Pancreatitis enteral nutrition

Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ 2004 328(7453) 1407. 

Pancreatitis—if patients have failed enteral nutrition beyond the ligament ofTreitz or cannot receive enteral nutrition (e.g., due to obstruction)... 

Abstinence from alcohol is the most important factor in preventing abdominal pain in the early stages of alcoholic CP, although reports of the effect of abstinence from alcohol have varied. Small and frequent meals (six meals per day) and a diet restricted in fat (50 to 75 g/day) are recommended to minimize postprandial pancreatic secretion and resulting pain. Parenteral or enteral nutrition (elemental diets) may be necessary, especially if the patient is chronically debilitated, and these nutritional approaches are less likely than oral ingestion of ordinary food to simulate pancreatic secretion, as stimulation of the pancreas is of some concern in that it may contribute to pain. ... 

Kotani J, Usami M, Nomura H, et al. Enteral nutrition prevents bacterial translocation but does not improve survival during acute pancreatitis. Arch Surg 1999 134 287-292. 

The gastrointestinal (Gl) tract is the optimal route for providing nutrients unless obstruction, severe pancreatitis, or other Gl complications are present (see Fig. 136-1). Other considerations that may have an impact on determination of an appropriate route for nutrition support include expected duration of nutrition therapy and risk of aspiration. Patients who have nonfunctional Gl tracts or are otherwise not candidates for enteral nutrition (EN) may benefit from PN. Use of the intravenous route for nutrition support is also commonly referred to as total parenteral nutrition (TPN) or hyperalimentation. Routine monitoring is necessary to ensure that the nutrition regimen is suitable for a given patient as his or her clinical condition changes and to minimize or treat complications early. 

Comparative studies In a systematic review of five randomized controlled comparisons of parenteral and enteral nutrition in patients with acute pancreatitis, there was diarrhea in 6 of 92 patients (7%) versus 24 of 82 (29%) respectively and hyperglycemia in 21 of 92 patients (23%) versus 7 of 82 (11%) [18 ]. The added risk of infections... 

Petrov MS, Van Santvoort HC, Besselink MGH, Van Der Heijden GJMG, Windsor JA, Gooszen HG. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis a meta-analysis of randomized trials. Arch Surg 2008 143 1111-7. 

Al-Omran M, Groof A, WiUce D. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev 2003. 

Enteral feedings may also prevent infection by decreasing translocation of bacteria across the gut wall. Preliminary data suggest that probiotics such as lactobacillus (along with a fiber supplement) may reduce bacterial translocation and possibly decrease pancreatic necrosis and abscess. If enteral feeding is not possible, total parenteral nutrition (TPN) should be implemented before protein and calorie depletion becomes advanced. Intravenous lipids should not be withheld unless the serum triglyceride concentration is greater than 500 mg/dL. At present, there is no clear evidence that nutritional support alters outcome in most patients with AP unless malnutrition exists. ... 

Most patients with malabsorption will require pancreatic enzyme supplementation and a reduction in dietary fat in order to achieve satisfactory nutritional status and become relatively asymptomatic. An initial prandial dose of 30,000 international units of lipase (uncoated tablet, capsule, or powder) is recommended to be given with each meal (see Fig. 34—5). Alternatively, the use of microencapsulated enteric-coated dosage forms may be used. The total daily lipase dose should be titrated to reduce steatorrhea. In some patients a reduction in dietary fat may be necessary. The addition of an antisecretory drug should be reserved for patients resistant to enzyme therapy (see Fig. 39-5). If these measures are ineffective, documentation of the diagnosis and exclusion of other diseases should be undertaken. 

Malabsorption requires treatment when steatorrhea is documented (>7 g of fat in the feces per 24 hours while on a diet of 100 g/day of fat) and persistent weight loss occurs despite efforts to correct it. The combination of pancreatic enzymes (lipase, amylase, and protease) and a reduction in dietary fat (to <25 g/meal) enhances the patient s nutritional status and reduces (but does not totally correct) steatorrhea. The success of a pancreatic enzyme preparation requires that it contain a high concentration of lipase and proteases, be enteric-coated to avoid destruction by gastric acid, and be the... 

McQave SA, Greene LM, Snider HL, et al. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enter Nutr 1996 21 14-20. 

Petrov MS, Whelan K. Comparison of complications attributable to enteral and parenteral nutrition in predicted severe acute pancreatitis a systematic review and meta-analysis. Br J Nutr 2010 103(9) 1287-95. 

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