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

Nutritional Management of Acute and Chronic Pancreatitis

John P. Grant, MDDuke University Medical Center


Clinical spectrum of pancreatitis

Clinical Spectrum of Pancreatitis

  • Acute edematous - mild, self limiting

  • Acute necrotizing or hemorrhagic - severe

  • Chronic


Etiology of acute pancreatitis

Etiology of Acute Pancreatitis

  • Biliary

  • Alcoholic

  • Traumatic

  • Hyperlipidemia

  • Surgery

  • Viral

  • Others


Diagnosis and monitoring of severity of acute pancreatitis

Diagnosis and Monitoring of Severity of Acute Pancreatitis

  • Amylase and lipase

  • Temperature and WBC

  • Abdominal pain


Determination of severity

Determination of Severity

  • Ranson’s Criteria

  • Imire ’s Criteria

  • Balthazar’ Severity Index


Ranson s criteria surg gynecol obstet 138 69 1974

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 criteria surg gynecol obstet 138 69 19741

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


Imrie s criteria gut 25 1340 1984

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

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


Nutritional management of acute and chronic pancreatitis

Grade A: normal pancreas with clinical pancreatitis


Nutritional management of acute and chronic pancreatitis

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


Nutritional management of acute and chronic pancreatitis

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


Nutritional management of acute and chronic pancreatitis

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


Nutritional management of acute and chronic pancreatitis

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


Nutritional management of acute and chronic pancreatitis

Grade E pancreatitis with normal enhancement - 0% necrosis


Nutritional management of acute and chronic pancreatitis

Grade E pancreatitis with <30% necrosis


Nutritional management of acute and chronic pancreatitis

Grade E pancreatitis with 40% necrosis


Nutritional management of acute and chronic pancreatitis

Grade E pancreatitis with 50% necrosis


Nutritional management of acute and chronic pancreatitis

Grade E pancreatitis with >90% necrosis and abscess formation


Nutritional management of acute and chronic pancreatitis

Balthazar, Radiology 174:331, 1990

Pancreatic Necrosis M&M


Ct severity index

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


Nutritional management of acute and chronic pancreatitis

Balthazar, Radiology 174:331, 1990

CT Severity Index and M&M


Standard management

Standard Management

  • Restore and maintain blood volume

  • Restore and maintain electrolyte balance

  • Respiratory support

  • ± Antibiotics

  • Treatment of pain


Indications for surgery

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 management1

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

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

Optimal Medical Management

  • Minimize exocrine pancreatic secretion

  • Avoid or suppress cytokine response

  • Avoid nutritional depletion


Optimal medical management1

Optimal Medical Management

  • Minimize exocrine pancreatic secretion

    • NPO

    • Ng tube decompression of stomach

    • Cimetidine

    • Provision of a hypertonic solution in proximal jejunum


Optimal medical management2

Optimal Medical Management

  • Minimize exocrine pancreatic secretion

  • Avoid or suppress cytokine response


Suppression of cytokines

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

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 management3

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

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 secretion1

Pancreatic Exocrine Secretion

  • IV amino acids

  • Somatostatin

  • Glucagon

  • Any hypertonic solution in jejunum

Depressants


Summary of ideal feeding solutions in acute pancreatitis

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 tpn sitzmann et al surg gynecol obstet 168 311 1989

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 tpn robin et al world j surg 14 572 1990

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 tpn robin et al world j surg 14 572 19901

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 tpn robin et al world j surg 14 572 19902

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 tpn kalfarentzos et al j am coll nutr 10 156 1991

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 tpn kalfarentzos et al j am coll nutr 10 156 19911

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 tpn kalfarentzos et al j am coll nutr 10 156 19912

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 tpn kalfarentzos et al j am coll nutr 10 156 19913

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

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

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

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

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 19971

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 19972

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 19973

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 19974

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

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 experience1

Duke Experience

* p < .05


Duke experience tpn

Duke Experience: TPN


Duke experience enteral

Duke Experience: Enteral


Tpn vs tf and acute phase response windsor et al gut 42 431 1998

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 response windsor et al gut 42 431 19981

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

Summary Recommendations

  • Initiate standard medical care immediately

  • Determine severity of pancreatitis

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


Caloric expenditure in pancreatitis

Caloric Expenditure in Pancreatitis

Average ratio MEE/predicted = 1.24


Nitrogen and fat needs in pancreatitis

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 needs in pancreatitis

Other Nutritional Needsin Pancreatitis

  • Calcium, Magnesium, Phosphorus

  • Vitamin supplements – especially B-complex

  • Supplement insulin as needed


Summary recommendations1

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 recommendations2

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 recommendations3

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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