Pancreatitis, parenteral nutrition

It is common practice to discontinue oral feedings during an attack of acute pancreatitis. In theory, discontinuation of oral intake will decrease the secretory functions of the pancreas and minimize further complications from the disease. Some patients can be fed with minimal oral intake. Tube feeding delivered via a nasojejunal tube will feed the patient beyond the ampulla of Vater, minimizing stimulation of the pancreas.15,16 If oral intake is discontinued for a protracted period, total parenteral nutrition must be used to maintain adequate nutrition.17,18... 

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

Monitoring Perform periodic complete blood counts and clinical chemistry tests. Monitor serum amylase levels in those individuals who have a history of elevated amylase, pancreatitis, ethanol abuse, who are on parenteral nutrition, or who are otherwise at high risk of pancreatitis. 

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

Serum amylase and triglyceride concentrations in patients with history of elevated amylase, pancreatitis, ethanol abuse, or receiving parenteral nutrition... 

Adverse effects are most commonly manifest as acute pancreatitis. The strongest association is with alcohol abuse. High plasma calcium, including that caused by hypervitaminosis D, and parenteral nutrition also increase the risk. Corticosteroids, didanosine, azathoipurine, diuretics (including thiazides and frusemide), sodium valproate, mesalazine and paracetamol (in overdose) have also been causally related. 

Total parenteral nutrition (TFN) means supplying all nutrients to a patient through a liquid diet fed intravenously. With TPN, food is not consumed, although one might expect continued sloughing off of enterocytes into the lumen. TPN often is used in the treatment of pancreatic diseases and in the care of very-low -birth-... 

The effects of parenteral nutrition on endocrine and exocrine functions of the pancreas have been investigated in experimental rats (23). The conclusion was that after parenteral nutrition treatment the insulin secretory response to glucose is impaired, the exocrine pancreas is hypoplastic, and the storage pattern of pancreatic exocrine enzymes is altered. 

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. ... 

Abou-Assi S, Craig K, O Keefe SJD, et al. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis Results of a randomized comparative study. Am J Gastroenterol 2002 97 2255-2262. Scolapio J, Malhi-Chowla N, Ukleja A. Nutrition supplementation in patients with acute and chronic pancreatitis. Gastroenterol Clin North Am 1999 28 695-707. 

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. 

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. 

The client diagnosed with acute pancreatitis is placed on total parenteral nutrition (TPN). Which intervention should the nurse implement ... 

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. 

Muwakkit S, Al-Aridi C, Saab R, Hourani R, Yazbeck N, Abboud M. Wernicke s encephalopathy during total parenteral nutrition in a child with acute lymphoblastic leukemia and acute pancreatitis. Neuropediatrics 2009 40(5) 249-51. 

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. ... 

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... 

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