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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
Imrie’s CriteriaGut 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
If > 3 or more present, 40% will be severeIf < 3 present, only 6% will be severe Predicts 79% of episodes
In first 48 hours of admission
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
Pancreatic Necrosis M&M
Balthazar, Radiology 174:331, 1990
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
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
100
110
120
130
140
150
160
0 2 4 6 8 10 12
RME % Initial
Postburn day
175 Kcal - 72 h
200 Kcal - 72 h
175 Kcal - 2 h
Alexander, Ann Surg 200:297, 1984
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)
Male/Female 112/44
Average age 39.3 ± 1.0
Etiology 124 EtOH (79%), 19 Biliary (12%)
Mortality Simple 4%, Complex 5%
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
Alcohol 2 (3%)
Cholelithiasis 57 (85%)
Hypertriglyceridemia 2 (3%)
Trauma/Idiopathic 6 (9%)
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
< 72 hours >72 hours
# Pts 38 29
Ranson’s Criteria 3.2 3.9
Complications
Respiratory Failure 3 (7.8%) 5 (17.2%)
Renal Failure 1 (2.6%) 2 (6.8%)
Pancreatic Necrosis 2 (5.3%) 7 (34.1%)
Abscesses 0 5 (17.2%)
Pseudocysts 1 (2.6%) 5 (17.2%)
Pancreatic Fistulae 2 (5.3%) 4 (13.8%)
Total 9 (23.6%) 28 (96.5%)
Death 5 (13%) 11 (38%)
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
Weight gain 1.6
Albumin (pre/post) 2.6/3.5*
Transferrin (pre/post) 128/176*
PNI (pre/post) 59.4/49.8
* p < .05
Duke Experience: TPN
# Pts Ranson’s Criteria > 3 305
Ave. Days of TPN 16
Range 1-127
Outcome
Surgical Intervention 223
Recovered diet PO/TF 211/54
Home TPN 8
Died 32 (10.5%)
TPN-related sepsis 18 (5.9%)
Duke Experience: Enteral
# Pts Ranson’s Criteria > 3 150
Ave. Days of TF 11
Range 1-60
Outcome
Surgical Intervention 24
Recovered oral diet 115
Home Enteral Nutrition 33
Died 2 (1.3%)
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
Author # Pts RQ MEE
Van Gossum 4 0.81 2080
Bluffard 6 0.87 2525
Dickerson 5 0.78 26 Kcal/kg
Velasco 23 0.86 1687
Duke 6 0.86 1817
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