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REVIEW

CURRENT
OPINION Nutritional management of acute pancreatitis
Kumar Krishnan

Purpose of review
Acute pancreatitis is one of the most common causes for hospitalization related to a gastrointestinal disorder.
It carries significant morbidity, and when severe, significant mortality. Multiple interventions have been
studied to treat pancreatitis. Of all these interventions, none is more important or impactful than nutrition.
Recent findings
High-quality evidence along with society guidelines have recommended the use of enteral nutrition over
parenteral nutrition in patients with pancreatitis. Recent systematic reviews and meta-analyses have been
published and will be reviewed here.
Summary
The use of enteral nutrition has been demonstrated to decrease mortality and infectious complications
compared with parenteral nutrition. The ideal timing of initiating enteral nutrition is not clear, however, early
nutrition (within 48 h) appears to be safe and tolerated. Most studies have utilized nasojejunal feeding tubes;
however, some patients may tolerate nasogastric or even oral refeeding. Clinicians who manage patients
with pancreatitis must be aware of the critical role of nutrition in preventing pancreatitis-related complications.
Keywords
enteral nutrition, nasojejunal feeding, pancreatic necrosis, pancreatitis

INTRODUCTION pancreatitis. This includes epigastric or abdominal


Acute pancreatitis is a condition characterized by pain that frequently will radiate to the back. The
inflammation and subsequent autodigestion of the pancreas resides in the retroperitoneum, and as such,
pancreatic parenchyma. It accounts for the signifi- typical peritoneal signs of pain are usually absent.
cant gastrointestinal-related morbidity and is the Patients will often times have nausea and vomiting
third most common gastrointestinal cause of admis- associated with this pain. The second is a serum
sion to a hospital in the United States [1]. It accounts amylase or lipase that is greater than three times
for over 2.5 billion dollars in annual healthcare costs. the upper limit of normal for the reference lab. It is
Pancreatitis can be classified based on severity. The important to note that and elevated serum lipase,
most recent consensus guidelines categorize pancrea- although sensitive, can be associated with other
titis into mild, moderately severe, and severe pan- nonpancreatic conditions (i.e., bowel obstruction,
creatitis. Severity is graded based on both clinical bowel inflammation, renal disease, and so on.) The
parameters (end-organ damage) as well as imaging- third is cross-sectional imaging that reveals signs of
based morphological criteria [2]. Severe pancreatitis pancreatitis. This is typically by way of multidetector
remains exceptionally challenging to treat in hospi- contrast-enhanced computed tomography scan.
tal with mortality as high as 30%. There are few novel Alternatively, MRI can also be used. The radiographic
interventions that have demonstrated consistent findings of acute pancreatitis can be categorized as
clinical benefit in the management of patients with parenchymal findings and peripancreatic findings.
pancreatitis. To date, nutritional support remains the Typical parenchymal findings include edema,
best studied and most efficacious treatment for
patients with pancreatitis. Here, we will review the Division of Gastroenterology, Department of Internal Medicine, Houston
current status of nutritional support in patients diag- Methodist Hospital, Weill Cornell Medical College, Houston, Texas, USA
nosed with acute pancreatitis. Correspondence to Kumar Krishnan, Division of Gastroenterology,
Department of Internal Medicine, Houston Methodist Hospital, Weill
Cornell Medical College, Houston, TX, USA. Tel: +1 713 441 3372;
DIAGNOSIS OF ACUTE PANCREATITIS e-mail: kkrishnan@houstonmethodist.org
Acute pancreatitis is diagnosed by the presence of Curr Opin Gastroenterol 2017, 33:102106
two out of three criteria. The first is pain typical for DOI:10.1097/MOG.0000000000000340

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Nutritional management of acute pancreatitis Krishnan

