Transcript Nutritional Management of Acute and Chronic Pancreatitis

Nutritional Management of
Acute and Chronic Pancreatitis
John P. Grant, MD
Duke 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
 Abdominal
and WBC
pain
Determination of Severity
 Ranson’s
 Imire
Criteria
’s Criteria
 Balthazar’
Severity Index
Ranson’s Criteria
Surg 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 Criteria
Surg 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 Criteria
Gut 25:1340, 1984
In first 48 hours of admission
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 severe
If < 3 present, only 6% will be severe
Predicts 79% of episodes
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
Balthazar, Radiology 174:331, 1990
Pancreatic Necrosis M&M
CT Severity Index
 Grade
 Degree
of necrosis
– Grade A = 0
– None = 0
– Grade B = 1
– 33% = 2
– Grade C = 2
– 50% = 4
– Grade D = 3
– >50% = 6
– Grade E = 4
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
 Avoid
exocrine pancreatic secretion
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
Alexander, Ann Surg 200:297, 1984
 30%
BSA burn in
guinea pigs
 Enteral feeding via
g-tube at 2 or 72
hours following
burn
 Mucosal weight
and thickness
were similar
175 Kcal - 72 h
200 Kcal - 72 h
175 Kcal - 2 h
Postburn day
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
Stimulants
 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
Pancreatic Exocrine Secretion
Depressants
 IV
amino acids
 Somatostatin
 Glucagon
 Any
hypertonic solution in jejunum
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 TPN
Sitzmann 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 TPN
Robin 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
Average age
112/44
39.3 ± 1.0
Etiology
124 EtOH (79%), 19 Biliary (12%)
Mortality
Simple 4%, Complex 5%
Pancreatitis: Effect of TPN
Robin 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 TPN
Robin 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 TPN
Kalfarentzos 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
Cholelithiasis
Hypertriglyceridemia
Trauma/Idiopathic
2
57
2
6
(3%)
(85%)
(3%)
(9%)
Pancreatitis: Effect of TPN
Kalfarentzos 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 TPN
Kalfarentzos 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 TPN
Kalfarentzos et al. J. Am. Coll. Nutr., 10:156, 1991
< 72 hours
>72 hours
# Pts
38
29
Ranson’s Criteria
3.2
3.9
Respiratory Failure
3 (7.8%)
5 (17.2%)
Renal Failure
1 (2.6%)
2 (6.8%)
Pancreatic Necrosis
2 (5.3%)
7 (34.1%)
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%)
Complications
Abscesses
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
Ave. Days of TPN
Range
Outcome
Surgical Intervention
Recovered diet PO/TF
Home TPN
Died
TPN-related sepsis
305
16
1-127
223
211/54
8
32 (10.5%)
18 (5.9%)
Duke Experience: Enteral
# Pts Ranson’s Criteria > 3
Ave. Days of TF
Range
Outcome
Surgical Intervention
Recovered oral diet
Home Enteral Nutrition
Died
150
11
1-60
24
115
33
2 (1.3%)
TPN vs TF and Acute Phase Response
Windsor 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 Response
Windsor 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
 If
severity of pancreatitis
severe, initiate early nutrition
support (within 72 hours)
Caloric Expenditure in
Pancreatitis
Author
# Pts
RQ
MEE
Van Gossum
4
0.81
2080
Bluffard
6
0.87
2525
Dickerson
5
0.78
26 Kcal/kg
23
0.86
1687
6
0.86
1817
Velasco
Duke
Average ratio MEE/predicted = 1.24
Nitrogen and Fat Needs
in 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 Needs
in 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