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1
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Xiao W, Zeng Y, Ai L, Wang G, Fu Y. Clinical Predictors and Prevalence of Enteral Nutrition Intolerance in Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis. Nutrients 2025; 17:910. [PMID: 40077780 PMCID: PMC11902221 DOI: 10.3390/nu17050910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2025] [Revised: 03/01/2025] [Accepted: 03/03/2025] [Indexed: 03/14/2025] Open
Abstract
Background: Acute pancreatitis (AP) leads to severe inflammation and nutritional deficits, with 80% of severe cases experiencing critical protein loss. Timely enteral nutrition is essential for recovery. This study systematically reviews and analyzes the incidence and predictors of enteral nutrition intolerance (ENI) in AP patients. Methods: Web of Science, Embase, Cochrane Library, and PubMed were searched up to May 2024. Studies reporting on ENI incidence and predictors in AP patients were included based on predefined criteria. Bias was assessed using standardized tools, and meta-analyses provided summary estimates with confidence intervals. Results: From the 2697 screened studies, 28 involving 4853 patients met the inclusion criteria. The pooled incidence of ENI was 26%. Significant predictors included comorbid diabetes, pancreatic necrosis, elevated pre-refeeding serum lipase levels, peri-pancreatic fluid collections, and systemic inflammatory response syndrome at admission. Higher ENI rates were observed in Europe, among patients with severe acute pancreatitis (SAP), those receiving nasoenteric feeding, and in prospective study cohorts. Conclusions: ENI affects approximately one-quarter of AP patients and is not significantly associated with age, sex, or the cause of AP. Its incidence varies by region, disease severity, feeding method and study design. Identifying predictors, such as comorbid diabetes and pancreatic necrosis, may help clinicians reduce the risk of ENI. The limitations of this study include the heterogeneity of the included studies and inconsistent ENI diagnostic criteria.
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Affiliation(s)
- Wei Xiao
- School of Health Science and Engineering, Shanghai Engineering Research Center of Food Microbiology, University of Shanghai for Science and Technology, Shanghai 200093, China; (W.X.); (L.A.)
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China;
| | - Yue Zeng
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China;
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
| | - Lianzhong Ai
- School of Health Science and Engineering, Shanghai Engineering Research Center of Food Microbiology, University of Shanghai for Science and Technology, Shanghai 200093, China; (W.X.); (L.A.)
| | - Guangqiang Wang
- School of Health Science and Engineering, Shanghai Engineering Research Center of Food Microbiology, University of Shanghai for Science and Technology, Shanghai 200093, China; (W.X.); (L.A.)
| | - Yang Fu
- Shanghai Key Laboratory of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China;
- Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 201620, China
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2
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Hamesch K, Hollenbach M, Guilabert L, Lahmer T, Koch A. Practical management of severe acute pancreatitis. Eur J Intern Med 2025; 133:1-13. [PMID: 39613703 DOI: 10.1016/j.ejim.2024.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Revised: 10/29/2024] [Accepted: 10/30/2024] [Indexed: 12/01/2024]
Abstract
Acute pancreatitis (AP) represents one of the most common reasons for hospital admission and intensive care treatment in internal medicine. The incidence of AP is increasing, posing significant financial burden on healthcare systems due to the necessity for frequent medical interventions. Severe acute pancreatitis (SAP) is a potentially life-threatening condition with substantial morbidity and mortality. The management of SAP requires prolonged hospitalization and the expertise of a multidisciplinary team, comprising emergency physicians, intensivists, internists, gastroenterologists, visceral surgeons, and experts in nutrition, infectious disease, endoscopy, as well as diagnostic and interventional radiology. Effective management and beneficial patient outcomes depend on continuous interdisciplinary collaboration. This review synthesizes recent evidence guiding the practical management of SAP, with a particular focus on emergency and intensive care settings. Both established as well as new diagnostic and therapeutic paradigms are highlighted, including workup, risk stratification, fluid management, analgesia, nutrition, organ support, imaging modalities and their timing, along with anti-infective strategies. Furthermore, the review explores interventions for local and vascular complications of SAP, with particular attention to the indications, timing and selection between endoscopic (both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS)), percutaneous and surgical approaches. Similarly, the management of biliary AP due to obstructive gallstones, including the imaging, timing of ERCP and cholecystectomy, are discussed. By integrating new evidence with relevant guidance for everyday clinical practice, this review aims to enhance the interdisciplinary approach essential for improving outcomes in SAP management.
