1、,Nutrition in Acute Pancreatitis“An Evidence Based Approach”,Which patients benefits from nutritional support in acute pancreatitis?,All patients with acute pancreatitis? (Mild pancreatitis is different from severe pancreatitis) Enteral or parenteral?,Where is the evidence?,Severity (Clinical, labor
2、atory and radiological signs)Nutritional status,Outcome predictors,- Mild form (80%),- Severe form (20%),Severity assesmentMild form (80%)- Ranson signs 3- CRP 3- CRP 120 mg/l- APACHE II score 8- Balthazars-CT-score 3,1068 patients, mean age 52.8 yrs, 589 edematous AP, 479 severe APMORTALITY: total
3、7.8%, mild aP 1%, severe aP 16.1%,Severity and outcome,Mortality can increase to up to 40% if sepsis and MOF occur,ESPEN Guidelines,Enteral Nutrition:Clinical Nutrition Vol 25 (2), April 2006Parenteral Nutrition: Clinical Nutrition Vol 28, July 2009,www.espen.org/education/ guidelines.htm,Severity o
4、f acute pancreatitis can be assessed adequatelyFor artificial nutritional interventions mild pancreatitis has to be separated from severe pancreatitisNutritional status has to be assessed on admission and during the course of the disease,Recommentation I,Main goals for nutrition in acute pancreatiti
5、s,To provide calories with EN or PN to reverse protein catabolism without stimulation of the exocrine pancreatic secretionTo improve or to avoid nutritional depletionTo reduce morbidity and mortality,How should nutritional support be done?,Parenteral or enteral? Gastral or jejunal?,EN vs PN and acut
6、e pancreatitis,Mild to moderate pancreatitisEarly EN (ED, NJ) vs PNPRCT N=32 EN PN n = 16 n = 16Caloric goal (day 4) 72% 86%Days to normal amylase 4.8 0.6 6.8 1.5Days to diet by mouth 5.6 0. 7.1 1.1LOH (days) 9.7 1.3 11.9 2.6Lengh of ICU stay (days) 1.3 0.9 2.8 1.3% Nosocomial infection 12.5 8.5 12.
7、5 8.5Mortality (%) 0.0 0.0Cost (US$) 761 50.3 3294 551.9*McClave et al, JPEN, 1997,* p 0.05,Is the situation differentin mild to moderate or severe pancreatitis?,EN vs PN and acute pancreatitis Severe pancreatitisEN (SED, NJ) vs PNPRCTN=38,EN PN n = 18 n = 20LOH (d) 40 (25-83) 39(22-73)LOICU (d) 10
8、(5-21) 12 (5-24)Complication -septic (Tot.nb) 5 (6) 10 (15)*- Hyperglycaemia 4 9- Pancr. necrosis 1 4Pneumonia 2 4Costs 3 times higher,Kalfarentzos et al, B J Surg, 1997,EN vs PN and acute pancreatitisSevere pancreatitis EN (NJ Hypocaloric) vs PNPRCTN=156,Enroled patients87% mild10% moderate 3% seve
9、re 75% improved on 48h bowel rest and iv. fluids discharged within 4 days Rest randomized to jejunal EN or PNAbou-Assi, et al, Am J Gastroenterology, 2002,Results of the randomized patients,n = 27 n = 26Ransons Criteria 2.5 (0.5) 3.1 (0.6)Nutr. Goal 88%* 54%Hyperglycemia (MOF) 14 pt.* (8) 4 pt.(7)Ca
10、theter Sepsis 9 pt.* 1 pt.Death 6 pt. 8 pt.Duration of feeding (d) 10.8* 6.7Hosp. Days 18.4 (2.9)* 15.2 (2.6)Hosp. Costs (US dollar) lower in EN (saving 2360.-)*p 195 mg/L,107 Patients,54 TPN 115 kJ/KG/d 1,2 g N 250 ml 20% Intralipid,53 TEN 115 kJ/KG/d 1,5 g N Survimed jejunal,APACHE II 16 4CRP 218
11、8,APACHE II 14 2CRP 211 9,Wu et al, Pancreas 2010,EN vs PN and severe acute pancreatitis,Wu et al, Pancreas 2010,EN vs PN and severe acute pancreatitis,Doley et al, J Pancreas 2009,EN vs PN in acute pancreatitis,Olah et al, Langenbecks Arch Surg 2010,847 patients,16 RCT,Recommendation II,There is no
