acini and mild infiltration of inflammatory cells. In AP-S and AP-R/S rats, the pancreas showed almost normal architecture.

CONCLUSION: The favorable treatment strategy for AP is to keep the pancreas at rest during an early stage followed by pancreatic stimulation by promoting endogenous CCK release.

The role of omega-3 fatty acids in acute pancreatitis: a meta-analysis of randomized controlled trials

To determine whether treatment with omega-3 fatty acids (ω-3 FA) provides benefits to patients with acute pancreatitis (AP). The Cochrane Library, PubMed, Embase, Web of Science, and Chinese Biomedical Literature Database were searched. Data analysis was performed using Revman 5.2 software. A total of eight randomized controlled trials (RCTs) were included. Overall, ω-3 FA treatment resulted in a significantly reduced risk of mortality (RR 0.35; 95% CI 0.16 to 0.75, p < 0.05), infectious complications (RR 0.54; 95% CI 0.34 to 0.85, p < 0.05) and length of hospital stay (MD -6.50; 95% CI -9.54 to -3.46, p < 0.05), but not length of ICU stay (MD -1.98; 95% CI -6.92 to 2.96, p > 0.05). In subgroup analysis, only patients who received ω-3 FA parenterally had some statistically significant benefits in terms of mortality (risk ratio (RR) 0.37; 95% confidence interval (CI) 0.16 to 0.86, p < 0.05), infectious complications (RR 0.5; 95% CI 0.28 to 0.9, p < 0.05) and length of hospital stay (mean difference (MD) -8.13; 95% CI -10.39 to -5.87, p < 0.001). The administration of ω-3 FA may be beneficial for decreasing mortality, infectious complications, and length of hospital stay in AP, especially when used parenterally. Large and rigorously designed RCTs are required to elucidate the efficacy of parenteral or enteral ω-3 FA treatment in AP.

Effect of enteral nutrition on cytokine production and plasma endotoxin in patients with severe acute pancreatitis

AIM: To assess the influence of enteral nutrition (EN) on interleukin (IL)-6, IL-10, and tumor necrosis factor-α (TNF-α) production and plasma endotoxin level in patients with severe acute pancreatitis (SAP).

METHODS: Seventy-two patients with SAP were randomly divided into two groups to receive either EN or parenteral nutrition (PN) on the basis of routine comprehensive treatment. Conventional indicators, TNF-α, IL-6, IL-10 and plasma concentration of endotoxin were evaluated on 0, 1, 4, 7, and 14 d after treatment. The infection rates, mortality, hospitalization days and hospitalization costs were compared for the two groups.

RESULTS: After 14 d of treatment, C-reactive protein (CRP) and white blood cell count (WBC) in the EN group were significantly lower than those in the PN group (P < 0.05). After 4 d of treatment, plasma concentration of endotoxin in the EN group was significantly lower than that in the PN group. On day 7, plasma concentrations of TNF-α and IL-6 in the EN group significantly declined compared with the PN group (P < 0.05). Plasma concentration of IL-10 in the EN group was significantly higher than that in the PN group after 4 d of treatment (P < 0.05).

CONCLUSION: In patients with SAP, early implementation of EN can regulate inflammation, and delay the development of complications such as systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). EN can protect the intestinal mucosal barrier, decrease plasma endotoxin level, and reduce systemic infection.

Parenteral immunonutrition in patients with acute pancreatitis: a systematic review and meta-analysis

BACKGROUND & AIMS

Acute pancreatitis is a systemic immunoinflammatory response to auto-digestion of the pancrease and peri-pancreatic organs. Patients with acute pancreatitis can rapidly develop nutritional deficiency; hence nutritional support is important and critical. Sometimes parenteral nutrition (PN) is inevitable in acute pancreatitis. Due to immunosuppressive and inflammatory nature of the disease, it seems that immunonutrients like glutamine and omega-3 fatty acids (ω-3 FAs) added to parenteral formulas may improve the conditions. We conducted a meta-analysis to evaluate the effects of parenteral immunonutrition on clinical outcomes (infectious complications, length of hospital stay (LOS) and mortality) in patients with acute pancreatitis.