resuscitation, antibiotics for suspected infection,


KEY POINTS and nutritional support. Localized complications,
 Enteral nutrition should be considered in all patients when present, such as pseudocyst and walled-off
with severe pancreatitis. necrosis are treated by procedural intervention such
as endoscopic or percutaneous debridement.
 Enteral nutrition is clearly better than parenteral
nutrition.
 Although nasojejunal feeding is ideal in most patients NUTRITIONAL SUPPORT
with pancreatitis, nasogastric feeding can be Of all the treatments that have been studied in patients
considered in some patients. with acute pancreatitis, the only treatment strategy
that has shown a clear benefit in terms of mortality is
nutritional support. There have been extensive studies
nonenhancement, and necrosis. Peripancreatic find- on the timing, route, and type of nutrition offered to
ings include acute peripancreatic fluid collections patients with pancreatitis. The systemic and local
and acute necrotic collections. complications that are common in patients with
Clinically, it is important to distinguish mild severe pancreatitis can impact the strategy employed.
from severe pancreatitis. The most recent Atlanta For example, narcotic use can result in delayed gastric
classifications have categorized three clinically emptying, and as such, gastric feeding can be problem-
relevant grades of pancreatitis. The first is mild atic. Further, the presence of large peripancreatic col-
interstitial pancreatitis. This is characterized by the lections can result in mass effect on the stomach or
absence of end-organ damage (renal failure, pulmon- duodenum. Frequently, these patients develop an
ary edema, and so on.) and radiographically by ileus related to the disease itself, or concomitant nar-
interstitial edema and peripancreatic stranding. cotic use, and as such the route and type of nutrition
Overall morbidity and mortality is low, and most may need to be altered.
patients have a complete recovery. Conversely,
severe pancreatitis is characterized by the presence
of persistent end-organ damage. Further, these PARENTERAL VS. ENTERAL NUTRITION
patients frequently develop localized complications Perhaps the largest debate in regards to nutrition in
such as peripancreatic fluid collections or acute the patient with pancreatitis is whether nutrition
necrotic collections. Morbidity and mortality is should be given enterally or parenterally. As men-
high in this group. Last are patients with moderately tioned earlier, because of mechanical and motility
severe pancreatitis. This group is characterized by derangements within the small bowel, parenteral
transient organ damage (<48 h) and the presence nutrition offers an attractive option to provide
of localized complications [2]. Outcomes of these nutrition without contributing to enteral flow in
patients are variable. the context of obstruction or ileus. Further, paren-
teral formulations can be titrated and adjusted daily
without the concern for vomiting or aspiration. In
MANAGEMENT OF ACUTE PANCREATITIS the awake patient who cannot take oral, it avoids the
Pancreatitis results in an immense inflammatory need to place a nasal feeding tube, which can be
response. This includes release of proinflammatory uncomfortable. Conversely, the advantages of
cytokines starting with tumor necrosis factor and enteral nutrition have been demonstrated in many
interleukin 1 [3]. This cytokine surge causes multi- other disease states such as the ICU or postoperative
system impairment. Vasodilation results in hypoten- patient [4,5]. Enteral nutrition prevents luminal
sion and acute kidney injury. Leaking capillaries mucosal atrophy as well as bacterial translocation,
results in acute respiratory distress syndrome and a proposed mechanism for sepsis in patients with
endotracheal intubation with ventilator support pancreatitis. It can, further, facilitate motility in
can be needed. Patients can develop sepsis-like syn- patients with ileus [6]. It is also associated with
dromes with marked leukocytosis, fever, and tachy- decreased cost compared with parenteral nutrition.
cardia. This in turn results in third-spacing of fluids In 2010, a Cochrane systematic review assessed
and extracapillary fluid retention. There have been eight randomized controlled trials with a total of 348
several proposed treatment strategies in patients with patients comparing enteral with parenteral nutrition
acute pancreatitis. Treatment strategies are targeted in the patients with pancreatitis. Enteral nutrition
at supporting or preventing end-organ damage and was provided by means of nasojejunal feeding tube in
treating complications. There is currently no direct all patients, whereas parenteral nutrition was pro-
pharmacotherapy for patients with pancreatitis, vided by a central venous catheter. In this study,
and as such, medical management includes fluid enteral nutrition resulted in a respiratory rate for

