Nutritional management of acute and chronic pancreatitis
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Nutritional Management of Acute and Chronic Pancreatitis. John P. Grant, MD Duke University Medical Center. Clinical Spectrum of Pancreatitis. Acute edematous - mild, self limiting Acute necrotizing or hemorrhagic - severe Chronic. Etiology of Acute Pancreatitis. Biliary Alcoholic

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Nutritional Management of Acute and Chronic Pancreatitis

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Nutritional Management of Acute and Chronic Pancreatitis

John P. Grant, MDDuke University Medical Center


Clinical Spectrum of Pancreatitis

  • Acute edematous - mild, self limiting

  • Acute necrotizing or hemorrhagic - severe

  • Chronic


Etiology of Acute Pancreatitis

  • Biliary

  • Alcoholic

  • Traumatic

  • Hyperlipidemia

  • Surgery

  • Viral

  • Others


Diagnosis and Monitoring of Severity of Acute Pancreatitis

  • Amylase and lipase

  • Temperature and WBC

  • Abdominal pain


Determination of Severity

  • Ranson’s Criteria

  • Imire ’s Criteria

  • Balthazar’ Severity Index


Ranson’s CriteriaSurg Gynecol Obstet 138:69, 1974

  • Age > 55 years

  • Blood glucose > 200 mg%

  • WBC > 16,000 mm3

  • LDH > 700 IU/L

  • SGOT > 250 U/L

If > 3 are present at time of admission, 60% die


Ranson’s CriteriaSurg Gynecol Obstet 138:69, 1974

  • Hct decreases > 10%

  • Calcium falls to < 8.0 mg%

  • Base deficit > 4 mEq/L

  • BUN increases > 5 mg%

  • PaO2 is < 60 mmHg

If > 3 are present within 48 hours of admission, 60% die


Age > 55

WBC 15,000 mm3

Glucose > 190 mg%

BUN > 23 mg%

PaO2 < 60 mmHg

Calcium <8.0 mg%

Albumin < 3.2 g%

LDH> 600 U/L

Imrie’s CriteriaGut 25:1340, 1984

In first 48 hours of admission

If > 3 or more present, 40% will be severe

If < 3 present, only 6% will be severe Predicts 79% of episodes


Balthazar’s Criteria

  • Appearance on unenhanced CT: Grade A to E

    • Edema within gland

    • Edema surrounding gland

    • Peripancreatic fluid collections

  • Appearance on enhanced CT:0 to 100% necrosis of gland

    • Degree of pancreatic necrosis


Grade A: normal pancreas with clinical pancreatitis


Grade B: Diffuse enlargement of the pancreas without peripancreatic inflammatory changes


Grade C: Enlarged pancreas with haziness and increased density of peripancreatic fat


Grade D: Enlarged body and tail of pancreas with fluid collection in left anterior pararenal space


Grade E: Fluid collections in lesser sac and anterior pararenal space


Grade E pancreatitis with normal enhancement - 0% necrosis


Grade E pancreatitis with <30% necrosis


Grade E pancreatitis with 40% necrosis


Grade E pancreatitis with 50% necrosis


Grade E pancreatitis with >90% necrosis and abscess formation


Balthazar, Radiology 174:331, 1990

Pancreatic Necrosis M&M


Grade

Grade A = 0

Grade B = 1

Grade C = 2

Grade D = 3

Grade E = 4

Degree of necrosis

None = 0

33% = 2

50% = 4

>50% = 6

CT Severity Index


Balthazar, Radiology 174:331, 1990

CT Severity Index and M&M


Standard Management

  • Restore and maintain blood volume

  • Restore and maintain electrolyte balance

  • Respiratory support

  • ± Antibiotics

  • Treatment of pain


Indications for Surgery

  • Need for pressors after adequate volume replacement

  • Persistent or increasing organ dysfunction despite maximum intensive care for at least 5 days

  • Proven or suspected infected necrosis

  • Uncertain diagnosis, progressive peritonitis or development of an acute abdomen


Standard Management

  • High M&M felt to be due to several factors:

    • High incidence of MOF

    • Need for surgery - often multiple

    • Development or worsening of malnutrition


Mechanisms Leading to Progression of Acute Pancreatitis

  • Stimulation of pancreatic secretion by oral intake (<24 hours)

  • Release of cytokines, poor perfusion of gland (24-72 hours)