METHODS

A computerized literature search on four databases (PubMed, Cochrane, ISI Web of Science, and Iran Medex) was performed to find all the randomized controlled trials (RCTs) assessed the effects of parenteral immunonutrition in acute pancreatitis. Necessary data were extracted and quality assessment of RCTs was performed with consensus in the study team. Fixed effects model was used to conduct the meta-analysis.

RESULTS

One hundred and ninety four references were found via our search in which 7 articles matched our criteria for enrolling the meta-analysis. Parenteral immunonutrition significantly reduced the risk of infectious complications (RR = 0.59; 95% CI, 0.39-0.88; p ≤ 0.05) and mortality (RR = 0.26; 95% CI, 0.11-0.59; p ≤ 0.001). LOS was also shorter in patients who received immunonutrition (MD = -2.93 days; 95% CI, -4.70 to -1.15; p ≤ 0.001).

CONCLUSION

Immunonutrients like glutamine and ω-3 FAs added to parenteral formulas can improve prognoses in patients with acute pancreatitis.

Enteral nutrition in acute pancreatitis: A review of the current evidence

The use of enteral feeding as part of the management of acute pancreatitis dates back almost two decades. This review describes the indications for and limitations of enteral feeding for the treatment of acute pancreatitis using up-to-date evidence-based data. A systematic review was carried out to analyse current data on the use of enteral nutrition in the management of acute pancreatitis. Relevant literature was analysed from the viewpoints of enteral vs parenteral feeding, early vs delayed enteral nutrition, nasogastric vs nasojejunal feeding, and early oral diet and immunonutrition, particularly glutamine and probiotic supplementation. Finally, current applicable guidelines and the effects of these guidelines on clinical practice are discussed. The latest meta-analyses suggest that enteral nutrition significantly reduces the mortality rate of severe acute pancreatitis compared to parenteral feeding. To maintain gut barrier function and prevent early bacterial translocation, enteral feeding should be commenced within the first 24 h of hospital admission. Also, the safety of nasogastric feeding, which eases the administration of enteral nutrients in the clinical setting, is likely equal to nasojejunal feeding. Furthermore, an early low-fat oral diet is potentially beneficial in patients with mild pancreatitis. Despite the initial encouraging results, the current evidence does not support the use of immunoenhanced nutrients or probiotics in patients with acute pancreatitis.

Early versus on-demand nasoenteric tube feeding in acute pancreatitis

BACKGROUND

Early enteral feeding through a nasoenteric feeding tube is often used in patients with severe acute pancreatitis to prevent gut-derived infections, but evidence to support this strategy is limited. We conducted a multicenter, randomized trial comparing early nasoenteric tube feeding with an oral diet at 72 hours after presentation to the emergency department in patients with acute pancreatitis.

METHODS

We enrolled patients with acute pancreatitis who were at high risk for complications on the basis of an Acute Physiology and Chronic Health Evaluation II score of 8 or higher (on a scale of 0 to 71, with higher scores indicating more severe disease), an Imrie or modified Glasgow score of 3 or higher (on a scale of 0 to 8, with higher scores indicating more severe disease), or a serum C-reactive protein level of more than 150 mg per liter. Patients were randomly assigned to nasoenteric tube feeding within 24 hours after randomization (early group) or to an oral diet initiated 72 hours after presentation (on-demand group), with tube feeding provided if the oral diet was not tolerated. The primary end point was a composite of major infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death during 6 months of follow-up.

RESULTS

A total of 208 patients were enrolled at 19 Dutch hospitals. The primary end point occurred in 30 of 101 patients (30%) in the early group and in 28 of 104 (27%) in the on-demand group (risk ratio, 1.07; 95% confidence interval, 0.79 to 1.44; P=0.76). There were no significant differences between the early group and the on-demand group in the rate of major infection (25% and 26%, respectively; P=0.87) or death (11% and 7%, respectively; P=0.33). In the on-demand group, 72 patients (69%) tolerated an oral diet and did not require tube feeding.

