Transcript
Sohair Soliman MD.
Tanta University
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Objectives
Severity of acute pancreatitis
Impact of adequate nutritional support
on clinical outcome
Benefits and risks of enteral and
parenteral nutrition
Best approach to nutritional support in
severe acute pancreatitis
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Pathophys- insult leads to leakage of pancreatic
enzymes into pancreatic and peripancreatic tissue
leading to acute inflammatory reaction
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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
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
CT shows
significant
Swelling and
inflammation
of the
pancreas
Severity of acute pancreatitis
Nutritional status
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BMR 1.5 time
-ve nitrogen balance up to 20-40g/day
Hyperlipidaemia
Hyperglycemia due to
insulin sensitivity
impaired insulin secretion
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Calories provision (Carb. Fat. Protein)
Enteral ??? …… exocrine enzymes
Rest ???
Parenteral ???
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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
Maintain intestinal integrity to prevent bacterial
translocation and subsequent SIRS
◦ Bacterial translocation
Probably major cause of infection
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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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;
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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
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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.
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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.
Height 174 cm, body weight 60 kg; BMI 20Blood pressure: 160/100 mmHg, Pulse rate 94 beats/min Abdominal tenderness, muscular guarding and distension
Laboratory findings: ◦ WBC 12x109 /L
Hct: 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
Abdominal ultrasound showed pancreatic swelling and parapancreatic fluid collection
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Acute alcoholic pancreatitis. At this time the
patient appears to have mild acute pancreatitis
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Possibly since he has a BMI of 20, and reduced
food intake for several days because of pain, nausea
and vomiting.
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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.
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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.
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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
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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
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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
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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).
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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%).
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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.
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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
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. 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.
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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.
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Physiology and pathophysiology of
chronic pancreatitis)
Treatment goals in CP with respect to
nutrition;
Indications for different nutritional
interventions in CP.
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Digestive enzyme
lipase lipids
amylase starch
trypsin protein
Bicarbonate
Nutrient in duodenal lumen influences
pancreatic secretory response
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Enzyme secretion
Fat maldigestion
Deficienoies of fat soluble vit.
Creatorrhoea
Glucose intolerance
Malnutriton &wt. loss
Pain
minerals ,micronutrient
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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
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Enteral sip feeding?? based on carbo.
&protein
Jejunal tube ?? peptide based with
MCT formula
Parenteral??
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Fatty food cook with olive oil
Fried food
Cake, cookies, donut
Red meat
Spicy food
Caffeine
Carbonate drinks
Butter, egg, cheese, pizza
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Yogurt
Vegetable soup
Spinach
Blueberries
Mushroom
Honey
Whole grain bread &pasta
Fish, beans, chicken& soybean
Green vegetable& fruits
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Nutritional treatment is only a
part of the multimodal
treatment in CP, next in
importance to pain control and
oral pancreatic enzyme
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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;
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