A transatlantic survey of nutrition practice in acute pancreatitis

RESEARCH PAPER

A transatlantic survey of nutrition practice inacute pancreatitisS. N. Duggan,*§ N. D. Smyth,� M. O’Sullivan,� S. Feehan,� P. F. Ridgway*§ & K. C. Conlon*§

*Department of Surgery, Trinity College Dublin, Dublin, Ireland

�Department of Nutrition & Dietetics, Adelaide & Meath Hospital, incorporating the National Children’s Hospital, Dublin, Ireland

�Department of Clinical Medicine, Trinity College Dublin, Dublin, Ireland

§Professorial Surgical Unit, Adelaide & Meath Hospital, incorporating the National Children’s Hospital, Dublin, Ireland

Introduction

Severe acute pancreatitis is a devastating disease with high

morbidity and mortality. The incidence is rising, most

likely as a result of an increase in alcoholic pancreatitis.

O’Farrell reported a 54% increase in admissions via acci-

dent and emergency with alcohol-induced acute pancrea-

titis over a 7-year period (O’Farrell et al., 2007). The

increase was highest among women and in younger age

groups. In the UK, there was a significant increase in acute

pancreatitis admissions between 1963 and 1998, particu-

larly in younger age groups (Goldacre & Roberts, 2004). In

the USA, the frequency of discharges with acute pancreati-

tis increased by 30.2% between 1997 and 2003, which was

at least partly the result of an increase in the incidence of

gallstones and increased alcohol use (Brown et al., 2008).

The increase in acute pancreatitis has serious repercussions

in terms of healthcare costs. In 2003, the direct cost of

admission for acute pancreatitis was estimated to have

exceeded $2 billion in the USA (Fagenholz et al., 2007).

Nutrition in acute pancreatitis

Despite an abundance of research in acute pancreatitis,

basic controversies still exist over the nutritional manage-

ment of patients with severe disease. Practice guidelines

have been published by expert groups on the appropriate

provision of enteral and parenteral nutrition. The Euro-

pean Society for Clinical Nutrition and Metabolism

(ESPEN) published pancreatitis guidelines in 2002 (Meier

Keywords

acute pancreatitis, enteral nutrition,

parenteral nutrition, survey of practice.

Correspondence

S. N. Duggan, 1.29 Department of Surgery,

Trinity Centre for Health Sciences, Adelaide &

Meath Hospital, incorporating the National

Children’s Hospital, Tallaght, Dublin 2,

Ireland.

Tel.: +0353 1 8964173

Fax: +0353 1 8963788

E-mail: [email protected]

How to cite this article

Duggan S.N., Smyth N.D., O’Sullivan M.,

Feehan S., Ridgway P.F. & Conlon K.C. (2012)

A transatlantic survey of nutrition practice in

acute pancreatitis. J Hum Nutr Diet.

doi:10.1111/j.1365-277X.2012.01256.x

Abstract

Background: Many guidelines exist for the nutritional management of acute

pancreatitis; however, little is known regarding current practice. We aimed to

investigate feeding practices, including the use of parenteral/enteral nutrition.

Methods: The study design was a cross-sectional, descriptive survey. Electronic

surveys were sent to dietitians in the UK, the Republic of Ireland and Canada.

Of 253 dietitians surveyed, 204 saw patients with acute pancreatitis regularly or

occasionally and were included in the analyses.

Results: Most dietitians (92.8%) considered early feeding to mean <48 h after

presentation. Over half (54.2%) favoured early feeding in severe disease, less in

obesity (42%) and more with pre-existing malnutrition (81.9%). There was a

tendency to feed earlier in university hospitals (P = 0.015), especially in obesity

(P = 0.011). There was a tendency towards enteral (versus parenteral) nutrition

in university hospitals (P = 0.000). The majority preferred the jejunal route

(64.2%), although this was lower in the UK (43.8%) than in Canada (77.8%)

or Ireland (54.2%). Under one-quarter of UK dietitians (23.2%) reported the

existence of a pancreatic multidisciplinary team in their institutions, although

this was lower in Ireland and Canada.

Conclusions: Despite guidelines, there are gaps in the nutritional management

of acute pancreatitis, including a continued reliance on parenteral feeding.

Journal of Human Nutrition and Dietetics

ª 2012 The Authors

Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd. 1

et al., 2002), followed by enteral and parenteral guidelines

in 2006 (Meier et al., 2009) and 2009 (Gianotti et al.,

2009), respectively. The American Society for Parenteral

and Enteral Nutrition (ASPEN) published updated guide-

lines in 2009 (McClave et al., 2009). General guidelines

with a nutritional component include the UK guidelines

for the management of acute pancreatitis (UK Working

Party on Acute Pancreatitis, 2005), Practice Guidelines in

Acute Pancreatitis from the Practice Parameters Commit-

tee of the American College of Gastroenterology (Banks &

Freeman, 2006) and the American Gastroenterology Asso-

ciation Technical Review on Acute Pancreatitis (Forsmark

& Baillie, 2007).

