Nutritional Management of Acute and Chronic Pancreatitis

1. Nutritional Management of Acute and Chronic Pancreatitis John P. Grant, MDDuke University Medical Center

2. Clinical Spectrum of Pancreatitis • Acute edematous - mild, self limiting • Acute necrotizing or hemorrhagic - severe • Chronic

3. Etiology of Acute Pancreatitis • Biliary • Alcoholic • Traumatic • Hyperlipidemia • Surgery • Viral • Others

4. Diagnosis and Monitoring of Severity of Acute Pancreatitis • Amylase and lipase • Temperature and WBC • Abdominal pain

5. Determination of Severity • Ranson’s Criteria • Imire ’s Criteria • Balthazar’ Severity Index

6. 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

7. 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

8. 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 Imrie’s CriteriaGut 25:1340, 1984 In first 48 hours of admission If > 3 or more present, 40% will be severe If < 3 present, only 6% will be severe Predicts 79% of episodes

9. 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

10. Grade A: normal pancreas with clinical pancreatitis

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

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

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

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

15. Grade E pancreatitis with normal enhancement - 0% necrosis

16. Grade E pancreatitis with <30% necrosis

17. Grade E pancreatitis with 40% necrosis

18. Grade E pancreatitis with 50% necrosis

19. Grade E pancreatitis with >90% necrosis and abscess formation

20. Balthazar, Radiology 174:331, 1990 Pancreatic Necrosis M&M

21. 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 CT Severity Index

22. Balthazar, Radiology 174:331, 1990 CT Severity Index and M&M

23. Standard Management • Restore and maintain blood volume • Restore and maintain electrolyte balance • Respiratory support • ± Antibiotics • Treatment of pain

24. 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

25. 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

26. 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)

28. Optimal Medical Management • Minimize exocrine pancreatic secretion • Avoid or suppress cytokine response • Avoid nutritional depletion

29. Optimal Medical Management • Minimize exocrine pancreatic secretion • NPO • Ng tube decompression of stomach • Cimetidine • Provision of a hypertonic solution in proximal jejunum

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

33. 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

35. 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 Alexander, Ann Surg 200:297, 1984 175 Kcal - 72 h 200 Kcal - 72 h 175 Kcal - 2 h Postburn day

36. Optimal Medical Management • Minimize exocrine pancreatic secretion • Avoid or suppress cytokine response • Avoid nutritional depletion • If gut not functioning – TPN • If gut functioning - Enteral

37. 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

38. Pancreatic Exocrine Secretion • IV amino acids • Somatostatin • Glucagon • Any hypertonic solution in jejunum Depressants

39. 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

42. 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

43. 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)

44. 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

45. 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

46. 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

47. 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

48. 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

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

50. 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