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Nutrition Therapy in Acute Pancreatitis

Nutrition Therapy in Acute Pancreatitis. Gila Greenbaum , Dietetic Intern, Sodexo 2014. Objectives. Define acute pancreatitis (AP) Differentiate between mild vs. severe AP (SAP)

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Nutrition Therapy in Acute Pancreatitis

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  1. Nutrition Therapy in Acute Pancreatitis Gila Greenbaum, Dietetic Intern, Sodexo 2014

  2. Objectives • Define acute pancreatitis (AP) • Differentiate between mild vs. severe AP (SAP) • Review research to determine recommended nutrition therapy (NT) for AP: I. Timing: when to initiate feedingsII. Diet: how to initiate feedings III. Enteral vs. Parenteral Nutrition • Review current guidelines: ACG, ASPEN, ESPEN

  3. Case Study Mrs. M is 88 year old female, c/o n/v, abdominal pain. Diagnosed with AP, and currently NPO with IV fluids for 5 days. She is anxious, and questions, “When will I be able to eat real food, and what foods can I eat?” What would you answer Mrs. M? http://www.connecttoresearch.org/publications/2

  4. What is AP? • Inflammatory disorder • Digestive enzymes damage the pancreas • Primary causes: alcohol abuse, gallstones

  5. Mild vs. Severe AP

  6. How to diagnose mild vs. severe AP? • Ranson’s Criteria: Clinical signs ≥3 associated with severe course • Acute Physiology and Chronic Health Evaluation (APACHE) II: physiologic measurements, age, PMH ≥ 8 associated with severe course • CT Severity Index (CTSI): based on extent of inflammation/complications on scan

  7. Goal of Nutrition Therapy in AP • Reduce burden of disease • Maintain positive nitrogen balance without over-stimulating pancreatic fluids • Dietary improvement and/or advancement

  8. What have we done in the past? • Prolonged fasting/NPO until normalization of enzymes, resolution of pain & inflammation • Oral feedings initiated with clear liquid diet • If oral feeding not possible: TPN

  9. What is the recommended NT in AP? • Let’s see what the current research has to say……. • Timing: when to initiate feedings • Diet: how to initiate feedings • Enteral Nutrition (EN) vs. Parenteral Nutrition (PN)

  10. I. Timing: when to initiate feedings • 4 studies reviewed in this section: • Eckerwall, Clinical Nutrition, 2007 • Chebli, Journal of Gastroenterology and Hepatology2005 • Baker, currently ongoing • Hegazi, JPEN, 2011

  11. 1) Eckerwall, 2007 • Immediate feeding vs. traditional fasting • Methods: 60 patients, randomized to fasting or immediate oral feeding group • Findings: (1) No differences between groups concerning pancreatic enzyme levels, pain or GI symptoms(2) LOH shorter in the oral feeding group (4 vs. 6 days)

  12. 2) Chebli, 2005 • Early oral refeeding may stimulate pancreatic secretion, increase inflammation, cause relapse of abdominal pain • Pain relapse during oral refeeding relatively high on day 1-2 since admission • Pain relapse increased hospital stay and overall costs on disease treatment

  13. 3) Baker, ongoing • Does starting EN within 24 hrs reduce infections compared to starting EN and/or oral diet 3-4 days after admission? • 208 patients randomized: EN within 24 hours (group A), or oral diet plus EN 72 hours (group B) • Group A: started at 20ml/hr, with goal rate 65ml/hr within 72 hrs • Group B: NPO for 72 hrs, then oral diet and/or EN

  14. 4) Hegazi, 2011 • Investigated early initiation DJF • Retrospective chart analysis • Nutrition Intervention: 20-25kcal/kg (IBW), 1.5g/kg protein via DJT • Results: (1) Early initiation: reduced mortality, fewer complications (2) Early achievement of feeding goal rate: shorter LOS (9d vs. 19d)

  15. --- Recap on Timing --- • Most studies: feeding can be initiated within 24-48 hrs American College of Gastroenterology (ACG) Guidelines (2013) • Timing to initiate feedings remains controversial • Feedings can be started when there is no n/v, and abdominal pain has resolved • Mean time between hospital admission and 1st meal: 1.5 days

  16. II. Diet: how to initiate feedings • 2 studies reviewed in this section: • Sathiaraj,Aliment PharmacolTher, 2008 • Jacobsen,Clinical Gastroenterologyand Hepatology, 2007

  17. 1) Sathiaraj, 2008 • Tolerance of soft diet (SD) vs. clear liquid diet (CLD) in feeding initiation • Methods: 101 patients randomized to CLD (458kcal/d, 11g fat/d) or SD (1040kcal/d, 20g fat/d) • Findings: SD patients had decreased LOH post feeding (4 vs. 6d), reduced total LOHS (5 vs. 8d), no differences in pain

  18. 2) Jacobsen, 2007 • Low fat solid diet (LFSD) vs. CLD • Patients fed within 1-3 days post admission • Results: (1) LFSD was well tolerated, (2) Did NOT result in shorter LOH • Significance: LFSD can be considered for patients who desire greater dietary choice when initiating feeding after mild AP

