Nutritional Management of Acute and Chronic Pancreatitis
description
Transcript of Nutritional Management of Acute and Chronic Pancreatitis
![Page 1: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/1.jpg)
Nutritional Management of Acute and Chronic
Pancreatitis
John P. Grant, MDDuke University Medical Center
![Page 2: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/2.jpg)
Clinical Spectrum of Pancreatitis
Acute edematous - mild, self limiting
Acute necrotizing or hemorrhagic - severe
Chronic
![Page 3: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/3.jpg)
Etiology of Acute Pancreatitis Biliary Alcoholic Traumatic Hyperlipidemia Surgery Viral Others
![Page 4: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/4.jpg)
Diagnosis and Monitoring of Severity of Acute Pancreatitis
Amylase and lipase Temperature and WBC Abdominal pain
![Page 5: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/5.jpg)
Determination of Severity
Ranson’s Criteria Imire ’s Criteria Balthazar’ Severity Index
![Page 6: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/6.jpg)
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
![Page 7: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/7.jpg)
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
![Page 8: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/8.jpg)
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
![Page 9: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/9.jpg)
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
![Page 10: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/10.jpg)
Grade A: normal pancreas with clinical pancreatitis
![Page 11: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/11.jpg)
Grade B: Diffuse enlargement of the pancreas without peripancreatic inflammatory changes
![Page 12: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/12.jpg)
Grade C: Enlarged pancreas with haziness and increased density of peripancreatic fat
![Page 13: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/13.jpg)
Grade D: Enlarged body and tail of pancreas with fluid collection in left anterior pararenal space
![Page 14: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/14.jpg)
Grade E: Fluid collections in lesser sac and anterior pararenal space
![Page 15: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/15.jpg)
Grade E pancreatitis with normal enhancement - 0% necrosis
![Page 16: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/16.jpg)
Grade E pancreatitis with <30% necrosis
![Page 17: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/17.jpg)
Grade E pancreatitis with 40% necrosis
![Page 18: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/18.jpg)
Grade E pancreatitis with 50% necrosis
![Page 19: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/19.jpg)
Grade E pancreatitis with >90% necrosis and abscess formation
![Page 20: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/20.jpg)
Pancreatic Necrosis M&M
Balthazar, Radiology 174:331, 1990
![Page 21: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/21.jpg)
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
![Page 22: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/22.jpg)
Balthazar, Radiology 174:331, 1990
CT Severity Index and M&M
![Page 23: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/23.jpg)
Standard Management Restore and maintain blood volume Restore and maintain electrolyte
balance Respiratory support ± Antibiotics Treatment of pain
![Page 24: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/24.jpg)
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
![Page 25: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/25.jpg)
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
![Page 26: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/26.jpg)
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)
![Page 27: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/27.jpg)
![Page 28: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/28.jpg)
Optimal Medical Management
Minimize exocrine pancreatic secretion
Avoid or suppress cytokine response Avoid nutritional depletion
![Page 29: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/29.jpg)
Optimal Medical Management Minimize exocrine pancreatic secretion
– NPO– Ng tube decompression of stomach– Cimetidine– Provision of a hypertonic solution in
proximal jejunum
![Page 30: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/30.jpg)
Optimal Medical Management Minimize exocrine pancreatic secretion Avoid or suppress cytokine response
![Page 31: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/31.jpg)
![Page 32: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/32.jpg)
![Page 33: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/33.jpg)
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
![Page 34: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/34.jpg)
![Page 35: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/35.jpg)
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
100110120130140150160
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
![Page 36: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/36.jpg)
Optimal Medical Management
Minimize exocrine pancreatic secretion Avoid or suppress cytokine response Avoid nutritional depletion
– If gut not functioning – TPN– If gut functioning - Enteral
![Page 37: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/37.jpg)
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
![Page 38: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/38.jpg)
Pancreatic Exocrine Secretion
IV amino acids Somatostatin Glucagon Any hypertonic solution in jejunum
Depressants
![Page 39: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/39.jpg)
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
![Page 40: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/40.jpg)
![Page 41: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/41.jpg)
![Page 42: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/42.jpg)
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
![Page 43: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/43.jpg)
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 112/44Average age 39.3 ± 1.0Etiology 124 EtOH (79%), 19 Biliary (12%)Mortality Simple 4%, Complex 5%
![Page 44: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/44.jpg)
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
![Page 45: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/45.jpg)
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
![Page 46: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/46.jpg)
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%)
![Page 47: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/47.jpg)
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
![Page 48: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/48.jpg)
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
![Page 49: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/49.jpg)
Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991
< 72 hours >72 hours# Pts 38 29Ranson’s Criteria 3.2 3.9Complications
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%)
![Page 50: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/50.jpg)
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
![Page 51: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/51.jpg)
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)
![Page 52: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/52.jpg)
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
![Page 53: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/53.jpg)
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
![Page 54: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/54.jpg)
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
![Page 55: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/55.jpg)
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
![Page 56: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/56.jpg)
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
![Page 57: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/57.jpg)
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
![Page 58: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/58.jpg)
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
![Page 59: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/59.jpg)
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
![Page 60: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/60.jpg)
Duke Experience: TPN# Pts Ranson’s Criteria > 3 305
Ave. Days of TPN 16Range 1-127
OutcomeSurgical Intervention 223Recovered diet PO/TF 211/54Home TPN 8Died 32
(10.5%)TPN-related sepsis 18 (5.9%)
![Page 61: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/61.jpg)
Duke Experience: Enteral
# Pts Ranson’s Criteria > 3 150Ave. Days of TF 11
Range 1-60Outcome
Surgical Intervention 24Recovered oral diet 115Home Enteral Nutrition 33Died 2 (1.3%)
![Page 62: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/62.jpg)
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
![Page 63: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/63.jpg)
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
![Page 64: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/64.jpg)
Summary Recommendations
Initiate standard medical care immediately
Determine severity of pancreatitis If severe, initiate early nutrition
support (within 72 hours)
![Page 65: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/65.jpg)
Caloric Expenditure in Pancreatitis
Author # Pts RQ MEEVan Gossum 4 0.81 2080Bluffard 6 0.87 2525Dickerson 5 0.78 26 Kcal/kgVelasco 23 0.86 1687Duke 6 0.86 1817
Average ratio MEE/predicted = 1.24
![Page 66: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/66.jpg)
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
![Page 67: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/67.jpg)
Other Nutritional Needsin Pancreatitis
Calcium, Magnesium, Phosphorus
Vitamin supplements – especially B-complex
Supplement insulin as needed
![Page 68: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/68.jpg)
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
![Page 69: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/69.jpg)
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
![Page 70: Nutritional Management of Acute and Chronic Pancreatitis](https://reader033.fdocuments.us/reader033/viewer/2022050802/56815e6a550346895dcce567/html5/thumbnails/70.jpg)
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