PDF herunterladen
Semin Respir Crit Care Med 2001; 22(1): 029-034
DOI: 10.1055/s-2001-13838
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Nutritional Support in Acute Pancreatitis: An Update on Management Issues

Pamela R. Roberts
  • Wake Forest University School of Medicine, Department of Anesthesiology, Winston-Salem, North Carolina
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
31. Dezember 2001 (online)

    Lizenzen und Reprints

ABSTRACT

About 20% of acute pancreatitis cases develop necrosis and have a high risk of inflammatory and infectious complications and a high mortality rate. Acute pancreatitis has a variety of causes and despite years of research its pathogenesis remains complex and obscure. Both local and systemic inflammatory responses play key roles in the pathophysiology of this disorder. Treatment plans continue to rely on supportive care without proven specific therapies. Pancreatic rest and use of total parenteral nutrition (TPN) were the gold standard for nutritional support of these challenging patients. Because numerous studies in other critically ill patients demonstrated benefits of enteral nutrition, recent investigations compared TPN to enteral nutrition in acute pancreatitis. These studies indicated that enteral nutrition delivered into the jejunum was tolerated well, even in patients with severe acute pancreatitis. ``Mild'' cases of pancreatitis should improve and tolerate oral nutrition within a few days. In contrast, ``severe'' cases of pancreatitis or those with a protracted clinical course require nutritional support to aid in preventing adverse effects of starvation and nutrient deficiencies. Current recommendations are to attempt enteral nutrition in patients with acute pancreatitis prior to instituting TPN. Further studies to determine optimal nutrient composition are warranted and should investigate the possibility of modulating the inflammatory response induced by pancreatitis to improve outcomes.

KEYWORD

Acute pancreatitis - enteral nutrition - parenteral nutrition - nutritional support