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Affiliation(s)
- Karim Hamesch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Marcus Hollenbach
- Department of Gastroenterology, Endocrinology, Infectious Diseases, University of Marburg UKGM, Marburg, Germany
| | - Lucía Guilabert
- Department of Gastroenterology, Dr. Balmis General University Hospital- Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Tobias Lahmer
- Clinic for Internal Medicine II, Klinikum rechts der Isar der Technischen, University of Munich, Munich, Germany
| | - Alexander Koch
- Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany.
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3
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Guilabert L, Cárdenas-Jaén K, de-Madaria E. Initial Management of Acute Pancreatitis. Gastroenterol Clin North Am 2025; 54:21-36. [PMID: 39880529 DOI: 10.1016/j.gtc.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
Abstract
The initial management of acute pancreatitis (AP) is continually evolving. Goal-directed moderate fluid resuscitation is now preferred over more aggressive strategies. Antibiotics should be administered only when there is a proven or highly probable infection rather than for prophylactic purposes. Urgent endoscopic retrograde cholangiopancreatography would be beneficial for patients with acute cholangitis. Same-admission cholecystectomy for mild biliary PA is safe, efficiently prevents relapse, and is associated with lower costs compared with interval cholecystectomy. Ongoing research into novel pharmacologic treatments and strategies is essential for further advancements in AP management.
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Affiliation(s)
- Lucía Guilabert
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain. https://twitter.com/Lguilabert1
| | - Karina Cárdenas-Jaén
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain. https://twitter.com/KarinaCardenasJ1
| | - Enrique de-Madaria
- Gastroenterology Department, Dr. Balmis General University Hospital, Alicante Institute of Health and Biomedical Research (ISABIAL), Servicio de Aparato Digestivo, 4 planta C, Pintor Baeza 12, 03010, Alicante, Spain; Clinical Medicine Department, Miguel Hernandez University, Campus UMH de Sant Joan, Edificio Francisco Javier Balmis, Carretera Nacional 332 s/n, 03550, San Juan de Alicante, Spain.
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4
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Ockenga J, Fromhold-Treu S, Löser C, Madl C, Martignoni M, Meier R, Rubin D, Schütte K, Stang K, Török HP, Wehle L, Weimann A. S3-Leitlinie Klinische Ernährung bei
Pankreaserkrankungen. AKTUELLE ERNÄHRUNGSMEDIZIN 2024; 49:451-475. [DOI: 10.1055/a-2328-6190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
ZusammenfassungSowohl die akute als auch die chronische Pankreatitis sind häufige Erkrankungen,
die ein erhebliches Risiko für eine Mangelernährung mit sich bringen und eine
Ernährungstherapie erfordern können. In ca. 20% der akuten Pankreatitiden tritt
eine nekrotisierende Pankreatitis auf, die mit einer erhöhten Morbidität und
Mortalität verbunden ist. Hier ist oftmals eine Ernährungstherapie mittels einer
enteralen oder parenteralen Ernährung notwendig, die neben medikamentösen,
endoskopischen, radiologischen oder chirurgischen Maßnahmen eine etablierte
Säule der multimodalen Therapie darstellt.Bei der chronischen Pankreatitis handelt es sich um eine chronische Entzündung
der Bauchspeicheldrüse mit Entwicklung einer Fibrose und langfristig Atrophie
des Organs. Bauchschmerzen, die zu einer verminderten oralen Aufnahme von
Nährstoffen führen, sowie exokrines und endokrines Versagen sind häufige
Komplikationen der Krankheit. All diese Faktoren stellen Risikofaktoren für eine
Unter- bzw. Mangelernährung dar. Daher sollten Patienten mit chronischer
Pankreatitis als ernährungsmedizinische Risikopatienten betrachtet, untersucht
und entsprechend behandelt werden. Darüber hinaus sollte bei Patienten mit
chronischer Pankreatitis auf Osteoporose und ein erhöhtes Frakturrisiko geachtet
werden, und entsprechende Präventivmaßnahmen erwogen werden.
