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Hsieh PH, Yang TC, Kang EYN, Lee PC, Luo JC, Huang YH, Hou MC, Huang SP. Impact of nutritional support routes on mortality in acute pancreatitis: A network meta-analysis of randomized controlled trials. J Intern Med 2024; 295:759-773. [PMID: 38561603 DOI: 10.1111/joim.13782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Nutritional administration in acute pancreatitis (AP) management has sparked widespread discussion, yet contradictory mortality results across meta-analyses necessitate clarification. The optimal nutritional route in AP remains uncertain. Therefore, this study aimed to compare mortality among nutritional administration routes in patients with AP using consistency model. METHODS This study searched four major databases for relevant randomized controlled trials (RCTs). Two authors independently extracted and checked data and quality. Network meta-analysis was conducted for estimating risk ratios (RRs) with 95% confidence interval (CI) based on random-effects model. Subgroup analyses accounted for AP severity and nutrition support initiation. RESULTS A meticulous search yielded 1185 references, with 30 records meeting inclusion criteria from 27 RCTs (n = 1594). Pooled analyses showed the mortality risk reduction associated with nasogastric (NG) (RR = 0.34; 95%CI: 0.16-0.73) and nasojejunal (NJ) feeding (RR = 0.46; 95%CI: 0.25-0.84) in comparison to nil per os. Similarly, NG (RR = 0.45; 95%CI: 0.24-0.83) and NJ (RR = 0.60; 95%CI: 0.40-0.90) feeding also showed lower mortality risk than total parenteral nutrition. Subgroup analyses, stratified by severity, supported these findings. Notably, the timing of nutritional support initiation emerged as a significant factor, with NJ feeding demonstrating notable mortality reduction within 24 and 48 h, particularly in severe cases. CONCLUSION For severe AP, both NG and NJ feeding appear optimal, with variations in initiation timings. NG feeding does not appear to merit recommendation within the initial 24 h, whereas NJ feeding is advisable within the corresponding timeframe following admission. These findings offer valuable insights for optimizing nutritional interventions in AP.
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Affiliation(s)
- Ping-Han Hsieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tsung-Chieh Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Enoch Yi-No Kang
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiing-Chyuan Luo
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ping Huang
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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Abstract
Acute pancreatitis (AP) is an inflammatory disease that can progress to severe acute pancreatitis (SAP), which increases the risk of death. AP is characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. Other contributing factors may include calcium (Ca2+) overload, mitochondrial dysfunction, impaired autophagy, and endoplasmic reticulum (ER) stress. In addition, exosomes are also associated with pathophysiological processes of many human diseases and may play a biological role in AP. However, the pathogenic mechanism has not been fully elucidated and needs to be further explored to inform treatment. Recently, the treatment guidelines have changed; minimally invasive therapy is advocated more as the core multidisciplinary participation and "step-up" approach. The surgical procedures have gradually changed from open surgery to minimally invasive surgery that primarily includes percutaneous catheter drainage (PCD), endoscopy, small incision surgery, and video-assisted surgery. The current guidelines for the management of AP have been updated and revised in many aspects. The type of fluid to be used, the timing, volume, and speed of administration for fluid resuscitation has been controversial. In addition, the timing and role of nutritional support and prophylactic antibiotic therapy, as well as the timing of the surgical or endoscopic intervention, and the management of complications still have many uncertainties that could negatively impact the prognosis and patients' quality of life. Consequently, to inform clinicians about optimal treatment, we aimed to review recent advances in the understanding of the pathogenesis of AP and its diagnosis and management.