Despite the wealth of guidelines, current nutritional

management of acute pancreatitis is largely unknown,

outside of specific institutions. A dietetic survey of prac-

tice in Canadian intensive care units (Greenwood et al.,

2004) found that, although enteral nutrition was widely

used, parenteral nutrition use remained prominent in

many intensive care units. There have been no published

surveys of nutritional practice in acute pancreatitis in

Ireland or the UK. Therefore, little is known about

nutrition practice and adherence to guidelines in these

countries.

Study objectives

The study objectives were to describe current nutrition

support practices in acute pancreatitis. The aim was to

compare practice between selected countries (representing

Europe and Northern America) and institution types.

Specifically, the aim was to examine the existence of pan-

creatic teams and protocols, practice in the timing of

feeding, enteral and parenteral nutrition, feeding routes,

requirements, formulae and specific nutrient additions.

Materials and methods

Survey design

The study design was a cross-sectional descriptive survey

of the nutritional management of acute pancreatitis

patients in six countries.

Survey

A 37-item survey was designed for completion by dieti-

tians. The first section asked whether the respondent sees

patients with pancreatitis (‘yes’/‘no’/‘occasionally’). Those

who responded ‘no’ were directed to the survey end and

excluded. Section 2 questioned setting (institution type,

beds, dedicated pancreatitis team). Subsequent sections

were: section 3, feeding practice; section 4, tube insertion;

section 5, additions to regimens; section 6, discontinuing

feeding; section 7, guidelines; section 8, demographics.

Replies were anonymous, although respondents were

invited to leave a contact email. Internet IP addresses were

recorded.

Data collection

The survey was electronically distributed to dietitians in

the UK (inclusive of four countries: England, Scotland,

Wales and Northern Ireland), the Republic of Ireland and

Canada (Appendix S1). In the UK and the Republic of

Ireland, the survey was distributed via the Nutrition

Interest Group of the Pancreatic Society of Great Britain

and Ireland. In Ireland, the survey was also distributed

via the Irish Nutrition & Dietetic Institute. In the UK, the

survey was placed on the British Dietetic Association

member’s only website, and distributed via electronic

publication E-Zine. In Scotland, surveys were also distrib-

uted via the Scottish Intensive care Society Dietitian’s

group. In Canada, the survey was electronically distrib-

uted using key dietetic links throughout seven Canadian

provinces, assisted by a dietitian in British Columbia.

Determination of response rate

The number of dietitians working in acute pancreatitis in

the participating countries is not known. In addition,

because the survey was electronically distributed and

placed on professional websites, the number of dietitians

targeted is not known. For these reasons, the determina-

tion of percentage response rate was precluded. The sur-

vey was first sent to members of the Nutrition Interest

Group of the Pancreatic Society of Great Britain and Ire-

land (n = 44). This group comprises dietitians through-

out Ireland and the UK who specialise in pancreatic

disease, and those who see patients with acute pancreatitis

completed the survey. However, to evaluate practice in

smaller institutions, the survey was opened to non-mem-

bers. In some institutions, several dietitians may have a

role in the nutritional management of acute pancreatitis.

Because this was a survey of dietetic practice, the survey

was not limited to one per institution.

Comparison to guidelines

To compare practice to guidelines, seven acute pancreatitis

management parameters were established based on the six

commonly used acute pancreatitis guidelines (Table 1).

Ethical considerations

Ethical approval was awarded by the chairman of the

Joint Ethics Committee of St James and The Adelaide &

Nutrition in acute pancreatitis S. N. Duggan et al.

ª 2012 The Authors

2 Journal of Human Nutrition and Dietetics ª 2012 The British Dietetic Association Ltd.

Meath Hospitals incorporating the National Children’s

Hospital.

Statistical analysis

Analyses were conducted using minitab, version 15

(Minitab Inc., State College, PA, USA). Chi-squared anal-

yses were performed to examine the differences in cate-

gorical variables. P < 0.05 was considered statistically

significant.

Results

Demographics and setting

In total, 253 dietitians took the survey. Forty-nine dieti-

tians reported not seeing patients with acute pancreatitis,

and were excluded from analyses. Two hundred and four

dietitians were included in the final analyses. For report-

ing, the Republic of Ireland was referred to as ‘Ireland’,

and the four countries of the UK (England, Scotland,

Wales and Northern Ireland) were amalgamated. The

response per country was 31 dietitians from Ireland, 56

dietitians from the UK and 117 dietitians from Canada,

representing an estimated 6.2%, 0.9% and 2% of regis-

tered dietitians in each country respectively.

The majority of responders in all countries were work-

ing in district or general hospitals, with 38.7% (n = 79)

working in university hospitals. Within Canada, 29%

(n = 34) were university hospital dietitians compared to

45.2% (n = 14) in Ireland and 55.3% (n = 31) in the UK.

The UK had the greatest response from larger hospitals,

with 53.6% (n = 30) working in a hospital with greater

than 600 beds compared to 25.8% (n = 8) in Ireland and

18.9% (n = 22) in Canada (Table 2).

Caseload and specialist teams

When asked to estimate the percentage of clinical case-

load allocated to pancreatic disease, 16.1% (n = 9) of UK

responders reported a pancreatic caseload of >30%.