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Affiliation(s)
- Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen-Mitte, Gesundheit Nord gGmbH,
Bremen, Deutschland
| | - Sophie Fromhold-Treu
- Abteilung für Gastroenterologie, Endokrinologie und
Stoffwechselkrankheiten, Zentrum für Innere Medizin, Universitätsmedizin
Rostock, Rostock, Deutschland
| | - Christian Löser
- Medizinische Klinik, DRK-Kliniken Nordhessen, Kassel,
Deutschland
| | - Christian Madl
- Zentrum für Gastroenterologische und Hepatologische Erkrankungen und
Gastrointestinale Endoskopie, Krankenanstalt Rudolfstiftung, Wien,
Österreich
| | - Marc Martignoni
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar,
Technische Universität München, Deutschland
| | - Rémy Meier
- Arztpraxis MagenDarm Basel AG, Basel, Schweiz
| | - Diana Rubin
- Zentrum für Ernährungsmedizin, Vivantes Klinikum Spandau, Berlin,
Deutschland
| | - Kerstin Schütte
- Klinik für Allgemeine Innere Medizin und Gastroenterologie,
Niels-Stensen-Kliniken Marienhospital Osnabrück, Osnabrück,
Deutschland
| | | | - Helga Paula Török
- Medizinische Klinik und Poliklinik II, Campus Innenstadt, Klinikum der
Ludwig-Maximilians-Universität München, München, Deutschland
| | - Lena Wehle
- Deutsche Gesellschaft für Ernährungsmedizin e.V., Berlin,
Deutschland
| | - Arved Weimann
- Abteilung für Allgemein-, Viszeral- und Onkologische Chirurgie,
Klinikum St. Georg gGmbH, Leipzig, Deutschland
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Wang Y, Liu Y, Jiang H, Chen W. Oral nutritional supplements improve clinical outcomes and are cost-effective for hospitalized patients in China. Nutrition 2024; 125:112503. [PMID: 38943697 DOI: 10.1016/j.nut.2024.112503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/20/2024] [Accepted: 05/25/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVE This study assessed the therapeutic benefits and modeled the cost-effectiveness of oral nutritional supplements (ONS) in China. METHODS Data were collected from 27 152 adult inpatients between January 1, 2018, and December 31, 2020. Propensity score matching was used for balancing the baseline characteristics between the ONS group and non-ONS group. A decision-tree model was developed to assess the cost-effectiveness of ONS for patients with nutritional risk, and the incremental cost-effectiveness ratio was the metric to determine the most cost-effective strategy. One-way sensitivity and probabilistic sensitivity analyses were conducted to assess the model's stability. In addition, subgroup analysis was conducted based on clinical characteristics. Differences in clinical outcomes between the groups were compared using Student's t test, Mann-Whitney U test, or chi-square test. RESULTS The ONS group displayed significantly lower levels of prealbumin, albumin, hemoglobin, and BMI than the non-ONS group at admission. The incidence of malignant tumors, intestinal obstruction, and inflammatory bowel disease was significantly higher in the ONS group than the non-ONS group. The ONS group had a significantly higher effective rate than the non-ONS group (51.7% versus 50.3%, P < 0.05). Analysis of the decision-tree model revealed that the ONS group experienced an increase in cost of 19 850.96 yuan but achieved an additional 1.3406 effectiveness rate, resulting in an incremental cost-effectiveness ratio of 14 807.51, which fell below China's 2020 per capita gross domestic product of 71 965 yuan. Sensitivity analysis further confirmed the robustness of the model. CONCLUSIONS ONS are demonstrated a high rate of efficacy, although patients currently using ONS are typically in a severe disease state. In addition, ONS is cost-effective. We suggest that the reimbursement coverage of ONS be expanded to include in-hospital patients who are at high nutritional risk.