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Affiliation(s)
- Zhi Zheng
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yi-Xuan Ding
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Yuan-Xu Qu
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Feng Cao
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
| | - Fei Li
- Department of General Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China
- Clinical Center for Acute Pancreatitis, Capital Medical University, Beijing, China
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Abstract
Although the pathophysiological mechanisms and consequences of gross derangements in iron metabolism are well known, little is known about the pathophysiological mechanisms underlying mild-to-moderate alterations in iron metabolism and their consequences. Growing evidence indicates that the exocrine pancreas has a bidirectional relationship with iron metabolism. Studies have shown alterations in circulating markers of iron metabolism, iron absorption, and intra-pancreatic iron deposition in pancreatitis. At the same time, exocrine pancreatic dysfunction has been shown in iron overload disorders. These observations reveal a compelling connection between the exocrine pancreas and iron metabolism, which are further elucidated by observations of therapeutic benefits of iron chelating agents and pancreatic enzyme replacement therapy. While the pancreas is not a major reservoir of iron in the body, better understanding of its relationship with iron metabolism may yield unexpected insights.
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Affiliation(s)
- Wandia Kimita
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Maxim S Petrov
- School of Medicine, University of Auckland, Auckland, New Zealand.
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Mosko JD, Leiman DA, Ketwaroo GA, Gupta N. Development of Quality Measures for Acute Pancreatitis: A Model for Hospital-Based Measures in Gastroenterology. Clin Gastroenterol Hepatol 2020; 18:272-275.e5. [PMID: 31760190 DOI: 10.1016/j.cgh.2019.11.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jeffrey D Mosko
- Center for Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David A Leiman
- Division of Gastroenterology, Duke University, Durham, and Duke Clinical Research Institute, Durham, North Carolina
| | - Gyanprakash A Ketwaroo
- Department of Medicine, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
| | - Neil Gupta
- Division of Gastroenterology and Nutrition, Loyola University Health System, Maywood, Illinois.
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Asrani VM, Brown A, Bissett I, Windsor JA. Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis. ACTA ACUST UNITED AC 2020; 6:5-24. [PMID: 32104727 DOI: 10.2478/jccm-2020-0009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
Introduction Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF. Aim To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice. Methods Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity. Results Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group. Conclusions There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.
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Hsieh PH, Su HY, Lin CY, Kang YN, Chang CC. Infection rate among nutritional therapies for acute pancreatitis: A systematic review with network meta-analysis of randomized controlled trials. PLoS One 2019; 14:e0219151. [PMID: 31291306 DOI: 10.1371/journal.pone.0219151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background Infection in acute pancreatitis (AP) is associated with nutritional therapies including naso-gastric (NG), naso-jejunal (NJ), and total parenteral nutrition (TPN). To examine infections among NG, NJ, TPN, and no nutritional support (NNS) in treating patients with AP. Methods The investigators completed comprehensive search in the Cochrane library, EMBASE, PubMed, Web of Science, and ClinicalTrials.gov without restriction on language and publication date before January 21, 2019. They also searched the reference lists of relevant studies for randomized controlled trials (RCTs) comparing NG, NJ, TPN, and NNS among patients with AP. Quantitative synthesis was conducted in a contrast-based network meta-analysis. To clarify effects, a network meta-analysis was conducted to calculate the surface under the cumulative ranking curve (SUCRA). Beside of overall infections, the event rates of infected pancreatic necrosis, bacteremia, line infection, pneumonia, urinary tract infection, and other types of infections were measured. Results The network meta-analysis of 16 RCTs showed that NJ had significantly lower overall infection rates compared with TPN (risk ratio: 0.59; 95% confidence interval: 0.38, 0.90); and NG had a larger effect size and higher rank probability compared with NJ, TPN, and NNS (mean rank = 1.7; SUCRA = 75.8). TPN was the least preferred (mean rank = 3.2; SUCRA = 26.6). Conclusions NG and NJ may be preferred therapies for treating patients with AP. Clinicians may consider NG as a first-line treatment for patients with AP (including severe AP) and even in patients receiving prophylactic antibiotics. In addition, we found that NNS should be avoided when treating patients with severe AP.