12、 evidence that neither EN or PN has a clinical beneficial effect on clinical outcome in patients with mild pancreatitis, if you can predict that the patient can consume normal food in between 5 days (A)If oral nutrition is not possible in 5 days enteral nutrition should be started immetiately (C) If
13、 this is true in patients with malnutrition is not known,ESPEN, Guidelines 2006/2009Treatment mild pancreatitis,Assessment of severity of acute pancreatitis,mild to moderate,fasting (2-5 days) analgesics i.v. fluid/electrolytes,no pain, enzymes,refeeding (3-7 days) diet rich in CH diet moderate in p
14、rotein/fat,normal diet,Recommendation III,Nutritional support in essential in patients with severe disease and nutritional risk factors (A)The route of nutrient delivery (parenteral/enteral) should be determined by the patient toleranceEN should be attempted in all patients first (C)Intakes should b
15、e monitored carefully to ensure adequate nutritional supportWhen enteral nutrition is not sufficient combine it with PN (C),ESPEN, Guidelines 2006/2009Treatment severe pancreatitis,Assessment of severity of acute pancreatitis,severe,early continuous enteral nutrition (naso-jejunal tube) elemental di
16、et or polymeric diet or immune-enhancing diet?,enteral nutrition is not possible,add parenteral nutrition- all in one - or single component solutions (CH, protein (AS), fat),TPN and continuous small amount of an enteral diet (10-30 ml/h) perfused to the jejunum,nutritional goal not reached,Recommend
17、ation IV,Patients with severe disease, complications or theneed for surgery require early nutritional support toprevent the adverse effects of nutrient deprivationContinous early enteral jejunal feeding over 24h is recommended (A)When side effects occur or the caloric goal can not be achieved, PN sh
18、ould be combined with EN (C),How nutrients should be applied?,4 trials showed that jejunal tubes are well toleratedthere was no exacerbation of pancreatitis-related symptomsMcClave, JPEN, 1997Cravo, Clin Nutr, 1989Kudsk, Nutr Clin Pract, 1990Nakad, Pancreas, 1998,Nasogastric or nasojejunal feeding i
19、n patients with severe pancreatitis?,Nasogastric vs nasojejunal feeding in patients with acute pancreatitis,Petrow et al, JOP 2008,Nutritional intolerance,Pain exazerbation,Nasogastric vs nasojejunal feeding in patients with acute pancreatitis,Petrow et al, JOP 2008,Diarrhea,Mortality,Nasogastric vs
20、 nasojejunal feeding in patients with acute pancreatitis,Petrow et al, JOP 2008; 9(4):440-448.,Recommendation V,Jejunal tube placement is safe and well tolerated (C)If nasogastric tube feeding is a useful and practical approach can not be answered up to now!,Which formula should be used?,Elemental,
21、semielemental, polymeric, or immunenhancing (Arg, RNA, n-3-FA, Glu) Enteral diet with pre- or probiotics TPN and glutamine and or n-3-FA,There is no clear consensus about the preferred formula but most trials were performed with semielemental diets,Tiengou et al, JPEN, 2006,Semielemental vs polymeri
22、c diet in acute pancreatitis,EN (immunmodulating) vs EN (standard),HospitalICUMortalityNStayStayEN (Arg/Glu)27.2 d* 8.6 d* 22.2%vs 1)16EN (STD)38.4 d34.8 d 28.6%EN (n-3-FA)13.1 d * 7.1%vs 2)28EN (STD)19.3 d 14.2%* p 0.05,1) Hallay et al, Hepatogastroenterol, 20012) Lasztity et al, Clin Nutr, 2005,Al
23、gorythm for using enteral formula,Severe acute pancreatitis,GI-function Normal,GI-function Impaired,Polymeric diet,Elemental- or semielemental diet,GI-function Impaired,Elemental- or semielemental diat,GI-function Normal,Polymeric diet,Synbiotics* in severe pancreatitis,Incidence of infected necrosi