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Affiliation(s)
- Yu Wang
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Liu
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Chen
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Bukowski JS, Jamer T, Kowalska-Duplaga K, Marczuk M, Stelmaszczyk-Emmel A, Banasiuk M, Banaszkiewicz A. Very early and early nutrition in children with pancreatitis-A randomised trial. J Pediatr Gastroenterol Nutr 2024; 79:343-351. [PMID: 38938000 DOI: 10.1002/jpn3.12301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVES The aim of our study was to assess the impact of the very early introduction of refeeding on the course of acute pancreatitis (AP) in children. Additionally, we evaluated the effect of nutrition on inflammatory markers, including cytokines. METHODS This prospective randomised study was conducted in three university hospitals in Poland. Patients, aged 1-18 years with AP, were randomised into two groups: A-refeeding within 24 h of hospital admission (very early), and B-refeeding at least 24 h after admission (early nutrition). The severity of AP was assessed after 48 h. The serum concentrations of four cytokines (tumour necrosis factor α [TNFα], interleukin-1β [IL-1β], interleukin-6 [IL-6] and interleukin-8 [IL-8]) and C-reactive protein, as well as the activity of amylase, lipase and aminotransferases, were measured during the first 3 days of hospitalisation. RESULTS A total of 94 children were recruited to participate in the study. The statistical analysis included 75 patients with mild pancreatitis: 42-group A and 33-group B. The two groups did not differ in the length of hospitalisation (p = 0.22), AP symptoms or results of laboratory tests. Analysis of cytokine levels was conducted for 64 children: 38-group A and 26-group B. We did not find a difference in concentrations of the measured cytokines, except for IL-1β on the third day of hospitalisation (p = 0.01). CONCLUSIONS The time of initiation of oral nutrition within 24 h (very early) or after 24 h (early) from the beginning of hospitalisation had no impact on the length of hospitalisation, concentrations of TNF-α, IL-1β, IL-6 and IL-8, activity of amylase and lipase or occurrence of symptoms in children with mild AP.
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Affiliation(s)
- Jan S Bukowski
- Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | - Tatiana Jamer
- Department of Paediatrics, Gastroenterology and Nutrition, Wroclaw Medical University, Wroclaw, Poland
| | - Kinga Kowalska-Duplaga
- Department of Paediatrics, Gastroenterology and Nutrition, Jagiellonian University Medical College, Cracow, Poland
| | - Martyna Marczuk
- Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | - Anna Stelmaszczyk-Emmel
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Banasiuk
- Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Banaszkiewicz
- Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, Warsaw, Poland
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7
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Liang XY, Wu XA, Tian Y, Gao H, Chen JJ, Feng QX. Effects of Early Versus Delayed Feeding in Patients With Acute Pancreatitis: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2024; 58:522-530. [PMID: 37428071 DOI: 10.1097/mcg.0000000000001886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 05/22/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND The aim of this study was to summarize the optimal strategy for early feeding in patients with acute pancreatitis. METHODS The search was undertaken in electronic databases, which compared early with delayed feeding in acute pancreatitis. The primary outcome was the length of hospital stay (LOHS). The second outcomes were intolerance of refeeding, mortality, and total cost of each patient. This meta-analysis followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guideline. Research is registered by PROSPERO, CRD42020192133. RESULTS A total of 20 trials involving 2168 patients were included, randomly assigned to the early feeding group (N = 1033) and delayed feeding group (N = 1135). The LOHS was significantly lower in the early feeding group than the delayed feeding group (mean difference: -2.35, 95% CI: -2.89 to -1.80; P < 0.0001), no matter the mild or severe subgroup ( Pint = 0.69). The secondary outcome of feeding intolerance and mortality were no significant difference (risk ratio: 0.96, 0.40 to 2.16, P = 0.87 and 0.91, 0.57 to 1.46, P = 0.69; respectively). Moreover, the hospitalization cost was significantly less in the early feeding group, resulting in an average savings of 50%. In patients with severe pancreatitis, early feeding after 24 hours may be beneficial ( Pint = 0.001). CONCLUSION Early oral feeding can significantly reduce the LOHS and hospitalization costs in patients with acute pancreatitis without increasing feeding intolerance or mortality. In patients with severe pancreatitis, early feeding after 24 hours may be beneficial.