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Gold-Smith FD, Chand SK, Petrov MS. Post-pancreatitis diabetes mellitus: towards understanding the role of gastrointestinal motility. MINERVA GASTROENTERO 2018; 64. [DOI: 10.23736/s1121-421x.18.02507-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology 2018; 154:1103-1139. [PMID: 29421596 DOI: 10.1053/j.gastro.2018.01.031] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Chris E Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
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Qi D, Yu B, Huang J, Peng M. Meta-Analysis of Early Enteral Nutrition Provided Within 24 Hours of Admission on Clinical Outcomes in Acute Pancreatitis. JPEN J Parenter Enteral Nutr 2018; 42:1139-1147. [PMID: 29377204 DOI: 10.1002/jpen.1139] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 11/27/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Desheng Qi
- Emergency Department; Xiangya Hospital; Central South University; Changsha Hunan China
| | - Bo Yu
- Intensive Care Unit; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Jia Huang
- Intensive Care Unit; Second Xiangya Hospital; Central South University; Changsha Hunan China
| | - Milin Peng
- Critical Care Medicine; Xiangya Hospital; Central South University; Changsha Hunan China
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Márta K, Szabó AN, Pécsi D, Varjú P, Bajor J, Gódi S, Sarlós P, Mikó A, Szemes K, Papp M, Tornai T, Vincze Á, Márton Z, Vincze PA, Lankó E, Szentesi A, Molnár T, Hágendorn R, Faluhelyi N, Battyáni I, Kelemen D, Papp R, Miseta A, Verzár Z, Lerch MM, Neoptolemos JP, Sahin-Tóth M, Petersen OH, Hegyi P. High versus low energy administration in the early phase of acute pancreatitis (GOULASH trial): protocol of a multicentre randomised double-blind clinical trial. BMJ Open 2017; 7:e015874. [PMID: 28912191 PMCID: PMC5722094 DOI: 10.1136/bmjopen-2017-015874] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Acute pancreatitis (AP) is an inflammatory disease with no specific treatment. Mitochondrial injury followed by ATP depletion in both acinar and ductal cells is a recently discovered early event in its pathogenesis. Importantly, preclinical research has shown that intracellular ATP delivery restores the physiological function of the cells and protects from cell injury, suggesting that restoration of energy levels in the pancreas is therapeutically beneficial. Despite several high quality experimental observations in this area, no randomised trials have been conducted to date to address the requirements for energy intake in the early phase of AP. METHODS/DESIGN This is a randomised controlled two-arm double-blind multicentre trial. Patients with AP will be randomly assigned to groups A (30 kcal/kg/day energy administration starting within 24 hours of hospital admission) or B (low energy administration during the first 72 hours of hospital admission). Energy will be delivered by nasoenteric tube feeding with additional intravenous glucose supplementation or total parenteral nutrition if necessary. A combination of multiorgan failure for more than 48 hours and mortality is defined as the primary endpoint, whereas several secondary endpoints such as length of hospitalisation or pain will be determined to elucidate more detailed differences between the groups. The general feasibility, safety and quality checks required for high quality evidence will be adhered to. ETHICS AND DISSEMINATION The study has been approved by the relevant organisation, the Scientific and Research Ethics Committee of the Hungarian Medical Research Council (55961-2/2016/EKU). This study will provide evidence as to whether early high energy nutritional support is beneficial in the clinical management of AP. The results of this trial will be published in an open access way and disseminated among medical doctors. TRIAL REGISTRATION The trial has been registered at the ISRCTN (ISRTCN 63827758).