Optimal Medical Management

  • Minimize exocrine pancreatic secretion

  • Avoid or suppress cytokine response

  • Avoid nutritional depletion


Optimal Medical Management

  • Minimize exocrine pancreatic secretion

    • NPO

    • Ng tube decompression of stomach

    • Cimetidine

    • Provision of a hypertonic solution in proximal jejunum


Optimal Medical Management

  • Minimize exocrine pancreatic secretion

  • Avoid or suppress cytokine response


Suppression of Cytokines

  • Antagonizing or blocking IL-1 and/or TNF activity – antibody and receptor antagonists

  • Preventing IL-1 and/or TNF production

    • Generic macrophage pacification

    • IL-10 regulation of IL-1 and TNF

    • Inhibiting posttranscriptional modification of pro-IL-1

  • Gene therapy to inhibit systemic hyperinflammatory response of pancreatitis


Postburn Hypermetabolism and Early Enteral Feeding

  • 30% BSA burn in guinea pigs

  • Enteral feeding via g-tube at 2 or 72 hours following burn

  • Mucosal weight and thickness were similar

Alexander, Ann Surg 200:297, 1984

175 Kcal - 72 h

200 Kcal - 72 h

175 Kcal - 2 h

Postburn day


Optimal Medical Management

  • Minimize exocrine pancreatic secretion

  • Avoid or suppress cytokine response

  • Avoid nutritional depletion

    • If gut not functioning – TPN

    • If gut functioning - Enteral


Pancreatic Exocrine Secretion

  • Water and Bicarbonate:

    • Acid in duodenum

    • Meat extracts in duodenum

    • Antral distention

  • Enzymes:

    • Fat and protein in duodenum

    • Ca, Mg, meat extracts in duodenum

    • Eating, antral distention

Stimulants


Pancreatic Exocrine Secretion

  • IV amino acids

  • Somatostatin

  • Glucagon

  • Any hypertonic solution in jejunum

Depressants


Summary of Ideal Feeding Solutions in Acute Pancreatitis

  • Parenteral: Crystalline amino acids, hypertonic glucose solutions (IV fat emulsions tolerated)

  • Enteral: Low fat, elemental, hypertonic solutions given into jejunum


Pancreatitis: Effect of TPNSitzmann et al, Surg Gynecol Obstet, 168:311, 1989

  • 73 patients with acute pancreatitis (ave. Ranson’s 2.5) were given TPN.

    • 81% had improved nutrition status

    • Mortality was increased 10-fold in patients with negative nitrogen balance

    • 60% required insulin (ave. 35 U/d)

    • Lipid well tolerated


Pancreatitis: Effect of TPNRobin et al, World J Surg, 14:572, 1990

  • 156 patients with acute MILD to MODERATE pancreatitis received TPN (70 simple – Ranson’s 1.6; 86 complex pancreatitis – Ranson’s 2.2)


Pancreatitis: Effect of TPNRobin et al, World J Surg, 14:572, 1990

  • Complications

    • 20 catheters were removed suspected sepsis (11%), 3 proven

    • 55% of patients required insulin (ave. 69 U/d)

    • 15% developed respiratory failure, 3% hepatic failure, 1% renal failure, and 1% GI bleeding


Pancreatitis: Effect of TPNRobin et al, World J Surg, 14:572, 1990

  • Nutritional status improved during TPN

  • TPN solution was well tolerated

  • TPN had no impact on course of disease


Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

  • 67 patients with SEVERE pancreatitis (Ranson’s criteria > 3) were given TPN

    • Age: 57.8 ± 2

    • Male/Female 25/42

    • Average Ranson’s 3.8 ± .21

    • Etiology


Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

  • Fat emulsion did not cause clinical or laboratory worsening of pancreatitis

  • 8.9% catheter-related sepsis vs 2.9% in other patients

  • Hyperglycemia occurred in 59 patients (88%) and required an average of 46 U/d insulin


Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

  • If TPN started within 72 hours: 23.6% complication rate and 13% mortality

  • If TPN started after 72 hours: 95.6% complication rate and 38% mortality


Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991


Pancreatitis: Effect of TF Kudsk et al, Nutr Clin Pract, 5:14, 1990

  • 9 patients with acute pancreatitis were given jejunostomy feedings following laparotomy

    • Although diarrhea was a frequent problem, TF was not stopped or decreased, TPN was not required

