Nutrition Support Blog: Nothing Cute About Acute Pancreatitis
September 28, 2011
Acute pancreatitis is one of the areas where noticeable progress in regards to the medical and nutrition therapy is evident in the past 25 years. The changes in practice for treatment of pancreatitis could serve as a model of the benefits of therapy based on data rather than knowledge of physiology. Traditional treatment of severe acute pancreatitis included nasogastric suction and suppression of gastric acid secretion because acid in the duodenum was a documented stimulus to pancreatic secretion. Patients were also maintained on strict gut-rest and provide with the “newfangled” parenteral hyperalimentation to counter the known hypermetabolism of severe pancreatitis.
Challenges to traditional medical therapy started as early as 1974 when a controlled trial suggested no benefit of strict mandatory nasogastric suction in the outcome of pancreatitis1, but it was not until the mid-1980’s before additional research started to alter practices of mandatory NG suction and universal acid suppression.2 Randomized studies of nutrition support in acute pancreatitis did not appear until 1987, and were among the first studies documenting that early parenteral nutrition (PN) created net negative effects without measurable benefit. Research demonstrating the feasibility and superiority of jejunal enteral nutrition support in acute pancreatitis did not appear until a decade later in 1997. Additional studies have cemented the preference for jejunal enteral support over parenteral support in acute pancreatitis (see http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/KrenitskyArticle-9_07.pdf for references).
While we have indeed “come a long way, baby” (archaic reference to a Virginia Slims commercial) regarding our approach to nutrition support for patients with severe acute pancreatitis, there are still a number of unanswered questions. The data comparing gastric with jejunal nutrition in severe pancreatitis has a number of notable flaws (outlined in the previous article link) that limit any take home conclusions. Additionally there is insufficient data to know how soon after the onset of severe pancreatitis to initiate nutrition support. We know that nearly 75% of patients with acute pancreatitis resolve within 7-10 days and do not benefit from starting any nutrition support beyond intravenous fluids. Those patients with more severe disease complicated by pancreatic necrosis or pseudocyst formation may not be able to tolerate oral intake for an extended period and are more likely to benefit from jejunal feeding. However, we do not have good data about the optimal time for these patients to remain without food by mouth.
Our clinical experience and observational data3 suggest that there may even be a clinical benefit for maintaining a longer period of nil per oris (No soup for You) in some patients receiving extended conservative therapy for pancreatitis complicated by a pseudocyst or necrosis. We recognize that this idea of maintaining no food by mouth for an extended period in an attempt to improve outcomes in complicated pancreatitis is controversial, and that it has not been tested in a controlled study. There is an inconvenience and potential social embarrassment with home nasal tubes, and known risks from percutaneous tubes like a PEG-J or direct PEJ. However, there is a distinct possibility that extending the period of no food by mouth and providing jejunal feedings may improve outcomes, decrease admissions and accelerate recovery in these cases of complicated pancreatitis. However, our past experiences with treating pancreatitis based on what we think we know teaches us that there is a real need for a randomized study to evaluate the full risks and potential benefits of extended jejunal feedings in this population.
1. Sax HC, Warner BW, Talamini MA, et al. Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J Surg. 1987;153:117-124.
2. Broe PJ, Zinner MJ, Cameron JL. A clinical trial of cimetidine in acute pancreatitis. Surg Gynecol Obstet. 1982;154(1):13-6.
3. Makola D, Krenitsky J, Parrish C, Dunston E, Shaffer HA, Yeaton P, Kahaleh M. Efficacy of enteral nutrition for the treatment of pancreatitis using standard enteral formula. Am J Gastroenterol. 2006;101(10):2347-55.
"I'm tired of all this nonsense about beauty being only skin-deep. That's deep enough. What do you want, an adorable pancreas?" --Jean Kerr