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Affiliation(s)
- Katalin Márta
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Anikó N Szabó
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Dániel Pécsi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Péter Varjú
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Judit Bajor
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia Sarlós
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Alexandra Mikó
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Kata Szemes
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Mária Papp
- 2nd Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Tornai
- 2nd Department of Internal Medicine, University of Debrecen, Debrecen, Hungary
| | - Áron Vincze
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Zsolt Márton
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | - Patrícia A Vincze
- Department of Pharmaceutics and Central Clinical Pharmacy, University of Pécs, Pécs, Hungary
| | - Erzsébet Lankó
- Department of Pharmaceutics and Central Clinical Pharmacy, University of Pécs, Pécs, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
| | - Tímea Molnár
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
| | - Roland Hágendorn
- 1st Department of Internal Medicine, University of Pécs, Pécs, Hungary
| | | | | | | | - Róbert Papp
- Surgery Clinic, University of Pécs, Pécs, Hungary
| | - Attila Miseta
- Department of Laboratory Medicine, University of Pécs, Pécs, Hungary
| | - Zsófia Verzár
- Department of Emergency Medicine, University of Pécs, Pécs, Hungary
| | - Markus M Lerch
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Miklós Sahin-Tóth
- Center for Exocrine Disorders, Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
| | - Ole H Petersen
- Medical Research Council Group, Cardiff School of Biosciences, Cardiff University, Cardiff, UK
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pecs, Hungary
- MTA-SZTE Translational Gastroenterology Research Group, Szeged, Hungary
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Affiliation(s)
- Maxim S Petrov
- a Department of Surgery , University of Auckland , Auckland , New Zealand
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Wu LM, Pendharkar SA, Asrani VM, Windsor JA, Petrov MS. Effect of Intravenous Fluids and Analgesia on Dysmotility in Patients With Acute Pancreatitis: A Prospective Cohort Study. Pancreas 2017; 46:858-66. [PMID: 28697124 DOI: 10.1097/MPA.0000000000000864] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Analgesia and intravenous fluid resuscitation are cornerstones of initial patient management in acute pancreatitis (AP). The aim was to investigate the effect of intravenous fluids and analgesia on gastrointestinal motility in the early course of AP. METHODS Gastrointestinal dysmotility was assessed using the Gastroparesis Cardinal Symptom Index (GCSI). One-way analysis of variance and analysis of covariance were conducted, adjusting for age, sex, body mass index, severity of AP, preexisting diabetes mellitus, and time from first symptom onset to hospital admission. RESULTS A total of 108 patients with AP were prospectively enrolled. Opioid analgesia, when compared with nonopioid analgesia, was significantly associated with increase in total GCSI score in both unadjusted and adjusted analyses. There was no significant difference between aggressive and nonaggressive fluid resuscitation in both unadjusted and adjusted analyses. A combination of opioids and any intravenous fluids was associated with a significantly increased total GCSI score compared with opioids and no intravenous fluids in both unadjusted and adjusted analyses. Duration of symptoms was the confounder that significantly affected 6 of 9 studied associations. CONCLUSIONS Intravenous fluids and analgesia significantly affect motility independent of severity and other covariates. Guidelines on prudent use of opioids and fluids in AP need to be developed, particularly taking into account duration of symptoms from onset to hospitalization.
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Stigliano S, Sternby H, de Madaria E, Capurso G, Petrov MS. Early management of acute pancreatitis: A review of the best evidence. Dig Liver Dis 2017; 49:585-94. [PMID: 28262458 DOI: 10.1016/j.dld.2017.01.168] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/27/2017] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.
