nutritional management of acute and chronic pancreatitis

Nutritional Management of Acute and Chronic

Pancreatitis

John P. Grant, MDDuke University Medical Center

Clinical Spectrum of Pancreatitis

Acute edematous - mild, self limiting

Acute necrotizing or hemorrhagic - severe

Chronic

Etiology of Acute Pancreatitis Biliary Alcoholic Traumatic Hyperlipidemia Surgery Viral Others

Diagnosis and Monitoring of Severity of Acute Pancreatitis

Amylase and lipase Temperature and WBC Abdominal pain

Determination of Severity

Ranson’s Criteria Imire ’s Criteria Balthazar’ Severity Index

Ranson’s CriteriaSurg Gynecol Obstet 138:69, 1974

Age > 55 years Blood glucose > 200 mg% WBC > 16,000 mm3

LDH > 700 IU/L SGOT > 250 U/L

If > 3 are present at time of admission, 60% die

Ranson’s CriteriaSurg Gynecol Obstet 138:69, 1974

Hct decreases > 10% Calcium falls to < 8.0 mg% Base deficit > 4 mEq/L BUN increases > 5 mg% PaO2 is < 60 mmHg

If > 3 are present within 48 hours of admission, 60% die

Imrie’s CriteriaGut 25:1340, 1984

Age > 55 WBC 15,000 mm3

Glucose > 190 mg% BUN > 23 mg%

PaO2 < 60 mmHg Calcium <8.0 mg% Albumin < 3.2 g% LDH> 600 U/L

If > 3 or more present, 40% will be severeIf < 3 present, only 6% will be severe Predicts 79% of episodes

In first 48 hours of admission

Balthazar’s Criteria Appearance on unenhanced CT:

Grade A to E– Edema within gland– Edema surrounding gland– Peripancreatic fluid collections

Appearance on enhanced CT:0 to 100% necrosis of gland– Degree of pancreatic necrosis

Grade A: normal pancreas with clinical pancreatitis

Grade B: Diffuse enlargement of the pancreas without peripancreatic inflammatory changes

Grade C: Enlarged pancreas with haziness and increased density of peripancreatic fat

Grade D: Enlarged body and tail of pancreas with fluid collection in left anterior pararenal space

Grade E: Fluid collections in lesser sac and anterior pararenal space

Grade E pancreatitis with normal enhancement - 0% necrosis

Grade E pancreatitis with <30% necrosis

Grade E pancreatitis with 40% necrosis

Grade E pancreatitis with 50% necrosis

Grade E pancreatitis with >90% necrosis and abscess formation

Pancreatic Necrosis M&M

Balthazar, Radiology 174:331, 1990

CT Severity Index Grade

– Grade A = 0– Grade B = 1– Grade C = 2– Grade D = 3– Grade E = 4

Degree of necrosis– None = 0– 33% = 2– 50% = 4– >50% = 6

Balthazar, Radiology 174:331, 1990

CT Severity Index and M&M

Standard Management Restore and maintain blood volume Restore and maintain electrolyte

balance Respiratory support ± Antibiotics Treatment of pain

Indications for Surgery Need for pressors after adequate volume

replacement Persistent or increasing organ dysfunction

despite maximum intensive care for at least 5 days

Proven or suspected infected necrosis Uncertain diagnosis, progressive peritonitis or

development of an acute abdomen

Standard Management High M&M felt to be due to several

factors:– High incidence of MOF– Need for surgery - often multiple– Development or worsening of

malnutrition

Mechanisms Leading to Progression of Acute Pancreatitis

Stimulation of pancreatic secretion by oral intake (<24 hours)

Release of cytokines, poor perfusion of gland (24-72 hours)

Optimal Medical Management

Minimize exocrine pancreatic secretion

Avoid or suppress cytokine response Avoid nutritional depletion

Optimal Medical Management Minimize exocrine pancreatic secretion

– NPO– Ng tube decompression of stomach– Cimetidine– Provision of a hypertonic solution in

proximal jejunum

Optimal Medical Management Minimize exocrine pancreatic secretion Avoid or suppress cytokine response

Suppression of Cytokines Antagonizing or blocking IL-1 and/or

TNF activity – antibody and receptor antagonists

Preventing IL-1 and/or TNF production– Generic macrophage pacification– IL-10 regulation of IL-1 and TNF– Inhibiting posttranscriptional

modification of pro-IL-1 Gene therapy to inhibit systemic

hyperinflammatory response of pancreatitis

Postburn Hypermetabolism and Early Enteral Feeding

30% BSA burn in guinea pigs

Enteral feeding via g-tube at 2 or 72 hours following burn

Mucosal weight and thickness were similar

100110120130140150160

0 2 4 6 8 10 12

RME % Initial

Postburn day

175 Kcal - 72 h

200 Kcal - 72 h

175 Kcal - 2 h

Alexander, Ann Surg 200:297, 1984

Optimal Medical Management

Minimize exocrine pancreatic secretion Avoid or suppress cytokine response Avoid nutritional depletion