Among Irish responders, 6.7% (n = 2) reported a greater

than 30% caseload, as did one dietitian in Canada. One

dietitian in Ireland and three in the UK reported a pan-

creatic caseload of greater than 50%. Over half of

responders in Ireland (51.6%, n = 16) and Canada

(57.3%, n = 67) were qualified for >8 years compared to

37.5% (n = 21) in the UK.

When asked if their teams accepted tertiary referrals for

acute pancreatitis, more than one-third reported accep-

tance of tertiary referrals (Table 2). Almost one-quarter of

responders in the UK (23.2%, n = 13) reported the exis-

tence of pancreatic multidisciplinary team, with 9.6%

(n = 3) of Irish responders and 3.4% of Canadian

responders reporting the presence of a pancreatic multi-

disciplinary team. When asked if the team seeing acute

pancreatitis patients had a formal pancreatitis management

protocol, 21.4% (n = 12) of responders in the UK, 8.3%

(n = 3) of Irish and 5.1% (n = 6) of Canadian responders

Table 1 Parameters used to examine current nutrition practice in acute pancreatitis based on the available nutrition pancreatitis guidelines

Parameter 1 Every hospital receiving acute admissions should have a single nominated clinical team to manage all patients with acute

pancreatitis (E)

Specialists in nutrition should form part of the multidisciplinary team in specialist units for the treatment of severe acute

pancreatitis (E)

Parameter 2 Early feeding for patients with severe acute pancreatitis is recommended (A, B, D)

Parameter 3 Enteral nutrition is preferred over parenteral nutrition (A, B, C, D, E, F)

Parameter 4 Jejunal feeding could be trialed if gastric feeding is not tolerated (B); either gastric or jejunal feeding may be used, but tolerance

may be increased by a tube placed lower in the gut (D); The nasogastric route can be used as it appears to be effective in

80% of cases (E); Nasojejunal feeding is preferred (over parenteral) (F)

Parameter 5 Indirect calorimetry is the most ideal method of calculating requirements (D); the Harris Benedict equation is unreliable where

there are septic complications (A); 104–146 kJ kg)1 day)1 (25–35 kcal kg)1 day)1) for severe acute pancreatitis, low caloric

provision [63–84 kJ kg)1 day)1 (15–20 kcal kg)1 day)1)] during the early catabolic stages of complicated disease (A)

Parameter 6 Peptide-based feeds are known to be safe, but standard could be tried it tolerated (B); Tolerance may be improved by altering

the formula type, including trying a peptide- based feed (D)

Parameter 7 Glutamine should be administered with parenteral nutrition (C)

Guidelines:

A. European Society for Clinical Nutrition and Metabolism (ESPEN) Guidelines on Nutrition in Acute Pancreatitis (2002).

B. ESPEN Guidelines on Enteral Nutrition: Pancreas (2006).

C. ESPEN Guidelines on Parenteral Nutrition: Pancreas (2009).

D. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: (American Society for Parenteral

and Enteral Nutrition) (2009).

E. UK Guidelines for the Management of Acute Pancreatitis. UK Working Party on Acute Pancreatitis (2005).

F. Practice Guidelines in Acute Pancreatitis. American College of Gastroenterology (2006).

S. N. Duggan et al. Nutrition in acute pancreatitis

ª 2012 The Authors


reported that such a protocol existed. Dietitians were also

asked if their teams had a formal pancreatitis feeding

protocol; 16.6% (n = 9) in the UK, 6.0% (n = 7) in Can-

ada and 5.5% (n = 2) in Ireland reported that a feeding

protocol exists in their teams. Data on specialist teams

are summarised in Fig. 1. Using chi-squared analysis,

those reporting that their unit accepted tertiary referrals

indicated that their units had a pancreatic multidisciplin-

ary team (P = 0.000) and a formal feeding protocol

(P = 0.041) but not a formal pancreatitis management

protocol (P = 0.363).

Feeding commencement

Respondents were asked to indicate what they considered

to be ‘early feeding’ from a given range (between <12 and

<72 h). The most common response was <24 h (50.8%).

Of the sample, 5.2% (n = 10) considered <12 h to be

‘early feeding’. The majority (92.8%) of dietitians chose

48 h or less as ‘early feeding’. Dietitians were given three

clinical scenarios to examine timing of feeding in different

situations. Questions related to their practice in feeding a

patient with: (i) severe acute pancreatitis; (ii) severe acute

pancreatitis with obese-range body mass index; and (iii)

severe acute pancreatitis with pre-existing malnutrition.

