This document discusses nutritional support in acute pancreatitis. It begins by assessing the severity of acute pancreatitis using the Ranson criteria and CT severity index. It then discusses the impact of adequate nutritional support on clinical outcomes and the benefits and risks of enteral versus parenteral nutrition. It recommends enteral nutrition over parenteral nutrition when possible, starting with a jejunal tube and peptide-based formula. For severe acute pancreatitis requiring mechanical ventilation, it suggests decreasing or stopping enteral nutrition and starting parenteral nutrition instead.

1. Nutritional Support In Acute Pancreatitis Sohair Soliman MD. Tanta University 11 March 2011 1

3. Impact of adequate nutritional support on clinical outcome

4. Benefits and risks of enteral and parenteral nutrition

5. Best approach to nutritional support in severe acute pancreatitis11 March 2011 2

6. Pancreatitis

7. Pathophys- insult leads to leakage of pancreatic enzymes into pancreatic and peripancreatic tissue leading to acute inflammatory reaction Acute pancreatitis

8. Gall stone pancreatitis by ERCP

9. 11 March 2011 6 Assessment Of Severity Of Acute Pancreatitis

10. Ranson Criteria Admission Age > 55 WBC > 16,000 Glucose > 10mmol/L LDH > 350 IU/L AST > 250 U/L During first 48 hours Hematocrit drop > 10% Serum calcium <2mmol Base deficit > 4.0 Increase in BUN >1.8mmol/L Fluid sequestration > 6L Arterial PaO2 < 60 5% mortality risk with <2 signs 15-20% mortality risk with 3-4 signs 40% mortality risk with 5-6 signs 99% mortality risk with >7 signs

11. CT Severity Index CT Grade A is normal (0 points) B is edematous pancreas (1 point) C is B plus extrapancreatic changes (2 points) D is severe extrapancreatic changes plus one fluid collection (3 points) E is multiple or extensive fluid collections (4 points) Necrosis score None (0 points) < 1/3 (2 points) > 1/3, < 1/2 (4 points) > 1/2 (6 points) TOTAL SCORE = CT grade + Necrosis 0-1 = 0% mortality 2-3 = 3% mortality 4-6 = 6% mortality 7-10 = 17% mortality

12. Ct Scan of acute pancreatitis CT shows significant Swelling and inflammation of the pancreas

13. Severity of acute pancreatitis Nutritional status 11 March 2011 10 Outcome Predictor

14.  BMR 1.5 time -ve nitrogen balance up to 20-40g/day Hyperlipidaemia Hyperglycemia due to insulin sensitivity impaired insulin secretion 11 March 2011 11 Nutritional Status In Acute Pancreatitis

15. Calories provision (Carb. Fat. Protein) Enteral ??? …… exocrine enzymes Rest ??? Parenteral ??? 11 March 2011 12 Consequences For Nutritional Support

16. Concern: Pancreatic Rest Avoid stimulation of pancreas secretion to attenuate inflammation Animal studies rate of pancreatic secretion inversely related to the distance from pylorus Human studies distal jejunal feeding does not stimulate exocrine pancreatic secretion

17. Benefit: Gut Motor Maintain intestinal integrity to prevent bacterial translocation and subsequent SIRS Bacterial translocation Probably major cause of infection

18. Bacterial Translocation

19. Energy requiremeents Acute Pancreatitis  Hyper catabolic state promoting nutritional deterioration Energy 25-35 kcal/kg/d Carbo 3-6g/kg/day bl.glucose not exceed 10mmol/l Protein 1.2 to1.5g/kg/d Fat 2g/kg/d

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24. severity of acute pancreatitis and the nutritional status predict outcome An adequate nutritional support is crucial in patients with severe and complicated pancreatitis In mild pancreatitis if they can start to eat within five to seven days, no specific nutritional support is recommended; 11 March 2011 21 Conclusion

25. If oral nutrition is not possible due to consistent pain for more than five to seven days, enteral nutrition should be started; If the caloric goal with enteral nutrition cannot be reached, parenteral nutrition should be supplemented; In case of surgery for pancreatitis, an intraoperative fine needle jejunostomy for postoperative feeding should be considered 11 March 2011 22

26. Early enteral nutrition with a jejunal tube is well tolerated and safe in patients with acute severe pancreatitis. Continuous jejunal administration with a peptide-based formula safe effective. Standard formula or immune-enhancing formulae can be tried if they are tolerated. 11 March 2011 23

27. 11 March 2011 24 Case A 48-year old man with a history of chronic alcohol abuse was admitted to the hospital with acute abdominal pain, which was dull, boring and steady. The pain was located in the epigastrium, more on the left side and radiated to the back. The pain had started three days previously. Associated symptoms were anorexia, nausea and vomiting. The patient had not eaten for three days.

29. Laboratory findings:

30. WBC 12x109 /LHct: 40 %CRP 80 mg/lCalcium 2.1 mmol/lGlucose 10 mmol/lLDH 300 U/lAST 70 U/lSerum amylase 700 U/lSerum lipase 1000 U/l

31. Abdominal ultrasound showed pancreatic swelling and parapancreatic fluid collection11 March 2011 25 Clinical findings:

32. Acute alcoholic pancreatitis. At this time the patient appears to have mild acute pancreatitis 11 March 2011 26 Q1: What is your diagnosis in this patient? How severe is the disease?