– If gut not functioning – TPN– If gut functioning - Enteral

Pancreatic Exocrine Secretion

Water and Bicarbonate:– Acid in duodenum– Meat extracts in duodenum– Antral distention

Enzymes:– Fat and protein in duodenum– Ca, Mg, meat extracts in duodenum– Eating, antral distention

Stimulants

Pancreatic Exocrine Secretion

IV amino acids Somatostatin Glucagon Any hypertonic solution in jejunum

Depressants

Summary of Ideal Feeding Solutions in Acute Pancreatitis

Parenteral: Crystalline amino acids, hypertonic glucose solutions (IV fat emulsions tolerated)

Enteral: Low fat, elemental, hypertonic solutions given into jejunum

Pancreatitis: Effect of TPNSitzmann et al, Surg Gynecol Obstet, 168:311, 1989

73 patients with acute pancreatitis (ave. Ranson’s 2.5) were given TPN. – 81% had improved nutrition status– Mortality was increased 10-fold in

patients with negative nitrogen balance

– 60% required insulin (ave. 35 U/d)– Lipid well tolerated

Pancreatitis: Effect of TPNRobin et al, World J Surg, 14:572, 1990

156 patients with acute MILD to MODERATE pancreatitis received TPN (70 simple – Ranson’s 1.6; 86 complex pancreatitis – Ranson’s 2.2)

Male/Female 112/44Average age 39.3 ± 1.0Etiology 124 EtOH (79%), 19 Biliary (12%)Mortality Simple 4%, Complex 5%

Pancreatitis: Effect of TPNRobin et al, World J Surg, 14:572, 1990

Complications– 20 catheters were removed suspected

sepsis (11%), 3 proven – 55% of patients required insulin (ave.

69 U/d)– 15% developed respiratory failure, 3%

hepatic failure, 1% renal failure, and 1% GI bleeding

Pancreatitis: Effect of TPNRobin et al, World J Surg, 14:572, 1990

Nutritional status improved during TPN TPN solution was well tolerated TPN had no impact on course of disease

Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

67 patients with SEVERE pancreatitis (Ranson’s criteria > 3) were given TPN– Age: 57.8 ± 2– Male/Female 25/42– Average Ranson’s 3.8 ± .21– Etiology

Alcohol 2 (3%)Cholelithiasis 57 (85%)Hypertriglyceridemia 2 (3%)Trauma/Idiopathic 6 (9%)

Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

Fat emulsion did not cause clinical or laboratory worsening of pancreatitis

8.9% catheter-related sepsis vs 2.9% in other patients

Hyperglycemia occurred in 59 patients (88%) and required an average of 46 U/d insulin

Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

If TPN started within 72 hours: 23.6% complication rate and 13% mortality

If TPN started after 72 hours: 95.6% complication rate and 38% mortality

Pancreatitis: Effect of TPNKalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991

< 72 hours >72 hours# Pts 38 29Ranson’s Criteria 3.2 3.9Complications

Respiratory Failure 3 (7.8%) 5 (17.2%)Renal Failure 1 (2.6%) 2 (6.8%)Pancreatic Necrosis 2 (5.3%) 7 (34.1%)Abscesses 0 5 (17.2%)Pseudocysts 1 (2.6%) 5 (17.2%)Pancreatic Fistulae 2 (5.3%) 4 (13.8%)

Total 9 (23.6%) 28 (96.5%)Death 5 (13%) 11 (38%)

Pancreatitis: Effect of TF Kudsk et al, Nutr Clin Pract, 5:14, 1990

9 patients with acute pancreatitis were given jejunostomy feedings following laparotomy– Although diarrhea was a frequent

problem, TF was not stopped or decreased, TPN was not required

– No fluid or electrolyte problems occurred– Serum amylase decreased progressively– Hyperglycemia was common but

responded to insulin

Pancreatitis: TPN vs TF McClave et al, JPEN, 21:14, 1997

32 middle aged male alcoholics with mild pancreatitis (Ranson’s ave. 1.3)

Randomized to receive either nasojejunal (Peptamen) or TPN within 48 hours of admission (25 kcal, 1.2 g protein/kg/d)

Pancreatitis: TPN vs TF McClave et al, JPEN, 84:1665, 1997

There was no difference in serial pain scores, days to normal amylase, days to PO diet, or percent infections between groups