Over half (54.2%) reported feeding early in severe acute

pancreatitis, with less (42%) feeding early in the case of

an obese patient and most (81.9%) feeding early where

there is pre-existing malnutrition. The data was further

analysed per institution-type. Using chi-squared analysis,

there was a tendency to feed earlier in university hospitals

compared to district/general hospitals in severe acute pan-

Table 2 Demographics and management-pattern of respondents

compared by country

Ireland,

n

UK,

n

Canada,

n Total

Completed surveys 31 56 117 204

Sees patients with acute

pancreatitis regularly

17 42 86 145

See patients with acute

pancreatitis occasionally

14 14 31 59

Age (years)

<25 3 7 4 14

26–33 15 30 39 84

34–42 6 11 32 49

43–51 4 6 18 28

>52 1 1 22 24

Male 1 6 4 11

Female 28 49 111 188

Years qualified

0–3 years 3 15 21 39

4–8 10 19 26 55

>8 16 21 67 104

University hospital 14 31 34 79

District/general hospital 16 25 78 119

Private hospital 1 0 0 1

Other 0 0 5 5

0–200 beds 8 0 33 41

201–400 beds 10 11 38 59

401–600 beds 5 15 24 44

601–800 beds 7 8 11 26

>800 beds 1 22 11 34

Pancreatic disease caseload

0–5% 15 26 76 117

6–10% 12 9 29 50

11–30% 1 12 8 21

31–50% 1 6 0 7

51–100% 1 3 0 4

Accept tertiary referrals?

Yes 12 27 39 78

No 12 12 29 53

Unsure 7 17 47 71

Pancreatic multidisciplinary team present?

Yes 3 13 4 20

No 28 40 109 177

Unsure 0 2 2 4

Patients with severe acute pancreatitis transferred to intensive care

unit or high-dependency unit?

Yes 15 27 37 79

No 14 11 58 83

Unsure 1 18 21 40

Formal pancreatitis management protocol?

Yes 3 12 6 21

No 24 18 91 133

Unsure 4 26 20 50

Formal pancreatitis feeding protocol?

Yes 2 9 7 18

No 28 43 108 179

Unsure 1 4 2 7

Figure 1 A summary of the presence of multidisciplinary teams

(MDT), the acceptance of tertiary referrals, and the existence of for-

mal management and feeding protocols compared to total numbers

as reported by dietitians.


ª 2012 The Authors


creatitis (P = 0.015) and the obese acute pancreatitis

patient (P = 0.011). There was no difference in practice

where there is pre-existing malnutrition (P = 0.125)

(Table 3).

Enteral feeding

Respondents were asked whether they enterally fed ‘rou-

tinely’, ‘occasionally’ or ‘never’. Over one-third (37.7%,

n = 77) report feeding ‘routinely’ with enteral nutrition

compared to 54.4% ‘occasionally’ feeding enterally and

7.8% ‘never’ feeding enterally. When analysed further,

55.7% of university hospitals dietitians reported using

enteral nutrition routinely compared to 26% of district/

general hospital dietitians. Using chi-squared analysis,

there was a significant tendency towards enteral nutrition

in university hospitals compared to district/general hospi-

tals (P = 0.000). The majority of both groups [university

hospital dietitians (91.1%) and district/general hospital

dietitians (80.6%)] reported using parenteral nutrition

‘occasionally’ or ‘never’. The UK had the highest reported

‘routine’ use of enteral nutrition (53.6%) and the lowest

‘routine’ use of parenteral nutrition (12.5%). Table 4

details enteral and parenteral usage per country.

When asked to identify perceived barriers to enteral

feeding in their institutions from a predefined list

(Table 5), 73.5% reported barriers to enteral feeding in

their institutions; 64.3% of UK dietitians, 75.2% of Cana-

dian dietitians and 83.9% of Irish dietitians. Those work-

ing in university hospitals (65.8%) were less likely than

those working in district/general hospitals (78.2%) to

have barriers to enteral feeding, although this fell outside

statistical significance (chi-squared, P = 0.057). The most

common perceived barrier was ‘medical preference’

(57.8%).

Route of feeding

Dietitians who reported enteral feeding ‘routinely’

(n = 162) were asked what their preferred route is for

enteral feeding: gastric or jejunal. Most (64.2%, n = 104)

reported that jejunal feeding was their preferred route.

Among countries, 77.8% of Canadian dietitians, 54.2% of

Irish dietitians and 43.8% of UK dietitians reported jeju-

nal feeding as the preferred route. Between institution

types, 70.8% of university hospital dietitians and 57% of

district/general hospital dietitians reported jejunal feeding

as their route of choice.

Requirements and formula

Dietitians were asked which predictive equations they use

to calculate requirements in severe acute pancreatitis

(multiple responses allowed). The most common was

Table 3 Comparison of timing of feeding in clinical scenarios per institution-type

University Hospital

District/General

Hospital

Severe acute pancreatitis Feed early 52 (64.8%) 57 (48.7%) P = 0.015a

Feed later 27 (34.2%) 61 (51.3%) v2 =5.875

Severe acute pancreatitis with obese-range BMI Feed early 42 (53.8%) 41 (35.7%) P = 0.011a

Feed later 36 (46.2%) 75 (64.3%) v2 =6.522

Severe acute pancreatitis with pre-existing malnutrition Feed early 69 (87.3%) 94 (78.8%) P = 0.125

Feed later 10 (12.7%) 25 (21.2%) v2 =2.275

aAchieves statistical significance.

BMI, body mass index.

Private and ‘other’ hospitals excluded due to small numbers.

