Nutritional support for acute pancreatitis.
The current review has summarized current data relevant to the nutritional support of patients with acute pancreatitis. Selection of the most appropriate form of nutritional support for patients with acute pancreatitis is intimately linked to a thorough understanding of the effects of various forms of enteral and parenteral nutrition on physiologic exocrine secretory mechanisms. Two basic concepts have emerged from the multiple studies that have addressed these issues to date: 1, enteral feeds should have low fat composition and be delivered distal to the ligament of Treitz to minimize exocrine pancreatic secretion and 2, parenteral substrate infusions, alone or in combinations similar to those administered during TPN, do not stimulate exocrine pancreatic secretion. From a practical standpoint, most patients with acute pancreatitis are diagnosed by nonoperative means and will manifest some degree of paralytic ileus during the early phase of the disease. Therefore, jejunal feeds are usually not a therapeutic option early in the course of this disease. On the basis of the clinical studies reviewed herein we propose general guidelines for the nutritional support of patients with acute pancreatitis: 1, most patients with mild uncomplicated pancreatitis (one to two prognostic signs) do not benefit from nutritional support; 2, nutritional support should begin early in the course of patients with moderate to severe disease (as soon as hemodynamic and cardiorespiratory stability permit); 3, initial nutritional support should be through the parenteral route and include fat emulsion in amounts sufficient to prevent essential fatty acid deficiency (no objective data exist to recommend specific amino acid formulations); 4, patients requiring operation for diagnosis or complications of the disease should have a feeding jejunostomy placed at the time of operation for subsequent enteral nutrition using a low fat formula, such as Precision HN (Sandoz, 1.3 percent calories as fat), Criticare HN (Mead Johnson, 3 percent calories as fat) or Vivonex High Nitrogen (Norwich Eaton, 0.87 percent calories as fat), and 5, oral feedings should be low fat in composition and should be reinstituted using traditional clinical criteria, including the symptoms of the patient, physical examination and computed tomographic appearance of the pancreas (clinicians should bear in mind the well documented exocrine stimulatory effects of even low fat oral feeds and the risks of early refeeding). These general guidelines must be individualized to incorporate what is perhaps the most important clinical variable--the premorbid nutritional state of the patient.(ABSTRACT TRUNCATED AT 400 WORDS)
Pisters
P W
PW
Department of Surgery, New York University Medical Center, New York 10016.
Ranson
J H
JH
D002985:Clinical Protocols / Q000592:standards; D004734:Energy Metabolism; D004750:Enteral Nutrition / Q000379:methods / Q000592:standards*; D005069:Evaluation Studies as Topic; D005217:Fat Emulsions, Intravenous / Q000627:therapeutic use; D006439:Hemodynamics; D006801:Humans; D009748:Nutrition Disorders / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D010195:Pancreatitis / Q000150:complications* / Q000378:metabolism / Q000503:physiopathology; D010289:Parenteral Nutrition, Total / Q000379:methods / Q000592:standards*; D011379:Prognosis
D005217:Fat Emulsions, Intravenous