CONCLUSIONS

This trial did not show the superiority of early nasoenteric tube feeding, as compared with an oral diet after 72 hours, in reducing the rate of infection or death in patients with acute pancreatitis at high risk for complications. (Funded by the Netherlands Organization for Health Research and Development and others; PYTHON Current Controlled Trials number, ISRCTN18170985.).

Parenteral immunonutrition in patients with acute pancreatitis: A meta-analysis of randomized controlled trials

AIM: To evaluate the effects of parenteral immunonutrition on clinical outcomes [infectious complications, length of hospital stay (LOS) and mortality] in patients with acute pancreatitis.

METHODS: Pubmed, Medline, Embase, Science Direct, CBM, Springer link, VIP and CNKI were electronically searched before 31^st May 2014 to collect the articles on parenteral immunonutrition in acute pancreatitis. The quality of the included trials was assessed according to the inclusive and exclusive criteria, and the data were extracted and analyzed using RevMan 5.2.7 software.

RESULTS: A total of seven randomized controlled trials studies with 264 pancreatitis patients were included. The number of patients receiving parenteral immunonutrition was 130 and the number of patient receiving standard parenteral nutrition was 134. Meta-analysis showed that parenteral immunonutrition significantly reduced the risk of infectious complications (RR = 0.56, 95%CI: 0.39-0.82, P = 0.002) and mortality (RR = 0.23, 95%CI: 0.10-0.52, P < 0.001). LOS was also shorter in patients who received immunonutrition (RR = -5.63, 95%CI: -9.69--1.57, P = 0.007).

CONCLUSION: Immunonutrients like glutamine and omega-3 fatty acids added to parenteral formulas can improve prognoses in patients with acute pancreatitis. Our findings still need to be verified by large, multicenter prospective randomized controlled trials.

Treatment options for acute pancreatitis

This Review covers the latest developments in the treatment of acute pancreatitis. The Atlanta Classification of acute pancreatitis has been revised, proposing several new terms and abandoning some of the old and confusing terminology. The 2012 Revised Atlanta Classification and the determinant-based classification aim to universally define the different local and systemic complications and predict outcome. The most important differences between these classifications are discussed. Several promising treatment options for the early management of acute pancreatitis have been tested, including the use of enteral nutrition and antibiotics as well as novel therapies such as haemofiltration and protease inhibitors. The results are summarized and the quality of evidence is discussed. Finally, new developments in the management of patients with infected pancreatic necrosis are addressed, including the use of the 'step-up approach' and results of minimally invasive necrosectomy.

Timing of enteral nutrition in acute pancreatitis: meta-analysis of individuals using a single-arm of randomised trials

INTRODUCTION

In acute pancreatitis, enteral nutrition (EN) reduces the rate of complications, such as infected pancreatic necrosis, organ failure, and mortality, as compared to parenteral nutrition (PN). Starting EN within 24 h of admission might further reduce complications.

METHODS

A literature search for trials of EN in acute pancreatitis was performed. Authors of eligible trials were requested to provide the data of all patients in the EN-arm of their trials. A meta-analysis of individual patient data was performed. The cohort of patients with EN was divided into patients receiving EN within 24 h or after 24 h of admission. Multivariable logistic regression, adjusting for predicted disease severity and trial, was used to study the effect of timing of EN on a composite endpoint of infected pancreatic necrosis, organ failure, or mortality.

RESULTS

Observational data from 165 individuals from 8 randomised trials were obtained; 100 patients with EN within 24 h and 65 patients with EN after 24 h of admission. In the multivariable model, EN started within 24 h of admission compared to EN started after 24 h of admission, reduced the composite endpoint from 45% to 19% (adjusted odds ratio [OR] of 0.44; 95% confidence interval [CI] 0.20-0.96). Within the composite endpoint, organ failure was reduced from 42% to 16% (adjusted OR 0.42; 95% CI 0.19-0.94).

CONCLUSIONS

In this meta-analysis of observational data from individuals with acute pancreatitis, starting EN within 24 h after hospital admission, compared with after 24 h, was associated with a reduction in complications.