Table 4 Reported enteral and parenteral usage in severe acute pan-

creatitis by country

Ireland UK Canada

Enteral nutrition

Routinely 10 (32.2%) 30 (53.6%) 37 (31.6%)

Occasionally 19 (61.3%) 25 (44.6%) 67 (57.3%)

Never 2 (6.5%) 1 (1.8%) 13 (11.1%)

Parenteral nutrition

Routinely 7 (22.6%) 7 (12.5%) 17 (17.8%)

Occasionally 20 (64.5%) 42 (75.0%) 88 (86.0%)

Never 4 (13.9%) 7 (12.5%) 12 (10.2%)

Table 5 Dietitians’ perceived barriers to enteral feeding in their insti-

tutions

Are there barriers to enteral feeding

in your institution?

Yes (%) No (%)

150 (73.5) 54 (26.5)

Please indicate what barriers there are n %

Medics preference 118 57.8

Technical difficulty

(in placing feeding tubes)

79 38.7

Lack of practice guidelines 61 29.9

Enteral nutrition used in the past,

but considered failure

18 8.8

Insufficient dietitian time 15 7.4

Dietitians preference 3 1.3


ª 2012 The Authors


Harris Benedict (Harris & Benedict, 1919) (n = 85) and

Schofield (Schofield, 1985) (n = 77). Other methods

included Ireton-Jones (Ireton-Jones & Jones, 2002)

(n = 36) and Mifflin St Jeor (Mifflin et al., 1990) (n = 9,

solely Canadian dietitians). The use of a range of simple

caloric estimation equations was also reported from 46 to

58.5 kJ kg)1 day)1 (11 to 14 kcal kg)1 day)1) (in obesity)

to 146.4 kJ kg)1 day)1 (35 kcal kg)1 day)1). Semi-elemen-

tal/peptide feed (n = 98, 49.2%) was the most commonly

cited formula used. Standard formulae were reported in

34.2% (n = 68) of cases and elemental in 10.6% (n = 21)

of cases. The majority (67%, n = 70) of those who jeju-

nally feed as first line reported using semi-elemental feeds

as first choice compared to 46.5% (n = 27) of those who

feed gastrically as first line. The most commonly cited

drivers of formula choice were evidence/guidelines

(78.3%, n = 155), availability (33.8%, n = 67) and con-

sultant preference (14.1%, n = 28). The least chosen

option was cost (7.1%, n = 14).

Tube insertion

Those using nasojejunal tubes were asked by which

method tubes were inserted in their institutions (multiple

responses allowed). The most common methods were

radiology (n = 95), endoscopy (n = 81) and bedside

insertion (n = 64). Where bedside techniques were used,

dietitians were asked who typically inserts the tubes

(more than one response allowed). The responses were

medics (n = 64), ward nurses (n = 31), specialist nurses

(n = 22) and dietitians (n = 5).

Additions

Dietitians were asked about their practice regarding spe-

cific nutrient additions in acute pancreatitis, choosing

from a list which included probiotics, pancreatic enzymes,

glutamine and micronutrients. Choices were ‘always’,

‘sometimes’ or ‘never’. Only 1.1% (n = 2) reported

‘always’ using probiotics in enteral feeding. The use of

probiotics was explored in terms of institution-type.

Almost all university hospital dietitians (93.2%, n = 68)

stated that they ‘never’ give probiotics with enteral feed-

ing. A lower percentage (79.4%, n = 77) of district/gen-

eral hospital dietitians reported ‘never’ giving probiotics

with enteral feeding. The majority (71.3%) reported using

pancreatic enzymes at least sometimes in enteral nutri-

tion, with 25.8% using enzymes at least sometimes with

parenteral feeding. Regarding glutamine, 1.2% (n = 2)

reported ‘always’ using enteral glutamine with enteral

nutrition, whereas 8.3% reported using parenteral gluta-

mine ‘always’ with parenteral feeding. The use of addi-

tions is detailed in Table 6.

Guidelines

The guidelines most familiar to respondents are presented

in Table 7 in order of preference. A minority were una-

ware of guidelines, specifically 12.9% (n = 15) of district/

general hospital dietitians and 2.6% (n = 2) of university

hospital dietitians. Similar percentages of those who see

patients regularly (9.2%, n = 13) and those who report

seeing acute pancreatitis patients occasionally (10.5%,

n = 6) reported being unaware of guidelines.

Discussion

The present study reports presents a survey of 204 dieti-

tians in six countries examining the nutritional manage-

ment of acute pancreatitis. The study surveyed different

areas of practice, including the existence of teams and pro-

tocols, the use of enteral and parenteral nutrition, and the

provision of specific nutrient additions. The results are dis-

cussed in the context of the available guidelines, which

were amalgamated as seven key parameters (Table 1).