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Jivanji CJ, Asrani VM, Pendharkar SA, Bevan MG, Gillies NA, Soo DHE, Singh RG, Petrov MS. Glucose Variability Measures as Predictors of Oral Feeding Intolerance in Acute Pancreatitis: A Prospective Pilot Study. Dig Dis Sci 2017; 62:1334-1345. [PMID: 28293757 DOI: 10.1007/s10620-017-4530-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 03/01/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Oral feeding intolerance (OFI) is a common complication in patients with acute pancreatitis (AP). Variations in blood glucose are associated with impaired gastrointestinal function but, to date, measures of glucose variability have not been investigated to predict OFI in patients with AP. AIM To investigate the usefulness of several glucose variability measures in predicting the occurrence of OFI early in the course of AP. METHODS In this prospective cohort study, six measures of glucose variability were calculated prior to the occurrence of OFI. Multivariate binary logistic regression analyses were conducted, and the diagnostic performance and accuracy of glucose variability measures were assessed. RESULTS Of the 95 prospectively enrolled patients, 21 (22%) developed OFI. After adjusting for confounders, admission blood glucose concentration and mean blood glucose concentration were significantly associated with OFI [odds ratio 1.49 (95% confidence interval 1.01-2.20) and odds ratio 1.67 (95% confidence interval 1.07-2.61), respectively]. Both admission blood glucose and mean blood glucose had an area under the curve of 0.83 and positive likelihood ratios of 6.45 and 10.19, respectively. Blood glucose concentration before refeeding, standard deviation of blood glucose concentration, coefficient of variation, and mean amplitude of glycemic excursions were not significantly associated with OFI. CONCLUSION In-hospital blood glucose concentrations are associated with subsequent development of OFI in patients with AP. In particular, admission blood glucose and mean blood glucose could be useful predictors of OFI in this setting.
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Affiliation(s)
- Chirag J Jivanji
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Varsha M Asrani
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Melody G Bevan
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Nicola A Gillies
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Danielle H E Soo
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ruma G Singh
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Maxim S Petrov
- Department of Surgery, University of Auckland, Auckland, New Zealand.
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Jivanji CJ, Asrani VM, Windsor JA, Petrov MS. New-Onset Diabetes After Acute and Critical Illness: A Systematic Review. Mayo Clin Proc 2017; 92:762-773. [PMID: 28302323 DOI: 10.1016/j.mayocp.2016.12.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 12/13/2016] [Accepted: 12/28/2016] [Indexed: 02/08/2023]
Abstract
Hyperglycemia is commonly observed during acute and critical illness. Recent studies have investigated the risk of developing diabetes after acute and critical illness, but the relationship between degree of in-hospital hyperglycemia and new-onset diabetes has not been investigated. This study examines the evidence for the relationship between in-hospital hyperglycemia and prevalence of new-onset diabetes after acute and critical illness. A literature search was performed of the MEDLINE, EMBASE, and Scopus databases for relevant studies published from January 1, 2000, through August 4, 2016. Patients with no history of diabetes before hospital discharge were included in the systematic review. In-hospital glucose concentration was classified as normoglycemia, mild hyperglycemia, or severe hyperglycemia for the meta-analysis. Twenty-three studies were included in the systematic review, and 18 of these (111,078 patients) met the eligibility criteria for the meta-analysis. The prevalence of new-onset diabetes was significantly related to in-hospital glucose concentration and was 4% (95% CI, 2%-7%), 12% (95% CI, 9%-15%), and 28% (95% CI, 18%-39%) for patients with normoglycemia, mild hyperglycemia, and severe hyperglycemia, respectively. The prevalence of new-onset diabetes was not influenced by disease setting, follow-up duration, or study design. In summary, this study found stepwise growth in the prevalence of new-onset diabetes with increasing in-hospital glucose concentration. Patients with severe hyperglycemia are at the highest risk, with 28% developing diabetes after hospital discharge.
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Affiliation(s)
- Chirag J Jivanji
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Varsha M Asrani
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Maxim S Petrov
- Department of Surgery, University of Auckland, Auckland, New Zealand.