Feeding tube placement: errors and complications

Feeding tube placement for enteral nutrition (EN) support is widely used in both critically ill and stable chronically ill patients who are unable to meet their nutrition needs orally. Nasal or oral feeding tubes can be performed blindly at the bedside or with fluoroscopic or endoscopic guidance into the stomach or small bowel. Percutaneous feeding tubes are used when EN support is required for longer periods (>4-6 weeks) and are most commonly placed endoscopically or radiographically. Although generally safe and effective, there is a wide spectrum of known complications associated with feeding tube placement. Errors made at the time of feeding tube placement can result in a number of these procedural and postprocedural complications. In many cases, a single error at the time of placement can result in numerous complications. A thorough knowledge of these errors and avoiding them in practice will decrease iatrogenic complications in a vulnerable population. In addition, early recognition and management of complications will further minimize morbidity and even mortality in enteral feeding tube placement. This article reviews the common errors leading to complications of enteral feeding tube placement and their prevention and management.

Audit of patients with severe acute pancreatitis admitted to an intensive care unit

BACKGROUND

Severe acute pancreatitis (SAP) is a disease with high morbidity and mortality. We undertook a study of patients with SAP admitted to the intensive care unit (ICU) of a tertiary referral hospital.

METHODS

Between 2002 and 2007, 50 patients with SAP were admitted in our intensive care unit (ICU). Data were collected from their medical records and their clinical profile, course and outcome were retrospectively analyzed. Patients were categorized into survivor and nonsurvivor groups, and were further classified based on interventions such as percutaneous drainage and surgical necrosectomy.

RESULTS

SAP contributed 5 % of total ICU admissions during the study period. Median age of survivors (n = 20) was 34 against 44 years in nonsurvivors (n = 30). Median Acute Physiology and Chronic Health Evaluation (APACHE) II score in nonsurvivors was 16.5 (8-32) vs. 12.5 (5-20) in survivors (p = 0.002). Patients with APACHE II score ≥12 had mortality >80 % compared to 23 % with score <12 (p < 0.001). Median Sequential Organ Failure Assessment (SOFA) scores on admission and on days 3, 7, 14, and 21 were significantly higher in nonsurvivors compared to survivors (p < 0.05). Mean (SD) intraabdominal pressure was 23 (3.37) mmHg in nonsurvivors vs. 19.05 (2.51) in survivors (p < 0.05). Patients with renal failure had significant mortality (p < 0.001). Length of ICU stay, requirement for vasopressor, total parenteral nutrition, and the amount of blood and blood product transfusions differed significantly between patients with and without intervention.

CONCLUSIONS

APACHE II and SOFA scores and other clinical data correlated with outcome in SAP admitted to ICU.

[Guidelines for specialized nutritional and metabolic support in the critically ill-patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): severe acute pancreatitis]

Severe acute pancreatitis (SAP) causes local and systemic complications leading to high catabolic, hypermetabolic and hyperdynamic stress states with marked morbidity and mortality. In the last decade, nutritional support has become a key element in the treatment of SAP. Thus, specialized nutrition is indicated from admission, with enteral nutrition being preferred to parenteral nutrition. Enteral nutrition should be initiated early using infusion through the jejunum beyond the ligament of Treitz to minimize pancreatic stress. There are no specific studies that establish the type of diet to be used but experts recommend the use of polymeric diets. Parenteral nutrition, without a specific formula, is indicated in patients with SAP who are intolerant to enteral nutrition or when the clinical signs of pancreatitis are exacerbated or aggravated by enteral nutrition. Even so, a minimal level of enteral infusion should be maintained to preserve the trophic effect of the intestinal mucosa. In the last few years, several studies of the administration of immunomodulatory diets in patients with SAP have been carried out to demonstrate their effects on the course of the disease. However, there are few clear recommendations on the prognostic benefits of pharmaconutrient enriched diets in these patients. There is substantial scientific evidence suggesting that the only clear indication for pharmaconutrition in patients with SAP is parenteral glutamine administration, which is recommended by all clinical guidelines with distinct grades of evidence.