  19. --- Recap on Diet --- • SD and LF solid diet are tolerated compared with CLD ACG Guidelines (2013): • Appropriate diet when initiating feedings: low fat low residue (soft) diet

  20. III. Enteral vs. Parenteral Nutrition • 2 studies reviewed in this section: • Eckerwall, Annals of Surgery, 2006 • Hegazi, J Parenter Enteral Nutr, 2011

  21. Nutrition Support

  22. New Research: EN vs. PN • EN: Encourages gut function, reduces bacterial overgrowth, fewer overall infections and complications • EN vs. PN: 1. 4.1 fewer days of nutritional support 2. Progressed to full oral feeding 1 day earlier • Cost savings: PN ($3294/pt) vs. EN ($761/pt)

  23. 1) Eckerwall, 2006 • 50 patients, randomized to EN or TPN group • Nutrition initiated within 24 hours • Only benefit of EN: improved blood glucose levels • Findings do not support suggested benefits of EN

  24. 2) Hegazi, 2011 • PN offers nutrients without pancreatic stimulation • PN associated with infections, metabolic complications • Pancreatic stimulation minimized during EN using mid to distal jejunum (40-60cm distal to the ligament of Treitz) http://www.normanallan.com/Misc/mingmen.htm

  25. --- Recap on Enteral vs. Parenteral --- • Most research: EN has eclipsed PN as the new "gold standard" of NT in AP ACG Guidelines (2013) • PN should be avoided in SAP unless EN not possible (e.g. paralytic ileus) or tolerated

  26. ESPEN Guidelines • EN has no positive impact on mild AP, only recommended for patients NPO > 5 days • EN is recommended for SAP • Only supplement with PN if needed • EN should be continuous, peptide-based formula

  27. ASPEN Guidelines • Energy Requirements: Calories: 25–35 kcal/kg/d Protein: 1.2–1.5 g/kg/d • Mild-moderate AP: 1. NPO, gradual advancement to oral diet within 3-4d 2. Only consider nutrition support if NPO > 5d • EN: preferred over PN, initiate first if feasible • EN Formula: small peptide-based MCT, continuous feeding • PN used only if EN not tolerated/indicated

  28. Summary • Timing: remains controversial, within 24-48 hours, with no n/v or abdominal pain • Diet: low fat low residue diet (usually with mild to moderate AP) • EN preferred over PN when possible (usually with SAP)

  29. Siow. Critical Care Nurse, 2008.

  30. RBMC Guidelines • There are currently no guidelines in place at the facility for nutrition therapy in AP • This research can help create standards of care

  31. Back to the case study……. Mrs. M is 88 year old female, c/o n/v, abdominal pain. Diagnosed with AP, and currently NPO with IV fluids for 5 days. She is anxious, and questions, “When will I be able to eat real food, and what foods can I eat?” What would you answer Mrs. M? Is your answer different from your initial answer?

  32. References • Eckerwall et al. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery—A randomized clinical study. Clinical Nutrition, Vol 26, Issue 6, 758-763, 2007. • Siow. Enteral Versus Parenteral Nutrition for Acute Pancreatitis. Critical Care Nurse, 28, 19-30, 2008. • Mirtallo et al. International Consensus Guidelines for Nutrition Therapy in Pancreatitis. JPEN J Parenter Enteral Nutr 36, 284-291, 2012. • Chebli et al. Oral refeeding in patients with mild acute pancreatitis: Prevalence and risk factors of relapsing abdominal pain. Journal of Gastroenterology and Hepatology, Vol 20, 9, 1385–1389, 2005. • Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol, 108, 1400-1415, 2013. • Sathiaraj et al. Clinical trial: oral feedings with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis. Aliment PharmacolTher, 28, 777-781, 2008.

  33. References cont. • Jacobsen et al. A Prospective, Randomized Trial of Clear Liquids Versus Low-Fat Solid Diet as the Initial Meal in Mild Acute Pancreatitis. Clinical Gastroenterology and Hepatology, 5, 946-951, 2007. • Hegazi et al. Early Jejunal Feeding Initiation and Clinical Outcomes In Patients with Severe Acute Pancreatitis. J Parenter Enteral Nutr Vol. 35, 1, 91-96, 2011. • Baker et al. Pancreatitis, very early compared with normal start of enteral feeding (PYTHON trial): design and rationale of a randomized controlled multicenter trial. Trials 12, 73, 2011. • Eckerwall et al. Early Nasogastric Feeding in Predicted Severe Acute Pancreatitis, A Clinical, Randomized Study. Annals of Surgery, Vol 244, 6, 959-967, 2006. • Ioannidis et al. Nutrition Support in Acute Pancreatitis. J Pancreas, 9, 4, 375-390, 2008. • Takeda et al. JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J HepatobiliaryPancreatSurg, 13, 42-47, 2006. • Meier et al. Nutrition in Pancreatitis. Best Pract Res ClinGastroenterol, 20, 3, 507-529, 2006.

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