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Hongyin L, Zhu H, Tao W, Ning L, Weihui L, Jianfeng C, Hongtao Y, Lijun T. Abdominal paracentesis drainage improves tolerance of enteral nutrition in acute pancreatitis: a randomized controlled trial. Scand J Gastroenterol 2017; 52:389-395. [PMID: 28050922 DOI: 10.1080/00365521.2016.1276617] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study is to determine whether abdominal paracentesis drainage (APD) could improve the administration of enteral nutrition (EN) in acute pancreatitis. METHODS Between January 2015 and April 2016, a total of 161 acute pancreatitis patients were enrolled and randomly assigned to either the APD group or the non-APD group. Several indexes associated with the administration of EN, including the gastroparesis cardinal symptom index (GCSI), the incidence of gastrointestinal adverse events, and the clinical outcomes, were recorded. RESULTS The mean GCSI scores were 13.6 ± 2.1 before randomization and 7.1 ± 2.3 after a week in the APD group. These scores were 13.9 ± 2.4 and 9.7 ± 1.9 in the non-APD group. The incidences of gastrointestinal adverse events in the two groups were similar (p > .05), except for diarrhea. However, the patients in the APD group spent less time achieving the nutrition target (25 per kilogram of body weight per day) and fully tolerated the oral diet (p < .05). Additionally, the clinical outcomes of the APD group were better compared with those of the non-APD group. CONCLUSION APD can improve the administration of EN in acute pancreatitis. Given the positive effect of EN on clinical outcomes, this phenomenon possibly explains why APD could improve the clinical outcomes of acute pancreatitis patients in some aspects.
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Affiliation(s)
- Liang Hongyin
- a Department of General Surgery , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
| | - Huang Zhu
- b Department of Postgraduate , Third Military Medical University , Chongqing , China
| | - Wang Tao
- a Department of General Surgery , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
| | - Lin Ning
- c Department of Clinical Nutrition , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
| | - Liu Weihui
- a Department of General Surgery , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
| | - Cui Jianfeng
- a Department of General Surgery , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
| | - Yan Hongtao
- a Department of General Surgery , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
| | - Tang Lijun
- a Department of General Surgery , Chengdu Military General Hospital , Chengdu , Sichuan Province , China
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Bevan MG, Asrani VM, Pendharkar SA, Goodger RL, Windsor JA, Petrov MS. Nomogram for predicting oral feeding intolerance in patients with acute pancreatitis. Nutrition 2017; 36:41-5. [DOI: 10.1016/j.nut.2016.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/28/2016] [Accepted: 06/06/2016] [Indexed: 02/06/2023]
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Szentesi A, Tóth E, Bálint E, Fanczal J, Madácsy T, Laczkó D, Ignáth I, Balázs A, Pallagi P, Maléth J, Rakonczay Z, Kui B, Illés D, Márta K, Blaskó Á, Demcsák A, Párniczky A, Pár G, Gódi S, Mosztbacher D, Szücs Á, Halász A, Izbéki F, Farkas N, Hegyi P. Analysis of Research Activity in Gastroenterology: Pancreatitis Is in Real Danger. PLoS One 2016; 11:e0165244. [PMID: 27776171 PMCID: PMC5077088 DOI: 10.1371/journal.pone.0165244] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 10/07/2016] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Biomedical investment trends in 2015 show a huge decrease of investment in gastroenterology. Since academic research usually provides the basis for industrial research and development (R&D), our aim was to understand research trends in the field of gastroenterology over the last 50 years and identify the most endangered areas. METHODS We searched for PubMed hits for gastrointestinal (GI) diseases for the 1965-2015 period. Overall, 1,554,325 articles were analyzed. Since pancreatology was identified as the most endangered field of research within gastroenterology, we carried out a detailed evaluation of research activity in pancreatology. RESULTS In 1965, among the major benign GI disorders, 51.9% of the research was performed on hepatitis, 25.7% on pancreatitis, 21.7% on upper GI diseases and only 0.7% on the lower GI disorders. Half a century later, in 2015, research on hepatitis and upper GI diseases had not changed significantly; however, studies on pancreatitis had dropped to 10.7%, while work on the lower GI disorders had risen to 23.4%. With regard to the malignant disorders (including liver, gastric, colon, pancreatic and oesophageal cancer), no such large-scale changes were observed in the last 50 years. Detailed analyses revealed that besides the drop in research activity in pancreatitis, there are serious problems with the quality of the studies as well. Only 6.8% of clinical trials on pancreatitis were registered and only 5.5% of these registered trials were multicentre and multinational (more than five centres and nations), i.e., the kind that provides the highest level of impact and evidence level. CONCLUSIONS There has been a clear drop in research activity in pancreatitis. New international networks and far more academic R&D activities should be established in order to find the first therapy specifically for acute pancreatitis.