24、s and abscess 4.5 30.4% (p 0.02) LOHS 13.7 21.4 d (ns) Need for re-surgery 1 7 (p 0.02),Olah et al, Br J Surg 2002,Enteral nutrition with 10g oat fibre (-glucan) and Lactobacillus plantarum 299, 109,Rand, db, controlled trial (N = 45), 1 week,*Probio,Probiotics Control p,Synbiotics* in severe pancre
25、atitis,Probiotics Control p MOF 15% 31% sig Septic complicatios 27% 52% ns LOHS (d) 15 20 ns Need for surgery 12% 24% ns Mortality 6% 21% ns,Olah et al, Hepatogastroenterol 2007,Enteral nutrition with 10g -glucan, inulin, pectin, resistant starch and Lb plantarum 299, pediacoccus, leuconostoc, parac
26、asei, 1010,Rand, db, controlled trial (N = 62), 1 week,*Synbiotic 2000,Synbiotics* in severe acute pancreatitis,Probiotics Placebo N=152 N=144 Infectious compl. 30% 28% Bowel ischaemia (N) 9* 0 Mortality 24 (16%)* 9 (6%),Multifibre diet plus and cornstarch, maltodextrin,Besselink et al, Lancet 2008,
27、and 4 Lactobacilli, 2 Bifidobacteria 1010, twice daily,Rand, db, placebo-controled trial, N= 298, 4 weeks,*Ecolocgic 641,(*/* sig),Comparison of the 3 studies using probiotics in acute pancreatitis,What went wrong?,Aggressive enteral Nutrition (30kcal/Tag)Patients with vasoactive treatmentMultifibre
28、 diet plus prebiotics (30g fibre/day)6 probiotic strains (2x/day 1010)- For the first time Bifidobacteria)Fermentation distension ischaemia?,PN (immunmodulating) vs PN (standard),GlutamineN- 3 fatty acids,McClave et al, JPEN, 2006,Acute pancreatitisGlutamine vs standard PNComplications,RR 0.68CI: 0.
29、42-1.09p= 0.11,Acute pancreatitisGlutamine vs standard PN,3 further randomized controlled trials Significant reduction of complications (N=40) Significant reduction of mortality Sahin et al, Eur J Cin Nutr 2007 Significant reduction of complications (N= 44) Fuentes-Orozco et al, JEPN 2008 Significan
30、t reduction in the length of organ failure N=76) Reduction of infection (early vs late) 8 vs 23% Reduction of surgery (early vs late) 13 vs 43% Reduction of mortality (early vs late) 5 vs 21% Xue et al, W J Gastroenterol 2008,N-3-FA in TPN in patients with severe acute pancreatitis,Wang et al, JPEN
31、2008,Prospective, randomized, double-blind study, PN over 5 days,N-3-FA in TPN in patients with severe acute pancreatitis,Patients supplemented with fish oilhad significantly lower CRP levels after 5 days of parenteral nutrition,Wang et al, JPEN 2008,N-3-FA in TPN in patients with severe acute pancr
32、eatitis,Xiong et al, JPEN 2008,Prospective, randomized, double-blind study,*P 0.05,During the initial stage of acute pancreatitis n-3 FA efficiently reducethe magnitude and persistence time of SIRS and retrieve the unbalance of the pro/anti-inflammatory cytokines,Recommendation VI,Elemental and semi
33、elemental formulas can be used safely in acute pancreatitis (A)Standard polymeric formulas can be tried if they are tolerated (C)There is no evidence for using immunomodulating formulas or probioticsIf TPN has to be used, glutaminecould have a beneficial effect (B), for n-3 FA we need further trials
34、,Conclusion,Nutritional support is essential in severe acute pancreatitisStarting with early enteral nutrition is recommendedThe combination of EN and PE make sense if enteral nutrition is inadaequateProbiotics can not be recommended yetMore studies in this field are necessaryIn PE glutamine ca be helpful,
