Nutrition in Acute PancreatitisNutrition in Acute Pancreatitis “An Evidence Based Approach” “An Evidence Based Approach” Which patients benefits Which patients benefits from nutritional support in from nutritional support in acute pancreatitis?acute pancreatitis? All patients with acute pancreatitis?All patients with acute pancreatitis?(Mild pancreatitis is different from severe(Mild pancreatitis is different from severepancreatitis) pancreatitis) Enteral or parenteral?Enteral or parenteral?Where is the evidence?Where is the evidence? SeveritySeverity(Clinical, laboratory and radiological signs)(Clinical, laboratory and radiological signs) Nutritional status Nutritional status Outcome predictorsOutcome predictors- Mild form (- Mild form ( 80%)80%)- Severe form (- Severe form ( 20%)20%)Severity assesmentSeverity assesment Mild form Mild form ( ( 80%)80%) - Ranson signs - Ranson signs 3 3 - CRP 3- Ranson cirteria 3 - CRP 120 mg/l- CRP 120 mg/l - APACHE II score 8- APACHE II score 8 - Balthazars-CT-score 3 - Balthazars-CT-score 3 1068 patients, mean age 52.8 yrs, 1068 patients, mean age 52.8 yrs, 589 edematous AP, 479 severe AP589 edematous AP, 479 severe APMORTALITY: total 7.8%,MORTALITY: total 7.8%, mildmild a aP 1%,P 1%, severe severe a aP 16.1%P 16.1%Severity and outcomeSeverity and outcomeMortality can increase to up to 40% if sepsis and MOF occurMortality can increase to up to 40% if sepsis and MOF occurESPEN GuidelinesESPEN Guidelines Enteral Nutrition:Enteral Nutrition: Clinical Nutrition Vol 25 (2), April 2006Clinical Nutrition Vol 25 (2), April 2006 Parenteral Nutrition:Parenteral Nutrition:Clinical Nutrition Vol 28, July 2009 Clinical Nutrition Vol 28, July 2009 www.espen.org/education/www.espen.org/education/guidelines.htm guidelines.htm Severity of acute pancreatitisSeverity of acute pancreatitis can be can be assessed adequatelyassessed adequatelyFor artificial nutritional interventionsFor artificial nutritional interventionsmild pancreatitis has to be separated from mild pancreatitis has to be separated from severe pancreatitis severe pancreatitis Nutritional status has to be assessedNutritional status has to be assessed on on admission and during the course of the admission and during the course of the diseasediseaseRecommentation IRecommentation IMain goals for nutrition in Main goals for nutrition in acute pancreatitisacute pancreatitis To provide calories with EN or PN to To provide calories with EN or PN to reverse protein catabolism without reverse protein catabolism without stimulation of the exocrine pancreatic stimulation of the exocrine pancreatic secretionsecretion To improve or to avoid nutritional To improve or to avoid nutritional depletiondepletion To reduce morbidity and mortality To reduce morbidity and mortality How should nutritional How should nutritional support be done?support be done?ParenteralParenteral or or enteral?enteral?Gastral or jejunal?Gastral or jejunal?EN vs PN and acute pancreatitisEN vs PN and acute pancreatitisMild to moderate pancreatitisMild to moderate pancreatitis EarlyEarly ENEN (ED, NJ) vs(ED, NJ) vs PNPN PRCT PRCT N=32N=32ENEN PNPNn = 16n = 16 n = 16n = 16Caloric goal (day 4)Caloric goal (day 4) 72%72% 86%86% Days to normal amylase 4.8 Days to normal amylase 4.8 0.6 0.6 6.8 6.8 1.5 1.5 Days to diet by mouthDays to diet by mouth 5.6 5.6 0. 7.1 0. 7.1 1.1 1.1 LOH (days)LOH (days) 9.7 9.7 1.3 11.9 1.3 11.9 2.6 2.6 Lengh of ICU stay (days) 1.3 Lengh of ICU stay (days) 1.3 0.9 2.8 0.9 2.8 1.3 1.3 % Nosocomial infection 12.5 % Nosocomial infection 12.5 8.5 12.5 8.5 12.5 8.5 8.5 Mortality (%)Mortality (%) 0.0 0.0 0.0 0.0 Cost (US$)Cost (US$) 761 761 50.3 50.3 3294 3294 551.9* 551.9*McClave et al, JPEN, 1997McClave et al, JPEN, 1997* p 195 mg/L107 Patients54 TPN54 TPN 115 kJ/KG/d1,2 g N250 ml 20% Intralipid53 TEN53 TEN 115 kJ/KG/d1,5 g NSurvimed jejunalAPACHE II 16 4 CRP 218 8 APACHE II 14 2 CRP 211 9 Wu et al, Pancreas 2010EN vs PN and severe acute EN vs PN and severe acute pancreatitispancreatitisWu et al, Pancreas 2010EN vs PN and severe acute EN vs PN and severe acute pancreatitispancreatitis Enteral Enteral nutrition (N= nutrition (N= 25)25)TPNTPN (N=25)(N=25)P P valuevalueInfectionInfection 16 16 (64.0%)(64.0%)15 (60.0%)15 (60.0%) 1.0001.000ICU stay ICU stay (days; median (days; median and range)and range)10 (0-44)10 (0-44)