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Affiliation(s)
- Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Emese Tóth
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Emese Bálint
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Júlia Fanczal
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Tamara Madácsy
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Dorottya Laczkó
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Imre Ignáth
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Anita Balázs
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Petra Pallagi
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - József Maléth
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Rakonczay
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Department of Pathophysiology, University of Szeged, Szeged, Hungary
| | - Balázs Kui
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Dóra Illés
- First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Katalin Márta
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Ágnes Blaskó
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Alexandra Demcsák
- Department of Pediatrics and Pediatric Health Center, University of Szeged, Szeged, Hungary
| | | | - Gabriella Pár
- Department of Gastroenterology, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Szilárd Gódi
- Department of Translational Medicine, First Department of Medicine, University of Pécs, Pécs, Hungary
| | - Dóra Mosztbacher
- Department of Pediatrics, János Balassa Hospital of County Tolna, Szekszárd, Hungary
| | - Ákos Szücs
- First Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Adrienn Halász
- First Department of Medicine, St. George University Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | - Ferenc Izbéki
- First Department of Medicine, St. George University Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- First Department of Medicine, University of Szeged, Szeged, Hungary
- Department of Translational Medicine, First Department of Medicine, University of Pécs, Pécs, Hungary
- Hungarian Academy of Sciences—University of Szeged, Momentum Gastroenterology Multidisciplinary Research Group, Szeged, Hungary
- * E-mail:
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Márta K, Farkas N, Szabó I, Illés A, Vincze Á, Pár G, Sarlós P, Bajor J, Szűcs Á, Czimmer J, Mosztbacher D, Párniczky A, Szemes K, Pécsi D, Hegyi P. Meta-Analysis of Early Nutrition: The Benefits of Enteral Feeding Compared to a Nil Per Os Diet Not Only in Severe, but Also in Mild and Moderate Acute Pancreatitis. Int J Mol Sci 2016; 17:E1691. [PMID: 27775609 DOI: 10.3390/ijms17101691] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/10/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022] Open
Abstract
The recently published guidelines for acute pancreatitis (AP) suggest that enteral nutrition (EN) should be the primary therapy in patients suffering from severe acute pancreatitis (SAP); however, none of the guidelines have recommendations on mild and moderate AP (MAP). A meta-analysis was performed using the preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). The following PICO (problem, intervention, comparison, outcome) was applied: P: nutrition in AP; I: enteral nutrition (EN); C: nil per os diet (NPO); and O: outcome. There were 717 articles found in Embase, 831 in PubMed, and 10 in the Cochrane database. Altogether, seven SAP and six MAP articles were suitable for analyses. In SAP, forest plots were used to illustrate three primary endpoints (mortality, multiorgan failure, and intervention). In MAP, 14 additional secondary endpoints were analyzed (such as CRP (C-reactive protein), WCC (white cell count), complications, etc.). After pooling the data, the Mann-Whitney U test was used to detect significant differences. Funnel plots were created for testing heterogeneity. All of the primary endpoints investigated showed that EN is beneficial vs. NPO in SAP. In MAP, all of the six articles found merit in EN. Analyses of the primary endpoints did not show significant differences between the groups; however, analyzing the 17 endpoints together showed a significant difference in favor of EN vs. NPO. EN is beneficial compared to a nil per os diet not only in severe, but also in mild and moderate AP.