Parameter 1: Specialist teams

Although a third of dietitians surveyed reported that their

teams accept tertiary referrals for severe acute pancreatitis,

Table 6 Use of additions in enteral and parenteral nutrition as

reported by dietitians

Addition Always Sometimes Never

Enteral nutrition

Probiotics 2 (1.1%) 25 (14.2%) 149 (84.7%)

Pancreatic enzymes 15 (8%) 119 (63.3%) 54 (28.7%)

Glutamine 2 (1.2%) 22 (12.8%) 147 (86%)

Micronutrients 17 (9.9%) 64 (37.4%) 90 (52.6%)

Parenteral nutrition

Probiotics 0 8 (4.9%) 156 (95.1)

Pancreatic enzymes 5 (3%) 35 (20.8%) 128 (76.2%)

Glutamine 14 (8.3%) 35 (20.7%) 120 (71%)

Micronutrients 91 (52%) 42 (24%) 42 (24%)

Table 7 Guidelines that dietitians are most familiar with for the nutri-

tional management of acute pancreatitis

Guidelines n %

American Society for Parenteral and

Enteral Nutrition (ASPEN) guidelines

81 40.7

European Society for Clinical Nutrition and

Metabolism (ESPEN) guidelines

58 29.2

Unaware of guidelines 19 9.55

Other 17 8.5

British Society of Gastroenterology guidelines 15 7.5

Irish Nutrition & Dietetic reference guide 7 3.5

American Gastroenterology Association guidelines 2 1.0


ª 2012 The Authors


less than one-quarter of dietitians in the UK reported that

their institutions have a specialist pancreatic multidisci-

plinary team. The figures were lower for Ireland and

Canada. Indeed, less than one-quarter of UK dietitians

reported being aware of an institutional protocol for the

management of acute pancreatitis. In Ireland and Canada,

the numbers were lower still, although the slightly more

favourable UK figures may be a result of the proportion-

ally higher number of university-hospital dietitians com-

pleting the survey. Even if dietitians were not aware of a

management protocol where one existed, we could expect

them to be aware of a formal feeding protocol. Neverthe-

less, the numbers of dietitians reporting the existence of a

formal feeding protocol were even lower. It appears that

teams and protocols occur simultaneously, with an associ-

ation between the acceptance of tertiary referrals and the

existence of a multi disciplinary team and feeding proto-

col, although not a pancreatitis management protocol.

The UK guidelines recommend that specialists in nutri-

tion should form part of the team for the treatment of

severe acute pancreatitis (UK Working Party on Acute

Pancreatitis, 2005). However, rather than specialising in

pancreatic disease, the survey showed that dietitians tend

to see pancreatic patients as part of a varied caseload,

with a minority of dietitians seeing pancreatic patients as

greater than half of their clinical caseloads. One could

argue that this is suboptimal; however, there are no

guidelines to specifically recommend appropriate dietetic

pancreatic staffing levels. The UK Working Party on

Acute Pancreatitis (2005) stated that the evidence for this

recommendation is of grade C quality.

Parameter 2: Early feeding

Although several guidelines recommend early feeding, only

the ASPEN guidelines (McClave et al., 2009) specify any

time frame, stating that a tube for feeding should be

inserted ‘as soon as fluid resuscitation is complete’.

Although the ESPEN 2006 guidelines (Meier et al., 2006)

suggest that feeding should be commenced ‘as early as pos-

sible’, especially in alcoholic acute pancreatitis with malnu-

trition, a specific time-frame is not given. The 2002 ESPEN

guidelines recommended early feeding in those with com-

plicated disease and, although a time frame was not speci-

fied, the guidelines discuss two studies (Kalfarentzos et al.,

1997; McClave et al., 1997) that defined early feeding as

<48 h. Whether or not early feeding in severe acute pancre-

atitis can prevent adverse outcomes compared to late initia-

tion of feeding remains untested by randomised controlled

trials. A systematic review (Petrov et al., 2009b) examined

whether the timing of nutrition support has an influence

on outcomes. Less risk was demonstrated when enteral

feeding was started within 48 h of presentation (compared

to parenteral nutrition), although there were no differences

in the groups when enteral feeding was started after 48 h.

Despite the lack of clarity, early feeding was a priority

for dietitians in all countries surveyed. Almost all dietitians

reported that they consider ‘early feeding’ to imply feeding

in <48 h of presentation. However, dietitians are more

likely to feed where there is pre-existing malnutrition, and

university hospital dietitians tend to favour earlier feeding.

District-hospital dietitians were less likely to feed early

where a patient has a body mass index in the obese range,

although this is not an issue among university-hospital

dietitians. The delay in feeding in obesity may not be

unexpected because an obese patient may not immediately

warrant nutritional concern. However, obese patients with

acute pancreatitis may have worse outcomes: obesity may

be a prognostic factor in the development of complications

in acute pancreatitis (Martinez et al., 2004).