    • No fluid or electrolyte problems occurred

    • Serum amylase decreased progressively

    • Hyperglycemia was common but responded to insulin


Pancreatitis: TPN vs TF McClave et al, JPEN, 21:14, 1997

  • 32 middle aged male alcoholics with mild pancreatitis (Ranson’s ave. 1.3)

  • Randomized to receive either nasojejunal (Peptamen) or TPN within 48 hours of admission (25 kcal, 1.2 g protein/kg/d)


Pancreatitis: TPN vs TF McClave et al, JPEN, 84:1665, 1997

  • There was no difference in serial pain scores, days to normal amylase, days to PO diet, or percent infections between groups

  • The mean cost of TPN was 4 times greater than TF


Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

  • 38 patients with severe necrotizing pancreatitis were given either jejunostomy feedings or TPN within 48 hours of diagnosis

    • 3 or more Ranson’s criteria

    • APACHE II score > 8

    • Grade D or E Balthazar criteria


Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

  • Jejunal feedings with Reabilan HN containing 52 g/L fat (61% long-chain and 39% medium-chain triglycerides)

  • TPN with Vamin as all-in-1 using Lipofudin long-chain/medium-chain triglycerides

  • Target support 1.5-2 g protein/kg/d and 30-35 kcal/kg/d


Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

  • Outcome:

    • Both enteral and parenteral nutrition were well tolerated with no adverse effects on the course of pancreatitis

    • No difference in total days on nutrition support (33 d); total days in ICU (11 d); time on ventilator (13 d); use of and time on antibiotics (22 d); mean length of hospital stay (40 d); or mortality


Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

  • Outcome:

    • TF patients had significantly less morbidity than TPN patients

      • Septic complications 5 vs 10 p < .01

      • Hyperglycemia 4 vs 9

      • All complications 8 vs 15 p < .05

    • Risk of developing complications with TPN was 3.47 times greater than with TF


Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

  • Outcome:

    • Cost of TPN was 3 times higher than TF

  • Conclusion:

    • Early enteral nutrition should be used preferentially in patients with severe acute pancreatitis


Duke Experience

  • 455 patients with moderate to severe pancreatitis were referred to NSS from 1990 – 1999

    • Ave. age: 48 (range 5-94)

    • Male/Female: 247/208


Duke Experience

* p < .05


Duke Experience: TPN


Duke Experience: Enteral


TPN vs TF and Acute Phase ResponseWindsor et al, Gut 42:431, 1998

  • 34 patients with acute pancreatitis were randomized to TPN or TF for 7 days

  • Evaluated initially and at 7 days for systemic inflammatory response syndrome, organ failure, ICU stay


TPN vs TF and Acute Phase ResponseWindsor et al, Gut 42:431, 1998

  • CT scan remained unchanged

  • Acute phase response significantly improved with TF vs TPN

    • CRP 156 to 84

    • APACHE II scores 8 to 6

    • Reduced endotoxin production and oxidant stress

  • Enteral feeding modulates the inflammatory response in acute pancreatitis and is clinically beneficial


Summary Recommendations

  • Initiate standard medical care immediately

  • Determine severity of pancreatitis

  • If severe, initiate early nutrition support (within 72 hours)


Caloric Expenditure in Pancreatitis

Average ratio MEE/predicted = 1.24


Nitrogen and Fat Needsin Pancreatitis

  • Nitrogen: 1.0 – 2.0 gm/kg/d

    • Nitrogen balance study is helpful

    • Value of BCAA not determined

  • Fat: Fat well tolerated IV and to limited degree in jejunum, no oral fat should be given

    • Value of lipids ? as stress increases


Other Nutritional Needsin Pancreatitis

  • Calcium, Magnesium, Phosphorus

  • Vitamin supplements – especially B-complex

  • Supplement insulin as needed


Summary Recommendations

  • If ileus is present, precluding enteral feeding, begin TPN within 72 hours:

    • Standard amino acid product

    • IV fat emulsions are safe

    • Supplement insulin and vitamins

    • Beware of catheter sepsis


Summary Recommendations

  • If intestinal motility is adequate, initiate enteral nutrition with jejunal access within 72 hours:

    • Low fat, elemental, hypertonic

    • Give fat intravenously as needed

    • Add extra vitamins

    • Decompress stomach as needed


Summary Recommendations

  • As disease resolves:

    • Begin TF if on TPN

    • Begin oral diet if on TF

      • low fat, small feedings

      • Then, high protein, high calorie, low fat

      • Supplement with pancreatic enzymes and insulin as needed


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