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Affiliation(s)
- Xi-Ying Liang
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | - Xin-An Wu
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | - Ying Tian
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | - Hang Gao
- Pancreatic Disease Center, Xi'an Peoples Hospital
| | | | - Quan-Xin Feng
- Pancreatic Disease Center, Xi'an Peoples Hospital
- Intensive Care Unit of Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaaxi, China
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8
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Kothari DJ, Sheth SG. Innovative pathways allow safe discharge of mild acute pancreatitis from the emergency room. World J Gastroenterol 2024; 30:1475-1479. [PMID: 38617458 PMCID: PMC11008414 DOI: 10.3748/wjg.v30.i11.1475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/22/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024] Open
Abstract
Acute pancreatitis (AP) is a leading cause of gastrointestinal-related hospitalizations in the United States, resulting in 300000 admissions per year with an estimated cost of over $2.6 billion annually. The severity of AP is determined by the presence of pancreatic complications and end-organ damage. While moderate/severe pancreatitis can be associated with significant morbidity and mortality, the majority of patients have a mild presentation with an uncomplicated course and mortality rate of less than 2%. Despite favorable outcomes, the majority of mild AP patients are admitted, contributing to healthcare cost and burden. In this Editorial we review the performance of an emergency department (ED) pathway for patients with mild AP at a tertiary care center with the goal of reducing hospitalizations, resource utilization, and costs after several years of implementation of the pathway. We discuss the clinical course and outcomes of mild AP patients enrolled in the pathway who were successfully discharged from the ED compared to those who were admitted to the hospital, and identify predictors of successful ED discharge to select patients who can potentially be triaged to the pathway. We conclude that by implementing innovative clinical pathways which are established and reproducible, selected AP patients can be safely discharged from the ED, reducing hospitalizations and healthcare costs, without compromising clinical outcomes. We also identify a subset of patients most likely to succeed in this pathway.
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Affiliation(s)
- Darshan J Kothari
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, United States
| | - Sunil G Sheth
- Division of Gastroenterology & Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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9
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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10
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Cúrdia Gonçalves T, Capela TL, Cotter J. Nutrition in Pancreatic Diseases: A Roadmap for the Gastroenterologist. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:1-13. [PMID: 38314032 PMCID: PMC10836866 DOI: 10.1159/000530835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/12/2023] [Indexed: 02/06/2024]
Abstract
While common pancreatic diseases, such as acute pancreatitis (AP), chronic pancreatitis (CP), and pancreatic cancer (PC), may greatly impact the normal pancreatic physiology and contribute to malnutrition, the adequate nutritional approach when those conditions are present significantly influences patients' prognosis. In patients with AP, the goals of nutritional care are to prevent malnutrition, correct a negative nitrogen balance, reduce inflammation, and improve outcomes such as local and systemic complications and mortality. Malnutrition in patients with CP is common but often a late manifestation of the disease, leading to decreased functional capacity and quality of life and increased risk of developing significant osteopathy, postoperative complications, hospitalization, and mortality. Cancer-related malnutrition is common in patients with PC, and it is now well recognized that early nutritional support can favorably impact survival, not only by increasing tolerance and response to disease treatments but also by improving quality of life and decreasing postoperative complications. The aim of this review was to emphasize the role of nutrition and to propose a systematic nutritional approach in patients with AP, CP, and PC.
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Affiliation(s)
- Tiago Cúrdia Gonçalves
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - Tiago Lima Capela
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
| | - José Cotter
- Gastroenterology Department, Hospital da Senhora da Oliveira – Guimarães, Guimarães, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B’s, PT Government Associate Laboratory, Guimarães/Braga, Portugal
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11
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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2024; 43:395-412. [PMID: 38169174 DOI: 10.1016/j.clnu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, HUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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12
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Chowdhury AR, Chang P, Zhou S, Das R, Xu M, Kim JS, Narala R, Sadik J, Shulman I, Buxbaum J. Optimal initial diet in mild acute pancreatitis: A comprehensive meta-analysis of randomized control trials. Pancreatology 2022; 22:858-863. [PMID: 35989218 DOI: 10.1016/j.pan.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/30/2022] [Accepted: 07/31/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We performed a comprehensive systematic review and meta-analysis comparing initiation of full solid diet (FSD) versus stepwise diet to better define the management of patients with mild acute pancreatitis (AP). METHODS Electronic databases were searched through August 2, 2021 for trials comparing initial FSD versus stepwise advancement in patients with mild AP on length of hospital stay (LOHS). We stratified by whether diet was initiated early (within 24 h or immediately upon presence of bowel sounds). RESULTS We identified seven RCTs that compared LOHS in AP patients who received initial oral intake with solid diet versus stepwise diet. Across the studies a total of 305 patients were randomized to immediate FSD and 308 patients to sequential advancement. Patients who were initiated on a FSD had a significant reduction in total LOHS (Standardized Mean Difference (SMD) -0.52 [95% CI -0.69, -0.36]). There was no difference in post refeeding abdominal pain, tolerance of diet, or necessity to cease diet between the two groups. Sub-analysis of three studies that initiated FSD early reduced total LOHS (OR -0.95 [95% CI -1.26, -0.65]) compared to those who received graded diet advancement as well as higher likelihood of tolerating the assigned diet (OR 6.8 [95% CI 1.2, 39.2]). CONCLUSIONS Our meta-analysis shows that initiation of FSD reduces total LOHS in patients with mild AP and does not increase post refeeding abdominal pain. Though additional high-quality studies are needed, these findings support initial solid diet for AP and consideration of feeding within the first 24 h.