The mean cost of TPN was 4 times greater than TF

Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

38 patients with severe necrotizing pancreatitis were given either jejunostomy feedings or TPN within 48 hours of diagnosis– 3 or more Ranson’s criteria– APACHE II score > 8– Grade D or E Balthazar criteria

Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

Jejunal feedings with Reabilan HN containing 52 g/L fat (61% long-chain and 39% medium-chain triglycerides)

TPN with Vamin as all-in-1 using Lipofudin long-chain/medium-chain triglycerides

Target support 1.5-2 g protein/kg/d and 30-35 kcal/kg/d

Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

Outcome:– Both enteral and parenteral nutrition

were well tolerated with no adverse effects on the course of pancreatitis

– No difference in total days on nutrition support (33 d); total days in ICU (11 d); time on ventilator (13 d); use of and time on antibiotics (22 d); mean length of hospital stay (40 d); or mortality

Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

Outcome:– TF patients had significantly less

morbidity than TPN patients»Septic complications 5 vs 10 p < .01»Hyperglycemia 4 vs 9 »All complications 8 vs 15 p < .05

– Risk of developing complications with TPN was 3.47 times greater than with TF

Pancreatitis: TPN vs TF Kalfarentzos et al, Br J Surg, 84:1665, 1997

Outcome:– Cost of TPN was 3 times higher than TF

Conclusion:– Early enteral nutrition should be used

preferentially in patients with severe acute pancreatitis

Duke Experience

455 patients with moderate to severe pancreatitis were referred to NSS from 1990 – 1999

– Ave. age: 48 (range 5-94)– Male/Female: 247/208

Duke Experience

Weight gain 1.6

Albumin (pre/post) 2.6/3.5*

Transferrin (pre/post) 128/176*

PNI (pre/post) 59.4/49.8

* p < .05

Duke Experience: TPN# Pts Ranson’s Criteria > 3 305

Ave. Days of TPN 16Range 1-127

OutcomeSurgical Intervention 223Recovered diet PO/TF 211/54Home TPN 8Died 32

(10.5%)TPN-related sepsis 18 (5.9%)

Duke Experience: Enteral

# Pts Ranson’s Criteria > 3 150Ave. Days of TF 11

Range 1-60Outcome

Surgical Intervention 24Recovered oral diet 115Home Enteral Nutrition 33Died 2 (1.3%)

TPN vs TF and Acute Phase ResponseWindsor et al, Gut 42:431, 1998

34 patients with acute pancreatitis were randomized to TPN or TF for 7 days

Evaluated initially and at 7 days for systemic inflammatory response syndrome, organ failure, ICU stay

TPN vs TF and Acute Phase ResponseWindsor et al, Gut 42:431, 1998

CT scan remained unchanged Acute phase response significantly

improved with TF vs TPN– CRP 156 to 84– APACHE II scores 8 to 6– Reduced endotoxin production and

oxidant stress Enteral feeding modulates the

inflammatory response in acute pancreatitis and is clinically beneficial

Summary Recommendations

Initiate standard medical care immediately

Determine severity of pancreatitis If severe, initiate early nutrition

support (within 72 hours)

Caloric Expenditure in Pancreatitis

Author # Pts RQ MEEVan Gossum 4 0.81 2080Bluffard 6 0.87 2525Dickerson 5 0.78 26 Kcal/kgVelasco 23 0.86 1687Duke 6 0.86 1817

Average ratio MEE/predicted = 1.24

Nitrogen and Fat Needsin Pancreatitis

Nitrogen: 1.0 – 2.0 gm/kg/d– Nitrogen balance study is helpful– Value of BCAA not determined

Fat: Fat well tolerated IV and to limited degree in jejunum, no oral fat should be given– Value of lipids ? as stress increases

Other Nutritional Needsin Pancreatitis

Calcium, Magnesium, Phosphorus

Vitamin supplements – especially B-complex

Supplement insulin as needed

Summary Recommendations If ileus is present, precluding

enteral feeding, begin TPN within 72 hours:– Standard amino acid product– IV fat emulsions are safe– Supplement insulin and vitamins– Beware of catheter sepsis

Summary Recommendations If intestinal motility is adequate,

initiate enteral nutrition with jejunal access within 72 hours:– Low fat, elemental, hypertonic– Give fat intravenously as needed– Add extra vitamins – Decompress stomach as needed

Summary Recommendations

As disease resolves:– Begin TF if on TPN– Begin oral diet if on TF

»low fat, small feedings»Then, high protein, high calorie, low fat»Supplement with pancreatic enzymes

and insulin as needed