REFERENCES

  • 1 Moynihan B. Acute pancreatitis.  Ann Surg . 1925;  81 132-142
    PubMedGoogle Scholar
  • 2 Denham W, Norman J. The potential role of therapeutic cytokine manipulation in acute pancreatitis.  Surg Clin of N Amer . 1999;  79 767-781
    PubMedGoogle Scholar
  • 3 Corfield A P, Cooper M J, Williamson R CN. Acute pancreatitis: a lethal disease of increasing incidence.  Gut . 1985;  26 724-729
    PubMedGoogle Scholar
  • 4 Steinberg W, Tenner S. Acute pancreatitis.  NEJM . 1994;  330 1198-1210
    PubMedGoogle Scholar
  • 5 Maxson C J, Greenfield S M, Turner J L. Acute pancreatitis as a common complication of 2'-3'-dideoxyinosine therapy in the acquired immunodeficiency syndrome.  Am J Gastroenterol . 1992;  87 708-713
    PubMedGoogle Scholar
  • 6 Lerch M M, Saluja A K, Dawra R, Saluja M, Steer M L. The effect of chloroquine administration on two experimental models of acute pancreatitis.  Gastroenterology . 1993;  104 1768-1779
    CrossrefPubMedGoogle Scholar
  • 7 Klar E, Messmer K, Warshaw A L, Herfarth C. Pancreatic ischaemia in experimental acute pancreatitis: mechanism, significance, and therapy.  Br J Surg . 1990;  77 1205-1210
    PubMedGoogle Scholar
  • 8 Toyama M T, Lewis M PN, Kusske A M, Reber P U, Ashley S W, Reber H A. Ischaemia-reperfusion mechanisms in acute pancreatitis.  Scand J Gastroenterol . 1996;  31(suppl) 20-23
    PubMedGoogle Scholar
  • 9 Scholmerich J. Interleukins in acute pancreatitis.  Scand J Gastroenterol . 1996;  31(suppl) 37-42
    PubMedGoogle Scholar
  • 10 Rae D, Beechey-Newman N, Burditt L, Sumar N, Hermon-Taylor J. Activation of human granulocyte type-1 prophospholipase A2 .  Scand J Gastroenterol . 1996;  31(suppl) 24-27
    PubMedGoogle Scholar
  • 11 Sweiry J H, Mann G E. Role of oxidative stress in the pathogenesis of acute pancreatitis.  Scand J Gastroenterol . 1996;  31(suppl) 10-15
    PubMedGoogle Scholar
  • 12 Kingsnorth A N. Platelet-activating factor.  Scand J Gastroenterol . 1996;  31(suppl) 28-31
    PubMedGoogle Scholar
  • 13 Steer M L. Pathogenesis of acute pancreatitis.  Digestion . 1997;  58(suppl) 46-49
    PubMedGoogle Scholar
  • 14 Schmid S W, Uhl W, Friess H. The role of infection in acute pancreatitis.  Gut . 1999;  45 311-316
    Google Scholar
  • 15 Bittner R, Block S, Buchler M, Berger H G. Pancreatic abscess and infected pancreatic necrosis: different local septic complications in acute pancreatitis.  Dig Dis Sci . 1987;  32 1082-1087
    CrossrefPubMedGoogle Scholar
  • 16 Dickerson R N, Vehe K L, Mullen J L, Feurer I D. Resting energy expenditure in patients with pancreatitis.  Crit Care Med . 1991;  19 484-490
    CrossrefPubMedGoogle Scholar
  • 17 Ragins H, Levenson S M, Signer R. Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation.  Am J Surg . 1973;  126 606-614
    PubMedGoogle Scholar
  • 18 Klein S, Kinney J, Jeejeebhoy K, Alpers D, Hellerstein M, Murray M, Twomey P. Nutrition support in clinical practice: review of published data and recommendations for future research directions.  J Parent Enter Nutr . 1998;  21 133-156
    PubMedGoogle Scholar
  • 19 McClave S A, Snider H, Owens N, Sexton L K. Clinical nutrition in pancreatitis.  Dig Dis Sci . 1997;  42 2035-2044
    CrossrefPubMedGoogle Scholar
  • 20 Marulendra S, Kirby D F. Nutrition support in pancreatitis.  Nutr Clin Prac . 1995;  10 45-53
    PubMedGoogle Scholar
  • 21 Karamitsios N, Saltzman J R. Enteral nutrition in acute pancreatitis.  Nutr Rev . 1997;  55 279-282
    PubMedGoogle Scholar
  • 22 Ranson J HC. The current management of acute pancreatitis.  Adv in Surg . 1995;  28 93-112
    PubMedGoogle Scholar
  • 23 Kalfarentzos F E, Karavias D D, Karatzas T M. Total parenteral nutrition in severe acute pancreatitis.  J Am Coll Nutr . 1991;  10 156-162
    PubMedGoogle Scholar
  • 24 Sax H C, Warner B W, Talamini M A, Hamilton F N, Bell R H, Fischer J E, Bower R H. Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects.  Am J Surg . 1987;  153 117-124
    CrossrefPubMedGoogle Scholar
  • 25 Roberts P R, Zaloga G P. Enteral nutrition. In: Grenvik A, Ayres SM, Holbrook PR, Shoemaker WC, eds. Textbook of Critical Care Medicine 4th ed. Philadelphia: WB Saunders 1999: 875-898
    Google Scholar
  • 26 Zaloga G P, Roberts P R. Early enteral feeding improves outcome. In: Vincent JL, ed. Yearbook of Intensive Care and Emergency Medicine Berlin: Springer 1997: 701-714
    Google Scholar
  • 27 Saito H, Trocki O, Alexander J W, Kopcha R, Heyd T, Joffe S N. The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury.  J Parenter Enteral Nutr . 1987;  11 1-7
    PubMedGoogle Scholar
  • 28 Bortenschlager L, Roberts P R, Black K W, Zaloga G P. Enteral feeding minimizes liver injury during hemorrhagic shock.  Shock . 1994;  2 351-354
    PubMedGoogle Scholar
  • 29 Roberts P R, Black K W, Zaloga G P. Effect of fasting and refeeding on renal blood flow: implications for perioperative management.  Anesthesiology . 1997;  87 A228
    PubMedGoogle Scholar
  • 30 Roberts P R, Black K W, Zaloga G P. Enteral feeding improves outcome and protects against glycerol-induced acute renal failure in the rat.  Am J Respir Crit Care Med . 1997;  156 1265-1269
    PubMedGoogle Scholar
  • 31 McClave S A, Greene L M, Snider H L, Makk L JK, Cheadle W G, Owens N A. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis.  J Parent Enter Nutr . 1997;  21 14-20
    CrossrefPubMedGoogle Scholar
  • 32 Kudsk K A, Campbell S M, O'Brien T, Fuller R. Postoperative jejunal feedings following complicated pancreatitis.  Nutr Clin Prac . 1990;  5 14-17
    PubMedGoogle Scholar
  • 33 Kalfarentzos F, Kehagias J, Kokkinis K, Gogos C A. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.  Br J Surg . 1997;  84 1665-1669
    CrossrefPubMedGoogle Scholar
  • 34 Windsor A CJ, Kanwar S, Li A GK. Compared to parenteral nutrition, enteral nutrition attenuates the acute phase response and improves disease severity in acute pancreatitis.  Gut . 1998;  42 431-435
    CrossrefPubMedGoogle Scholar
  • 35 Hamvas J, Schwab R, Pap A. Jejunal feeding in necrotising acute pancreatitis: a retrospective study.  Acta Chirurgica Hungarica . 1999;  38 177-185
    PubMedGoogle Scholar
  • 36 McArdle A H, Echave W, Brown R A. Effect of elemental diet on pancreatic secretion.  Am J Surg . 1974;  128 690-692
    PubMedGoogle Scholar
  • 37 Neviackas J A, Kerstein M D. Pancreatic enzyme response with an elemental diet.  Surg Gynecol Obstet . 1976;  142 71-74
    PubMedGoogle Scholar
  • 38 Cassim M M, Allardyce D B. Pancreatic secretion in response to jejunal feeding of elemental diet.  Ann Surg . 1974;  2 228-231
    PubMedGoogle Scholar
  • 39 Wolfe B M, Keltner R M, Kaminski D L. The effect of an intraduodenal elemental diet in pancreatic secretion.  Surg Gynecol Obstet . 1975;  140 241-245
    PubMedGoogle Scholar
  • 40 Kelly G A, Nahrwold D L. Pancreatic secretion in response to an elemental diet and intravenous hyperalimentation.  Surg Gynecol Obstet . 1976;  143 87-91
    PubMedGoogle Scholar
  • 41 Stabile B E, Debas H T. Intravenous versus intraduodenal amino acids, fats, and glucose as stimulants of pancreatic secretion.  Surg Forum . 1981;  32 224-226
    PubMedGoogle Scholar
  • 42 Vidon N, Hecketsweiler P, Butel J. Effect of continuous jejunal perfusion of elemental and complex nutritional solutions on pancreatic enzyme secretion in human subjects.  Gut . 1978;  19 194-198
    PubMedGoogle Scholar
  • 43 Keith R G. Effect of a low fat elemental diet on pancreatic secretion during pancreatitis.  Surg Gynecol Obstet . 1980;  151 337-343
    PubMedGoogle Scholar
  • 44 Duerksen D R, Bector S, Yaffe C, Parry D M. Does jejunal feeding with a polymeric immune-enhancing formula increase pancreatic exocrine output as compared with TPN?.  <~>A case report. Nutrition . 2000;  16 47-49
    PubMedGoogle Scholar
      >