Pancreatitis - enteral vs paraenteral nutrition - evidence based medicine - elgha parambi

1. ENTERAL vs. PARENTERAL
NUTRITION IN PATIENTS
WITH ACUTE PANCREATITIS
EBM-FINAL PAPER
PAPER | 20155216200 | NAME

2. PAGE 1
ACUTE PANCREATITIS
− The incidence of a sudden inflammation of
Pancreas.
− Mortality rates of 80% occur that are due to
complications
− Affects middle-aged adults
 Men
 women
− Degree of inflammation
 Mild edema
 Severe hemorrhagic necrosis
− Common Causes
 Gallbladder Disease
 Chronic alcohol abuse
− Less Common
 Abdominal trauma
 Viral infections
 Duodenal ulcers
PATHOPHYSIOLOGY OF ACUTE PANCREATITIS
 Premature activation of trypsin leads to increased pancreatic digestive enzymes.
 Results in intrapancreatic inflammation, leading to extra pancreatic inflammation.
 Complications
 sepsis
 multiple organ dysfunction
 acute respiratory syndrome

3. PAGE 2
CLINICAL PRESENTATION
 Left upper quadrant pain
 Abdominal tenderness
 Nausea and vomiting
 Crackles present in lungs
 Decreased or absent bowel sounds
COMPLICATIONS
 Pseudocyst
 Pancreatic abscess
 Pancreatic infection
- 13.5% of mortality rates are due to infection.
CURRENTLY
 No standard protocol for providing nutritional support.
 Parenteral nutritional support common practice.
 High levels of morbidity, cost, complications, and mortality.
CASE SCENERIO
A 35-year-old female patient complaining of sharp epigastric pain
associated with nausea and frequent vomiting. Acute pancreatitis
has been diagnosed. Gallbladder disease, alcohol, drugs and other
common etiologies have been ruled out by history, examination &
investigations.
Which nutritional intervention, enteral or parenteral feeding,
improves dietary intake, results in fewer treatment
complications, and decreases length of hospitalization?
1. ASK THE QUESTION

4. PAGE 3
BACKGROUND QUESTION
What is the diagnostic tests for acute appendicitis and which
is suitable for this case? What is the gold standard for acute
appendicitis? Combination between diagnostic tests and
clinical findings is required for accurate diagnosis of acute
appendicitis.
 There is many diagnostic tests including laboratory and
imaging tests.
 35% of wrong diagnosis for acute appendicitis result in
appendectomy for normal appendix is accepted percent.
SEARCH STRATEGIES
 Text book ,chapters appendices
 Guides to diagnostic tests
 Selected electronic reference tool for background health
information
BACKGROUND ANSWERS:
 Gold Standard is exploratory laparotomy (Histological
result from the surgery). Imaging diagnostic tests is
suitable to decrease negative appendectomy rates. One
Size doesn't fits all rule . Our case is for adult non
complicated patient with high Alvarado score ensure
high possibility to have acute appendicitis. According to
our Scenario and background question answers, we
choose CT scan test to compare with the gold
standard.

5. PAGE 4
2. FORMULATING A FOCUSED QUESTION
PICO QUESTION (TREATMENT)
 P – Patients with acute pancreatitis
 I – Parenteral feeding
 C – Enteral feeding
 O – Improves dietary intake resulting fewer treatment
complications, and decreases length of hospitalization.
In adult patients with acute pancreatitis, which nutritional
intervention, enteral or parenteral feeding, improves dietary
intake, results in fewer treatment complications, and decreases
length of hospitalization?
FOREGROUND QUESTION:
“In adult patients with acute pancreatitis, which nutritional
intervention, enteral or parenteral feeding, improves dietary
intake, results in fewer treatment complications, and decreases
length of hospitalization?”
LITERATURE REVIEW
 Randomized control trials and 3 meta-analysis were
reviewed to compare patient outcomes.
 Databases used:
 Ovid
 CINAHL
 MEDLINE

6. PAGE 5
 Cochrane Systematic Reviews
 Studies compared:
 Nutrition support
 Enteral & Parenteral
 Complications
 Length of stay
 Dietary improvement
 Cost of care
 Screening Methods
 APACHE II score
 Ranson criteria
 Evaluation upon admission and 48 hours after
admission
 Algorithms to aid in addressing nutritional support
CHARACTERISTICS OF STUDY PARTICIPANTS
 Adults with severe acute pancreatitis
 Nutritional Intervention. Which is better?
 Parenteral nutrition
 Enteral nutrition
 APACHE II score > 10
 Classify severity of disease in ICU
 Measured during the first 24 hours of admission
 Point score system
 Based on 12 routine physiological measurement
 Blood pressure, heart rate, temperature,
respiratory rate etc.
 Ranson score > 2