Parameter 3: Enteral feeding

The guidelines are unanimous in recommending enteral,

rather than parenteral nutrition as first line therapy for

patients with acute pancreatitis. In addition, a Cochrane

review published in 2010 recommended that enteral

nutrition should be considered the standard of care for

patients with acute pancreatitis requiring nutritional sup-

port (Al-Omran et al., 2010). It is therefore surprising

that just over one-third (37.7%) report ‘routine’ use of

enteral nutrition, although, when amalgamating the ‘rou-

tine’ and ‘occasional’ enteral feeders, the percentage

increased to 92%. A notable 7.8% of dietitians report

‘never’ feeding with enteral nutrition. Again, those in uni-

versity hospitals are more likely to use ‘routine’ enteral

nutrition than those employed in district or general hos-

pitals. Among countries, practice in the UK appears to be

the most consistent with guidelines, with the highest ‘rou-

tine’ use of enteral feeding and the lowest ‘routine’ use of

parenteral nutrition. However, this may be biased by the

fact that the UK had the highest proportion of university-

hospital dietitians participating in the survey. University-

hospital dietitians and UK dietitians were also the least

likely to perceive barriers to enteral nutrition. Dietitians

perceived that ‘medical preference’ is the largest barrier to

enteral feeding. Differentiation was not made between

medics who were aware of the guidelines and chose to

ignore them, and those that were not aware of the guide-

lines, as had been done by the Canadian ICU survey in

2004 (Greenwood et al., 2004).

Parameter 4: Route of feeding

The majority of dietitians surveyed reported using the

jejunal rather than gastric feeding. Jejunal feeding was


ª 2012 The Authors


more common among university hospital dietitians than

district/general hospital dietitians. However, although the

UK had the most university dietitians in the survey, jeju-

nal feeding was most common in Canada and least com-

mon in the UK. This UK bias towards gastric feeding

may be a reflection of the 2005 UK study in which jejunal

feeding was compared with gastric feeding, showing no

difference in mortality (Eatock et al., 2005). In reference

to this study, the ESPEN guidelines postulated that acute

pancreatitis could not have been very severe in those

patients if gastric emptying was maintained. The UK

study has been criticised for likely comparing gastric to

duodenal rather than jejunal feeding, based on the posi-

tion of the tube tip.

The optimal route of enteral feeding continues to be

controversial, as is indicated by the contradictory guide-

lines. Meanwhile, because jejunal feeding is known to be

safe, conferring theoretical benefits in avoiding stimula-

tion of the injured pancreas, it appears prudent to feed

jejunally where feasible, particularly in severe cases. Barri-

ers to jejunal feeding include difficulty in the insertion of

tubes. Bedside insertion provides a method of jejunal tube

placement that is quick and cost-effective. Studies have

described methods of blind bedside insertion by nursing

(Lord et al., 1993) and dietetic staff (Cresci & Martindale,

2003), including from the main author’s unit (Duggan

et al., 2009).

Parameter 5: Nutritional requirements

Basal metabolic rate increases in severe acute pancreatitis,

as a result of inflammation and pain, leading to an increase

in total energy expenditure (Meier et al., 2006). In the

absence of indirect calorimetry, dietitians rely on predictive

equations to calculate nutritional requirements in various

clinical situations. In practice, there are a variety of meth-

ods used to calculate requirements in severe acute pancrea-

titis. The most commonly reported prediction equation

was Harris Benedict (Harris & Benedict, 1919). This is

despite the fact that it that its use is unreliable in the com-

plicated septic patient (Dickerson et al., 1991; Meier et al.,

2002). Although dietitians were not asked to differentiate

between practice in critically ill patients or otherwise, the

survey question specified severe acute pancreatitis. Like-

wise, respondants were not specifically asked about the use

of calorimetry. There was some regional difference in equa-

tions used, with the Mifflin-St Jeor equation (Mifflin et al.,

1990) being used exclusively in Canada.

Parameter 6: Formula

Peptide-based (semi elemental) feeds were the most com-

monly used formulae (49.2%) in severe acute pancreatitis,

especially by those who feed jejunally (67%). Dietitians

were driven in their decision by the evidence-base or by

guidelines, and not by cost. In theory, peptide-based regi-

mens should be superior because they do not rely on the

pancreatic secretion of digestive enzymes, and therefore

should not exacerbate the injured pancreas. Immuno-

enriched formulae containing immune system modulating

substrates such as glutamine, arginine and omega-3 fatty

acids may also confer benefits. However, when the toler-

ance and safety of enteral formulations in acute pancreati-

tis was systematically reviewed, Petrov et al. (2009a) found

that the use of semi elemental formulae did not result in a

significant difference in the risk of infectious complica-

tions or death. Supplementation with immuno-nutrients

or probiotics did not improve clinically meaningful out-

comes either. This study suggests that the more expensive

specialist feeds are unnecessary in acute pancreatitis.

Parameter 7: Glutamine and other additions

The use of additions to enteral and parenteral formulae is

usually based on clinical judgment in a given scenario,

rather than by guidelines. An example is the use of pan-

creatic enzymes during enteral feeding, or the addition of

pancreatic enzymes to tube feeds, for which there is little

guidance. The dietitian along with the team usually deter-

mines the need for such intervention based on clinical

symptoms and the tolerance to feeding. Over seven in 10

dietitians surveyed use pancreatic enzymes at least ‘some-

times’ during enteral feeding. This area of nutrition sup-

port warrants further investigation.

The guidelines recommend providing parenteral gluta-

mine with parenteral nutrition. There are no guidelines

for the provision of probiotics or enteral glutamine. The

survey showed a notable use of glutamine in patients with

severe acute pancreatitis, although it is more commonly

used parenterally than enterally, being used at least ‘some-

times’ by one-third of those surveyed.

