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Sohair Soliman MD. Tanta University 11 March 2011 1
51
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Page 1: Nutrition in pancreatitis shw

Sohair Soliman MD.

Tanta University

11 March 2011 1

Page 2: Nutrition in pancreatitis shw

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

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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

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CT shows

significant

Swelling and

inflammation

of the

pancreas

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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

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Maintain intestinal integrity to prevent bacterial

translocation and subsequent SIRS

◦ Bacterial translocation

Probably major cause of infection

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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.

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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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