Nutritional therapy in patients with acute pancreatitis requiring critical care unit management: a prospective observational study in Australia and New Zealand

OBJECTIVE

To determine nutritional therapy practices of patients with severe acute pancreatitis (defined as those receiving critical care management in an intensive care unit or high-dependency unit) in Australia and New Zealand with focus on the choice of enteral nutrition or parenteral nutrition.

DESIGN

Prospective observational multicentered study performed at 40 sites in Australia and New Zealand over 6 months.

SETTING

Intensive care units or high-dependency units within Australia and New Zealand.

PATIENTS

Those with severe acute pancreatitis diagnosed by elevated lipase and/or amylase. Patients with chronic pancreatitis were excluded.

MEASUREMENTS

The primary outcome was the proportion of patients who received enteral nutrition, parenteral nutrition, or concurrent enteral nutrition/parenteral nutrition. Secondary outcomes included other aspects of nutritional therapy and the severity and clinical outcomes of acute pancreatitis.

MEASUREMENTS AND MAIN RESULTS

We enrolled 121 patients and 117 were analyzed. The mean age was 61 (sd 17) years and 53% were men. Enteral nutrition was delivered to 58 (50%; 95% confidence interval [CI], 41-59%) and parenteral nutrition to 49 (42%; 95% CI, 33-51%) patients. Parenteral nutrition was more frequently used as the initial therapy (58%; 95% CI, 49-67%) than enteral nutrition (42%; 95% CI, 33-51%). The most common reason for parenteral nutrition prescription was the treating doctor's preference (60%). Enteral nutrition (74%) was more often used than parenteral nutrition (40%) on any individual study day. Concurrent enteral nutrition and parenteral nutrition occurred in 28 (24%) patients on 14% of days. Complications of acute pancreatitis requiring critical care unit management were observed in 45 (39%) patients. The median (interquartile range) duration of intensive care unit and hospital stay were 5 (2-10) and 19 (9-31) days, respectively. The hospital mortality rate was 15% (95% CI, 8-21%), and there was a tendency toward higher mortality for patients who only received parenteral nutrition than for those who only received enteral nutrition (28% vs. 7%, p=.06).

CONCLUSIONS

For patients with acute pancreatitis requiring critical care unit management in Australian and New Zealand intensive care units, enteral nutrition is used most commonly, but parenteral nutrition is more often used as the initial route of nutritional therapy. Given that clinical practice guidelines currently recommend enteral nutrition as the initial route of nutritional therapy in severe acute pancreatitis, improved education about and dissemination of these guidelines seems warranted.

Fatty acid composition of plasma lipid classes in chronic alcoholic pancreatitis

BACKGROUND/AIMS

Supplementation of n-3 long-chain polyunsaturated fatty acids (LCPUFA) is considered as adjuvant therapy in acute pancreatitis. We investigated plasma fatty acid status in chronic pancreatitis (CP).

METHODS

Patients with alcoholic CP (n = 56, gender: 33/23 male/female, age: 60.0 [14.0] years (median [IQR]), who reported giving up alcohol consumption several years ago and 51 control subjects were included into the study. The fatty acid composition of plasma phospholipids (PL), triacylglycerols (TG) and sterol esters (STE) was analyzed.

RESULTS

The sum of monounsaturated fatty acids was significantly higher in patients with CP than in controls (PL: 12.83 [3.35] vs. 12.20 [1.95], TG: 40.51 [6.02] vs. 37.52 [5.80], STE: 20.58 [7.22] vs. 17.54 [3.48], CP vs. control, % weight/weight, median [IQR], p < 0.05). Values of arachidonic acid were significantly lower in patients with CP than in controls (PL: 10.57 [3.56] vs. 11.66 [3.25], STE: 8.14 [2.63] vs. 9.24 [2.86], p < 0.05). Values of eicosapentaenoic acid and docosahexaenoic acid did not differ and there was no difference in the ratio of n-3 to n-6 LCPUFA.

CONCLUSION

Our present data do not furnish evidence for the supplementation of n-3 LCPUFA to the diet of CP patients in relatively good clinical condition.