There has been much written in the recent past regarding

probiotics in severe acute pancreatitis. Following the publi-

cation of the largest study of probiotics to date (Besselink

et al., 2008), the Dutch Acute Pancreatitis Study Group

showed that jejunal infusion of probiotics more than dou-

bled mortality compared to placebo in 298 patients with

predicted severe acute pancreatitis. Although dietitians

were not asked to clarify whether they infused probiotics by

the gastric or jejunal route, it was nevertheless unexpected

that 1.1% of dietitians reported ‘always’ using probiotics

with enteral feeding, whereas 14.2% reported ‘sometimes’

using probiotics during enteral feeding.

Reflecting the plethora of practice guidelines available,

dietitians reported a variety of guidelines when asked

which they were most familiar with for the nutritional


ª 2012 The Authors


management of acute pancreatitis. The majority of dieti-

tians who were not aware of guidelines were from district

or general hospitals. Not surprisingly, guidelines produced

by working groups of the two major nutrition bodies,

ASPEN (McClave et al., 2009) and ESPEN (Meier et al.,

2006), were the most commonly cited.

The limitations of the present study include the fact

that it was not possible to determine a percentage

response rate because the numbers of dietitians working

in pancreatic disease is unknown. Nevertheless, the survey

was completed by all dietitians in the Nutrition Interest

Group of the Pancreatic Society of Great Britain and Ire-

land who see patients with acute pancreatitis. Response

was proportionally highest in Ireland, most likely a result

of the survey being co-ordinated from Ireland. The

response was proportionally lowest in the UK. How this

affects interpretation is unclear; however, because univer-

sity hospital responses were higher from the UK, this

introduces an obvious bias. Despite this, the present study

is the largest of its kind in acute pancreatitis.

This was a survey of dietitians, rather than of medics.

Because the decision to feed ultimately lies with the phy-

sician in charge, a separate survey of practice among

medics would be required. Nevertheless, dietitians’ aware-

ness of the guidelines, perception of barriers to feeding,

and intended practice are important questions. In addi-

tion, dietitians may perceive barriers to feeding that may

not be apparent to all members of the team. Arguably,

targeting medics may have been useful for reporting the

existence of protocols, particularly pertaining to medical

management. However, it could be counter-argued that a

protocol should be visible by all members of a multidisci-

plinary team.

As a result of the anonymous electronic survey format,

an assumption is made that the information provided is

accurate. Finally, because the survey was voluntary, this

may introduce response bias.

Despite these limitations, the survey was the largest of

its kind, including six countries, representative of Europe

and North America. Actual current practice was com-

pared with international guidelines, and perceptions and

barriers were also identified.

The present study highlights deficits in the nutri-

tional management of acute pancreatitis, including a

continued reliance on parenteral nutrition. Although

the aim to feed early appears widespread, dietitians

perceive medical opinion as a barrier to enteral feeding.

The present study highlights the gaps between guide-

lines and practice, providing a platform for quality

improvement interventions. Tailoring education strate-

gies and research to overcome barriers to optimal prac-

tice will ultimately advance the nutritional management

of acute pancreatitis.

Acknowledgments

The Health Research Board had no involvement in the

study design, data analysis or interpretation, nor in

the decision to submit the manuscript for publication.

The authors acknowledge the assistance of the Dietetic

professional bodies, including the British Dietetic Asso-

ciation and The Irish Nutrition & Dietetics Institute.

We also thank The Nutrition Interest Group of the

Pancreas Society of Great Britain and Ireland and The

Scottish Intensive Care Society Dietitian’s Group.

Special thanks are given to Ms Janet Greenwood, spe-

cialist intensive care dietitian (Vancouver, Canada), who

provided contact for various dietetic links throughout

Canada.

Conflict of interests, source of funding andauthorship

The authors declare that they have no conflict of interests.

The authors wish to acknowledge financial support by

means of a Health Professional’s Fellowship from the

Health Research Board, Ireland (HPF/2009/46).

SND conceived and designed the study, acquired, analy-

sed and interpreted the data, drafted and revised the

manuscript. NS assisted in the design of the study, the

interpretation of data, and revised the manuscript. MO’S

assisted in the design of the study, and revised it for

important intellectual content. SF assisted in the design

of the study, and revised it for important intellectual

content. PFR assisted in the design of the study, the

interpretation of data, the drafting of the manuscript,

and revised the paper for important intellectual content.

KCC assisted in the design of the study and the inter-

pretation of data, and revised the paper for important

intellectual content. All authors critically reviewed the

manuscript and approved the final version submitted for

publication.

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Supporting information

Additional Supporting information may be found in the

online version of this article.

Appendix S1. Dietitian’s survey of nutritional practice

in patients with severe acute pancreatitis.

Please note: Wiley-Blackwell are not responsible for the

content or functionality of any supporting materials sup-

plied by the authors. Any queries (other than missing

material) should be directed to the corresponding author

for the article.


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A transatlantic survey of nutrition practice in acute pancreatitis

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