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Nutritional Strategies in Acute Pancreatitis

This overview discusses the occurrence, pathophysiology, signs and symptoms, diagnosis, and treatment methods for acute pancreatitis. It also explores nutritional strategies such as NPO, total parenteral nutrition, and enteral nutrition.

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Nutritional Strategies in Acute Pancreatitis

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  1. Nutritional Strategies in Acute Pancreatitis Kim Feltner Advisor: Gilbert Boissonneault University of Kentucky

  2. Overview • Occurrence and Disease significance • Pathophysiology • Signs and Symptoms • Diagnosis • Treatment Methods

  3. Pancreatitis • Incidence ranges from 1-5 cases per 10,000 people each year • In 85-90% of patients, will subside in 3-7 days • Most common causes • Alcohol, gallstones • Others • Hypertriglyceridemia, viral infections (mumps or hepatitis), scorpion bites, some drugs such as valproic acid, sulfonamides, and thiazide diuretics and others

  4. Pathophysiology • Autodigestion • Activation of proteolytic enzymes trypsinogen, chymotrypsin, and trypsin occurs in the pancreas instead of activation in the intestinal lumen • These activated proteolytic enzymes digest pancreatic and peripancreatic tissue • More enzymes become activated causing digestion of cellular membranes that cause proteolysis, edema, and interstitial hemorrhage

  5. Pathophysiology • Proteases are packaged in precursor form and there are also protease inhibitors in the acinar cell and in the pancreatic secretions preventing autodigestion from occurring • Death of the acinar cells releases enzymes and begins autodigestion • Death of acinar cells caused by: • Duct obstruction or reflux of bile or duodenal contents into pancreas • Certain drugs or alcohol

  6. Symptoms • Abdominal pain • Steady and boring located epigastrically may radiate to back, chest, flanks, or lower abdomen • N/V

  7. Signs • Low-Grade Fever • Tachycardia • Hypotension • Diminished or absent bowel sounds • Pain may be relieved by bending forward (patient may be curled up)

  8. Signs • Turner’s Sign • Discoloration of the flanks reflecting tissue catabolism of hemoglobin • May indicate severe necrotizing pancreatitis From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, 3rd ed. London, Mosby, 2003.

  9. Signs • Cullen’s sign  • Faint blue discoloration around the umbilicus • Result of hemoperitoneum http://content.nejm.org.ezproxy.uky.edu/cgi/content/full/340/2/149

  10. Diagnosis • CT scan may confirm clinical impression of pancreatitis • Sometimes 3 days after dx to identify necrotizing pancreatitis • CT of abdomen may show gallstones • ERCP if gallstones suspected • Usually not used after first attack unless cholangitis or jaundice

  11. Lab Abnormalities • ↑ Serum amylase • ↑ Lipase parallel with amylase • Hyperglycemia • Hypocalcemia • Leukocytosis • ↑ CRP  suggests pancreatic necrosis and also causes ↓ albumin

  12. Admission Age > 55yrs WBC > 16,000/mm3 Blood Glucose >200mg/dL Serum LDH > 350 IU/L Serum AST > 250 U/L 0-2 criteria  1% mortality 3-4 criteria  16%mortality 5-6 criteria  40% mortality 7-8 criteria 100% mortality Initial 48 hours ↓ Hematocrit > 10% ↑ BUN > 5 mg/dL Serum calcium < 8mg/dL Arterial Po2 < 60mmHg Base deficit > 4 mEq/L Est. fluid sequestration > 6 L Development indicates worsening prognosis Severity AssessmentRanson’s Criteria

  13. Treatment • Narcotics for pain • IV fluids for hydration • Normally kept NPO to avoid stimulation of pancreas until free of pain and N/V • If pancreatitis does not subside within a few days • Total Parenteral Nutrition (TPN) • Enteral nutrition

  14. Nutritional Strategies • NPO • Nothing by mouth • Fluids replenished by IV • Reduces stimulation of the pancreas to prevent worsening of the disease state • Mild cases may begin oral intake within 3-4 days • Gastric decompression • Nasogastric tube suction to remove the acidic stomach contents and prevent them from reaching the jejunum • Recent studies have really shown no benefit to this therapy

  15. Nutritional Strategies • Total Parenteral Nutrition (TPN) • Placement of Central Venous Catheter in order to provide complete nutrition (internal jugular, subclavian) • May be required if an ileus is present or if patient has been NPO for 7-10 days • Very invasive, should not be used very early in pancreatitis • High risk of catheter related infections and sepsis

  16. Nutritional Strategies • Enteral Nutrition • Naso-gastric feeding usually preferred (inexpensive and easier-no radiology or endoscopy) • Distal to the ligament of treitz produce no change in complications, mortality, or length of hospital stay • Enteral feeding has been shown to improve the systemic inflammatory response

  17. What Next? • After free of pain, N/V, bowel sounds return • Begin with clear liquid diet • Very few calories (Enlive is a supplement to clear liquids to provide more calories) • Low residue food in liquid form to minimize amt of food to be digested in the intestines • Next step up to full liquid diet • All liquids added so some protein and fat are available • Next step up to small meals, low fat, low cholesterol, low triglyceride • May need to provide counseling to patient to avoid recurrent attacks • Avoid alcohol, eat small meals

  18. References • Arend W.P., Ausiello D., Goldman L., editors. Cecil Textbook of Medicine. 22nd ed. Philadelphia: W. B. Saunders; 2004. 779-884. • Conn's Current Therapy 2004. 56th ed. Philadelphia: W. B. Saunders; 2004. 563-573. • Fauci B., Hauser K., Jameson L., editors. Principles of Internal Medicine. 15th ed. Vol. 2. New York: McGraw Hill; 2001. 2249-2257. • Green II H.L., Noble J., et al, editors. Textbook of Primary Care Medicine. 3rd ed. St. Louis: Mosby; 2001. 1792-1803. • Heinrich S., Shafer M., Rousson V., Clavien P. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Annals of Surgery. 2005 Feb;243(2):154-168. • Marik P.E., Zaloga G.P. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. British Medical Journal (2004):1-6. • Mcphee S. J., Papadakis M.A, Tierney, Jr L.M., editors. Current Medical Diagnosis and Treatment. Los Altos: California: Lange Medical Publications; 2005. 671-676. • Radenkovic D., Johnson C. Nutritional support in acute pancreatitis. Nutritonal in Clinical Care. 2004; 7(3):98-103. • Raimondo M., Scolapio J.S. What route to feed patients with severe acute pancreatitis: vein, jejunum, or stomach? The American Journal of Gastroenterology. 2005 Feb;100(2):440 • Retally C.A., Skarda S., Garza M.A, Schenker S. The usefulness of laboratory tests in the early assessment of the severity of acute pancreatitis. Critical Reviews in Clinical Laboratory Science. 2003; 40(2):117-149

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