7. PAGE 6
 Predict severity of disease & mortality
 Uses parameters such as:
 Age
 White blood cell count at admission
 Hematocrit 48 hours after admission
 Serum urea nitrogen level 48 hours after
admission
3. EVIDENCE BASED FINDINGS
 Dietary Improvement
 4.1 fewer days of nutritional support
 80% progressed to oral diet without problem
 Nutritional level returned to baseline within 24 hours
of enteral nutrition
 Maintain gut integrity
 Decreased incidence of hyperglycemia
 Complications related to parenteral nutrition. What are
complications?
 Sepsis
 Catheter-related infection
 Nosocomial infection
 Prolonged starvation leads to bacterial overgrowth
 Ileus up to 5 days longer
 Length of Stay. Increased or decreased?
 Median length of stay reduced by 2.9 days
 Cost of Care. Cost effective?
 Parenteral vs. Enteral

8. PAGE 7
 $2608 vs. $1375
 After sensitivity analysis : $2608 vs. $957
 In the reviewed studies, evidence showed that patients
receiving enteral nutrition therapy had fewer treatment
complications, experienced dietary improvement, had a
shorter length of hospitalization, and a lower cost of care.
TRAIL
 Background: Acute pancreatitis creates a catabolic stress
state promoting a systemic inflammatory response and
nutritional deterioration. Adequate supply of nutrients plays
an important role to ensure optimum recovery. Total
parenteral nutrition (TPN) has been the standard practice
for providing exogenous nutrients to patients with severe
acute pancreatitis. However, recent data suggest that
enteral nutrition (EN) is feasible. Thus, a comparison of EN
and TPN in patients with acute pancreatitis needs to be
made.
 Objectives: To compare the effect of total parenteral
nutrition (TPN) versus enteral nutrition (EN) on mortality,
morbidity and length of hospital stay in patient with acute
pancreatitis.
 Search strategy: Trials were identified by computerized
searches of The Cochrane Controlled Trials Register,
MEDLINE, and EMBASE. Additional studies were identified
and included where relevant by searching Scisearch, the
bibliographies of review articles and identified trials, and
personal files. The search was undertaken in August, 2000.
No language restrictions were applied.

9. PAGE 8
 Selection criteria: Randomized clinical trials, in which
nutrition support with TPN were compared to EN in patients
with acute pancreatitis.
 Data collection and analysis: Two reviewers independently
abstracted data and assessed trial quality. Information was
collected on death, length of hospital stay, systemic
infection, local septic complications, and other local
complications.
 Main results: Two trials with a total of 70 participants were
included. The relative risk (RR) for death with EN vs TPN was
0.56 (95% CI 0.05 to 5.62). Mean length of hospital stay was
reduced with EN (WMD -2.20, 95% CI -3.62 to -0.78). RR for
systemic infection with EN vs TPN was 0.61 (95% CI 0.29 to
1.28). In one trial, RR for local septic complications and
other local complications with EN vs TPN was 0.56 (95% CI
0.12 to 2.68) and 0.16 (95% CI 0.01 to 2.86) respectively.
 Reviewer's conclusions: Although there is a trend
RECOMMENDED PROTOCOL
 Identify early predictors of acute pancreatitis by using
reliable scoring systems to indicate severity
 Acute Physiology and Chronic Health Evaluation
(APACHE II)
 Ranson Criteria
PROPOSED PROTOCOL
 Assess patients nutritional status
 History of present illness

10. PAGE 9
 Physical assessment
 Serum levels of protein and albumin
 Obtain dietary consult
 Insert nasogastric or nasojejunal tube
 Initiate enteral nutrition within first 48 hours
 Continue enteral nutrition until patient may begin oral
feedings
 Advance oral feedings as tolerated
 If patient does not tolerate enteral nutrition begin
parenteral nutrition
4. SUGGESTIONS FOR FURTHER STUDY
 Increase sample size in future studies
 Standardize operational definitions of study outcome
variables so that studies may be compared.
 Standardize severity scoring systems in future studies
5. APPLYING THE EVIDENCE
CONCLUSION
 The American College of Gastroenterology supports the use
of enteral nutrition
 Stabilize the gut barrier function
 Prevent complications associated with bacterial
infection
 The reviewed studies provided evidence that the use of
enteral nutrition is the choice of nutritional therapy for
patients with acute severe pancreatitis.

11. PAGE 10
 Doctors can play an important role in the healthcare team
by influencing the team members to use the appropriate
nutritional intervention in patients with acute severe
pancreatitis.
 towards reductions in the adverse outcomes of acute
pancreatitis after administration of EN, clearly there are
insufficient data to draw firm conclusions about the
effectiveness and safety of EN versus TPN. Further trials are
required with sufficient size to account for clinical
heterogeneity and to measure all relevant outcomes.