33. Possibly since he has a BMI of 20, and reduced food intake for several days because of pain, nausea and vomiting. 11 March 2011 27 Q2: Is the patient at nutritional risk?

34. At admission, the patient had mild acute pancreatitis (Ranson Score 0). The patient can be treated with fluid and electrolyte resuscitation and analgesics. At the moment, he needs no nutritional support, because most of these patients recover fast and can start eating in the next five to seven days. 11 March 2011 28 Q3: How will you manage this patient and does he need nutritional support?

35. In the next 48 hours there was an increase of the hematocrit by 15%, BUN 3 mmol/l. Serum calcium dropped to 1.7mmol/l, PO2 was 59 mmHg, base deficit > 5 mEq/l. The estimated fluid sequestration was around 5 liters. CRP increased to 200 mg/l. 11 March 2011 29

36. The patient has now developed severe acute pancreatitis (Ranson Score 5, CRP 200 mg/l). This patient now needs immediate nutritional support, In this situation, a nasojejunal feeding tube 11 March 2011 30 Q4: How would you now analyse the severity of the disease? Should you now start nutritional therapy? When yes, what route would you choose?

37. 25 to 30 kcal/kg multiplied by the actual body weight in kg would be sufficient. For more precise assessment of the caloric needs, indirect calorimetry can be performed 11 March 2011 31 Q5: How do you calculate the caloric needs?

38. Normally, an enteral polymeric diet or even an immune-modulating diet would be used. If these diets are not tolerated, a semi-elemental diet can be tried 11 March 2011 32 Q6: Which formula will you choose?

39. On day 7, the patient had to be intubated due to progressing respiratory insufficiency and mechanical ventilation had to be started. Abdominal CT scanning confirmed severe acute pancreatitis 6 points After mechanical ventilation was started, enteral feeding became difficult because of continuous distension of the abdomen and because of high gastric aspiration volumes (> 300 ml per 2 hours). 11 March 2011 33

40. The flow rate of the enteral feed should be decreased. If this is not helpful, enteral nutrition should be stopped. Parenteral nutrition should be started either as a supplement to the reduced EN or to provide total feeding if no EN is possible. The energy content of the parenteral feed should be calculated as follows: Necessary energy (100%) = energy from enteral nutrition (x%) + energy from parenteral nutrition (y%). 11 March 2011 34 Q7: How would you now feed this patient?

41. With enteral nutrition only few data are available on the use of immunomodulating diets. In parenteral nutrition, supplementation with glutamine has shown some beneficial effects. 11 March 2011 35 Q8: Would you use an immuno-modulating enteral and/or a parenteral formula in this situation?

42. After two weeks, infected pancreatic necrosis was confirmed by positive fine needle aspiration culture (Pseudomonas). CRP increased to 400 mg/l. Because of progressive haemodynamic instability, the patient was operated upon. Laparatomy, drainage of abscess and peritoneal lavage were performed 11 March 2011 36

43. . After surgery you can use a fine needle jejunostomy placed during the operation. At this stage of the disease, a combination with enteral and parenteral nutrition may be more beneficial. 11 March 2011 37 Q9: How would you plan postoperative feeding in this patient?

44. It is important that patient gets enough protein and energy in the recovery period. If this patient develops partial pancreatic insufficiency, the use of MCT and supplementation with pancreatic enzymes can be helpful. 11 March 2011 38 Q10: How would you now plan nutritional support in the recovery period?

45. 11 March 2011 39 Nutritional Support In Chronic Pancreatitis

46. Physiology and pathophysiology of chronic pancreatitis) Treatment goals in CP with respect to nutrition; Indications for different nutritional interventions in CP. 11 March 2011 40 Objectives

47. Digestive enzyme lipase lipids amylase starch trypsin protein Bicarbonate Nutrient in duodenal lumen influences pancreatic secretory response 11 March 2011 41 Pancreatic Physiology

48.  Enzyme secretion Fat maldigestion Deficienoies of fat soluble vit. Creatorrhoea Glucose intolerance Malnutriton &wt. loss Pain minerals ,micronutrient 11 March 2011 42 Pathophysiology

49. Pancreatic enzyme Proton pump inhibitor Fat soluble vitamins ,vit B12 High caloric intake 35kcal/k/day Protein 1-1.5g/k/day High carbohydrate insulin Fat 0.7-1.0g/k/day (MCT) Antioxidant as selenium &vit. C 11 March 2011 43 Nutritional Management

50. Enteral sip feeding?? based on carbo. &protein Jejunal tube ?? peptide based with MCT formula Parenteral?? 11 March 2011 44 Role Of Enteral Feeding

51. Fatty food cook with olive oil Fried food Cake, cookies, donut Red meat Spicy food Caffeine Carbonate drinks Butter, egg, cheese, pizza 11 March 2011 45 Food Avoided

52. Yogurt Vegetable soup Spinach Blueberries Mushroom Honey Whole grain bread &pasta Fish, beans, chicken& soybean Green vegetable& fruits 11 March 2011 46 Food Given

53. Nutritional treatment is only a part of the multimodal treatment in CP, next in importance to pain control and oral pancreatic enzyme 11 March 2011 47 Conclusion

54. Dietary modification of fat intake (e.g. medium chain triglycerides) is only necessary if pancreatic enzyme therapy fails; Supplementary enteral nutrition (sip- or tube-feeding) is indicated if oral feeding doesn't reach the therapeutic goals; 11 March 2011 48 Conclusion

55. 11 March 2011 49 THANK YOU

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