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.

Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis: a systematic review and meta-analysis

Enteral nutrition (EN) reduces infectious complications and mortality compared with parenteral nutrition (PN) in patients with predicted severe acute pancreatitis. However, to date the complications attributable to the administration of EN and PN in this patient group have not been comprehensively studied. The aim of the study was to systematically review the complications related to the use of nutrition in patients with predicted severe acute pancreatitis receiving EN v. PN. The Cochrane Library, MEDLINE and Scopus were searched. Randomised controlled trials (RCT) of EN v. PN in predicted severe acute pancreatitis were selected. Pooled estimates of complications were expressed as OR with corresponding 95 % CI. Data from five RCT were meta-analysed. Diarrhoea occurred in six of ninety-two (7 %) patients receiving PN and twenty-four of eighty-two (29 %) patients receiving EN (OR 0.20; 95 % CI 0.09, 0.43; P < 0.001). Hyperglycaemia developed in twenty-one of ninety-two (23 %) patients receiving PN and nine of eighty-two (11 %) receiving EN (OR 2.59; 95 % CI 1.13, 5.94; P = 0.03). Given a significant reduction in infectious complications and mortality associated with the use of EN over PN that has been consistently demonstrated in previous studies, the former should be the treatment of choice in acute pancreatitis. Further clinical studies should investigate the strategies to mitigate the complications of enteral tube feeding in patients with acute pancreatitis.

Evidence-based use of enteral nutrition in acute pancreatitis

PURPOSE

A systematic review was carried out to analyze current evidence-based data on the use of enteral nutrition in the management of acute pancreatitis.

METHODS

Literature search was performed on "Pubmed" and "Medline" databases to identify articles investigating the role and potential effect of enteral nutrition on the outcome of patients with acute pancreatitis. Relevant data were analyzed from the viewpoints of possible benefits and complications, route and timing of administration, and composition of nutrients.

RESULTS

Thirty-two prospective randomized controlled trials and 15 meta-analyses of those were identified and included in this overview. Strong evidence suggests that enteral nutrition significantly reduces mortality rate of severe acute pancreatitis. While both nasogastric and nasojejunal feeding appear to be safe in severe pancreatitis, early low-fat oral diet is possibly beneficial in patients with mild pancreatitis. Since maintenance of the gut barrier function is one of the crucial effects of enteral nutrition, enteral feeding should be commenced within the first 24 h after hospital admission, in order to prevent early bacterial translocation. However, it seems that neither immunonoenhanced nutrients nor probiotic supplementation are able to reduce mortality further, and--therefore--cannot be recommended for patients with acute pancreatitis.

CONCLUSION

Although enteral nutrition is undoubtedly a key component of the management of acute pancreatitis, the exact role of that is needed to be defined yet. In particular, conflicting data from studies on nutrient compositions will require further clarification in the future.

Importance of nutritional management in diseases with exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) resulting from conditions such as chronic pancreatitis (CP), acute pancreatitis (AP) and upper gastrointestinal (GI) surgery increases risk for malnutrition and metabolic problems. Poor nutrition is associated with more complications and higher mortality. Therefore, effective nutritional management should be a high priority in these patients. In CP, poor nutrition has been shown to significantly affect quality of life and functional status. Clinical study data show that dietary counselling combined with pancreatic enzyme replacement therapy is effective in improving nutritional status and is therefore recommended in these patients. In AP, early enteral nutrition reduces complications and mortality. However, EPI persists in many cases after the resolution of AP; these patients remain at increased risk for malnutrition and require further nutritional support. In patients undergoing surgery, preoperative weight loss is a risk factor for postoperative morbidity and mortality; outcomes can be improved considerably by preoperative screening to identify high-risk patients and by providing appropriate perioperative nutritional support. Pre- and perioperative enteral nutrition are cost-effective interventions that can improve outcomes in patients undergoing GI surgery. In all of these patient populations, nutritional management, including risk assessment and individualized nutritional support, is a key component of an effective multimodal therapeutic approach.