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Nutrition

all-cause mortality of 0.5 (95% confidence interval included only patients with predicted severe pan-
0.280.91) compared with enteral nutrition. The creatitis. The primary composite end point was
benefit on mortality was even greater in patients with major infection or death. In total, 30 patients in
severe pancreatitis. Length of hospital stay trended to the early group compared with 29 patients in the
favor enteral nutrition group, but this was not sig- delayed/on-demand group reached the composite
nificant. Last, systemic infection rates were also sig- end point. There was no statistically significant
nificantly lower in the enteral nutrition group [7]. difference in major infection or death between
Similar findings were noted in a more recent the two groups. Further, a majority of patients in
meta-analysis of patients with severe pancreatitis. the on-demand group were able to tolerate PO with-
&&
In this meta-analysis, eight studies were used for out the need for nasal/enteral nutrition [14 ].
comparison. Enteral nutrition was associated with These data suggest that although some studies
a decreased risk of mortality, infectious compli- favor early enteral nutrition using a nasal catheter,
cations, and organ failure. No difference in hospital on-demand enteral feeding vs. oral feeding can be
stay was noted [8]. safely performed in a subset of patients after 72 h.
The cumulative evidence from high-quality
studies and the pooled meta-analyses provide strong
clinical evidence that enteral nutrition is superior GASTRIC VS. JEJUNAL FEEDING
to parenteral nutrition in patients with pancrea- It has been suggested that gastric feeding results in
titis, both mild and severe. This has resulted in pancreatic stimulation, that ultimately contributes
strong recommendations by the Americal College to pain and ongoing symptoms of pancreatitis. As
of Gastroenterology, American Gastroenterological such, traditionally, enteral nutrition was delivered
Association (AGA), and International Association of through the placement of a nasal jejunal feeding
Pancreatology/American Pancreas Association to tube. This tube can be placed with fluoroscopic
support the use of enteral nutrition in patients with guidance, or more commonly, endoscopically.
pancreatitis [911]. The primary limitation to nasojejunal feeding is
the need for endoscopy services and a familiarity
of placing nasojejunal catheters. Nasojejunal
TIMING OF ENTERAL NUTRITION catheters are frequently tolerated; however, some
The timing of nutrition in patients with pancreatitis patients complain of discomfort and gagging related
has been debated as well. Most patients with mild to the tube passing in the hypopharynx. Further,
interstitial pancreatitis are clinically well with brief inadvertent removal or displacement of the tube is
bowel rest, with resumption of oral intake within common, and subsequently necessitates additional
4872 h. Others are unable to take per oral (PO) for endoscopy to reposition. It is for this reasons that
prolonged periods of time, and hence require nasogastric feeding is an attractive option.
nutritional support. Three studies have been performed which have
A retrospective study in 1200 patients with severe compared nasogastric with nasojejunal feeding. In
acute pancreatitis compared outcomes of patients 2005, a randomized controlled trials was performed
treated with early (<48 h) vs. late (>48 h) enteral in 50 patients with severe pancreatitis comparing
nutrition. In total, 81% of patients in the late enteral nasojejunal to nasogastric feeding. They noted no
nutrition group developed end-organ damage com- difference in mortality between the groups. Further,
pared with only 21% of those in the early nutrition there were no clinically significant differences in
&
group [12 ]. A recent meta-analysis of eight random- tolerance to tube feeding. Hospital stay was similar
ized controlled trials compared early (<24 h) vs. late in both groups which led to the conclusion that
(>24 h) enteral nutrition. In this study, the odds ratio simple nasogastric feeding was well tolerated and a
of developing organ failure was decreased in patients simpler modality for enteral nutrition [15]. A second,
who received early enteral nutrition. Interestingly, smaller study noted no difference in pain parameters
when comparing patients with predicted severe pan- compared to nasogastric or nasojejunal feeding, indi-
creatitis, there was no statistical benefit to early vs. cating that gastric feeding, and subsequent pancre-
late enteral nutrition. Further, there was no mortality atic stimulation did not exacerbate pain [16]. A more
benefit noted in early vs. late nutrition [13]. recent noninferiority trial also indicated that naso-
A landmark study (the Python study) sought to gastric feeding was not inferior to nasojejunal feeding
determine whether early enteral nutrition was in regards to pain or infectious complications [17]. A
indeed better than delayed nutrition. This was a pooled meta-analysis of all studies assessing nasogas-
prospective randomized control trial comparing tric feeding revealed no difference in mortality,
enteral nutrition within 24 h to oral refeeding vs. length of stay, infectious complications, or tolerabil-
on-demand enteral nutrition after 72 h. The study ity between the two strategies [18].

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Nutritional management of acute pancreatitis Krishnan

It is our practice to perform nasojejunal feeding Financial support and sponsorship


in patients who are at high risk of aspiration. We None.
further favor nasojejunal feeding in the intubated
patient. In patients who are not in the ICU and are at Conflicts of interest
low risk for aspiration, we consider a trial of naso-
There are no conflicts of interest.
gastric feeding. If it is not tolerated, we then perform
endoscopic nasojejunal feeding-tube placement.
REFERENCES AND RECOMMENDED
READING
TYPES OF FORMULA Papers of particular interest, published within the annual period of review, have
been highlighted as:
There are several enteral nutrition formulations & of special interest
available. In general, they can be categorized as && of outstanding interest

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was defined as feeding within 48 h. Their data indicate a substantial benefit in
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high-quality studies reveal that enteral nutrition is nutrition. These data, again, provide support for early nutrition in the critically ill
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