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Abstract
PURPOSE OF REVIEW The role of enteral nutrition on gastrointestinal dysmotility in the critically ill remains controversial. RECENT FINDINGS The mechanisms of gastrointestinal dysmotility during critical illness remain poorly investigated. Low amounts of enteral feeding stimulate motility and have trophic effects. Therefore, enteral feeding is feasible even during gastrointestinal dysmotility as seen in the hemodynamically compromised patient. Rapid 'ramp-up' of administration rate of tube feeding bears the risk of overload and even detrimental ischemic bowel necrosis. The recent American Society for Parenteral and Enteral Nutrition guidelines do not recommend the measurement of gastric residual volume. The use of concentrated enteral solutions with 1.5 kcal/ml may result in greater calorie delivery. Biomarkers like plasma citrulline and plasma or urine intestinal fatty-acid-binding protein reflect the functional integrity of the bowel and may potentially support monitoring. SUMMARY To improve enteral nutrition protocols, the definitions of gastrointestinal dysfunction, gastric dysmotility, and feeding intolerance should be clearly defined in the future. In the concept of integrity of the gut, enteral nutrition should not be stopped completely during gastrointestinal dysfunction but restricted to a 'minimal' trophic feeding rate. In malnourished and high-risk patients intolerant to enteral feeding supplemental parenteral nutrition should be started on day 4 or earlier.
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Affiliation(s)
- Arved Weimann
- aDepartment of General Surgery and Clinical Nutrition, St. George Hospital, Leipzig bDepartment of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Munich, Germany
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Asrani VM, Yoon HD, Megill RD, Windsor JA, Petrov MS. Interventions That Affect Gastrointestinal Motility in Hospitalized Adult Patients: A Systematic Review and Meta-Analysis of Double-Blind Placebo-Controlled Randomized Trials. Medicine (Baltimore) 2016; 95:e2463. [PMID: 26844455 PMCID: PMC4748872 DOI: 10.1097/md.0000000000002463] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Gastrointestinal (GI) dysmotility is a common complication in acute, critically ill, postoperative, and chronic patients that may lead to impaired nutrient delivery, poor clinical, and patient-reported outcomes. Several pharmacological and nonpharmacological interventions to treat GI dysmotility were investigated in dozens of clinical studies. However, they often yielded conflicting results, at least in part, because various (nonstandardized) definitions of GI dysmotility were used and methodological quality of studies was poor. While a universally accepted definition of GI dysmotility is yet to be developed, a systematic analysis of data derived from double-blind placebo-controlled randomized trials may provide robust data on absolute and relative effectiveness of various interventions as the study outcome (GI motility) was assessed in the least biased manner.To systematically review data from double-blind placebo-controlled randomized trials to determine and compare the effectiveness of interventions that affect GI motility.Three electronic databases (MEDLINE, SCOPUS, and EMBASE) were searched. A random effects model was used for meta-analysis. The summary estimates were reported as mean difference (MD) with the corresponding 95% confidence interval (CI).A total of 38 double-blind placebo-controlled randomized trials involving 2371 patients were eligible for inclusion in the systematic review. These studies investigated a total of 20 different interventions, of which 6 interventions were meta-analyzed. Of them, the use of dopamine receptor antagonists (MD, -8.99; 95% CI, -17.72 to -0.27; P = 0.04) and macrolides (MD, -26.04; 95% CI, -51.25 to -0.82; P = 0.04) significantly improved GI motility compared with the placebo group. The use of botulism toxin significantly impaired GI motility compared with the placebo group (MD, 5.31; 95% CI, -0.04 to 10.67; P = 0.05). Other interventions (dietary factors, probiotics, hormones) did not affect GI motility.Based on the best available data and taking into account the safety profile of each class of intervention, dopamine receptor antagonists and macrolides significantly improve GI motility and are medications of choice in treating GI dysmotility.
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Affiliation(s)
- Varsha M Asrani
- From the Department of Surgery, University of Auckland (VMA, HDY, RDM, JAW, MSP); and Nutrition and Dietetics, Auckland City Hospital, Auckland, New Zealand (VMA)
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