Review Article - Journal of Gastroenterology and Digestive Diseases (2017) Volume 2, Issue 3
Severe acute pancreatitis nutrition therapy.
Background: Nutrition Support “crucial to the management of Acute Pancreatitis” (AP). In a significant proportion, this process causes a massive systemic inflammatory response, increasing risk for deterioration of nutritional status, septic morbidity, organ failure (OF), and prolonged hospitalization (LOS). Prevalence increased between 2002-2012 in 16.4%. Overall mortality from 5 to 20% depending on severity. Aetiology First: Biliary (decrease frequency), but there is an increase causes by alcohol consumption and Metabolic Syndrome. Obesity is related with AP severity. AP patients are normally prescribed nil per os (NPO) at admission. Although early introduction of diet has proven to shorten the length of stay, it is still not clear when and how to introduce diet. Early enteral nutrition (EEN) has shown a significative benefit over parenteral nutrition (PN) in terms of infection rates, hyperglycemia and mortality rates. To prevent pancreas auto-digestion, which leads to the release of pro-inflammatory mediators, immune system and gut barrier plays an important role in the pathogenesis of AP. Methodology: This is a literature review. Objectives: Review the diagnosis, pathophysiology of AP combined with timing to introduce Nutritional Support Enteral or Parenteral to try to lower the morbi-mortality and LOS. Results/discussion: Consider the “Timing of Nutrition Intervention”. Bakker Meta-Analysis EN arm of 8 RCTs (Before vs. After 24 hrs.): mortality/OF/infect necrosis: 19%* vs 45%; OF: 16% vs *42%. Petrov Meta-Analysis of 11 RCTs *p<0.05 Rx started within 48 hrs (EN vs. PN): no significant differences. Petrov in his study Early vs. Delayed EN in severe AP: EIN (enteral ecoimmune nutrition) moderate’s excessive immune responses (SIRS, CRP levels), EIN improves clinical outcome. Total serum Ca decrease in the first 24 hr. is as predictor of severity a risk of necrosis development in AP. Mg supplementation decrease significantly proteases activation and severity in AP and antagonist pathological Ca signaling. Have to be clear the meaning of tolerance and gastric vs jejunal feeding: pain, diarrhea and ileus. w-3 FA may be beneficial for decreasing mortality, infectious complications, and LOS in AP, when used PN delay up to 5 days in initiation of PN may be appropriate to allow for restarting oral or enteral feeding. Use PN should be considered when EN is not feasible after 1 week from onset of pancreatitis episode. Conclusion: Nutritional status must be evaluated. When oral feeding is not tolerated EN feeding through a nasogastric/nasojejunal feeding tube should be attempted within the first 72 h. PN only if enteral route not available, optimal timing remains unclear. Antioxidants w-3 FA, vitamins and minerals (Ca, Mg, Vit C), and the role of immune-nutrients, important to be consider. The preferred route of administration was significantly (P<0.001) related to the practice type: academic physicians (52.1%, 61/117) were more likely to utilize NJ tubes compared to private practitioners (19.9%, 32/161), were most likely to use TPN/PPN than academic physicians (20.5%, 24/117). Predicting the nutritional tolerance remains challenging as current evaluation system needs to be improved.Author(s): Gertrudis Adrianza de Baptista*