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Affiliation(s)
- Aneesa R Chowdhury
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Patrick Chang
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Selena Zhou
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Rishi Das
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Mimi Xu
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Jin Sun Kim
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Rachan Narala
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Jonathan Sadik
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA
| | - Ira Shulman
- Department of Pathology, University of Southern California, USA
| | - James Buxbaum
- Division of Gastrointestinal and Liver Diseases, University of Southern California, USA.
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13
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Cañamares-Orbís P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients 2022; 14:4570. [PMID: 36364832 PMCID: PMC9656643 DOI: 10.3390/nu14214570] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/23/2022] [Accepted: 10/24/2022] [Indexed: 08/13/2023] Open
Abstract
This review summarizes the main pancreatic diseases from a nutritional approach. Nutrition is a cornerstone of pancreatic disease and is sometimes undervalued. An early identification of malnutrition is the first step in maintaining an adequate nutritional status in acute pancreatitis, chronic pancreatitis and pancreatic cancer. Following a proper diet is a pillar in the treatment of pancreatic diseases and, often, nutritional counseling becomes essential. In addition, some patients will require oral nutritional supplements and fat-soluble vitamins to combat certain deficiencies. Other patients will require enteral nutrition by nasoenteric tube or total parenteral nutrition in order to maintain the requirements, depending on the pathology and its consequences. Pancreatic exocrine insufficiency, defined as a significant decrease in pancreatic enzymes or bicarbonate until the digestive function is impaired, is common in pancreatic diseases and is the main cause of malnutrition. Pancreatic enzymes therapy allows for the management of these patients. Nutrition can improve the nutritional status and quality of life of these patients and may even improve life expectancy in patients with pancreatic cancer. For this reason, nutrition must maintain the importance it deserves.
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Affiliation(s)
- Pablo Cañamares-Orbís
- Gastroenterology, Hepatology and Nutrition Unit, San Jorge University Hospital, Martínez de Velasco Avenue 36, 22004 Huesca, Spain
| | - Guillermo García-Rayado
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
| | - Enrique Alfaro-Almajano
- Digestive Disease Department, Lozano Blesa University Clinic Hospital, San Juan Bosco Avenue 15, 50009 Zaragoza, Spain
- Aragón Health Research Institute (IIS Aragón), San Juan Bosco Avenue 13, 50009 Zaragoza, Spain
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14
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Takada T, Isaji S, Mayumi T, Yoshida M, Takeyama Y, Itoi T, Sano K, Iizawa Y, Masamune A, Hirota M, Okamoto K, Inoue D, Kitamura N, Mori Y, Mukai S, Kiriyama S, Shirai K, Tsuchiya A, Higuchi R, Hirashita T. JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:1057-1083. [PMID: 35388634 DOI: 10.1002/jhbp.1146] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/02/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan. METHOD In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. RESULTS Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Based on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced computed tomography (CT) grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which were shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 h of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics are administered in mild pancreatitis. CONCLUSION All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.
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Affiliation(s)
- Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shuji Isaji
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Masahiro Yoshida
- Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, School of Medicine, International University of Health & Welfare, Chiba, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Keiji Sano
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Iizawa
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Chiba, Japan
| | - Yasuhisa Mori
- Department of Surgery I, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Kunihiro Shirai
- Department of Emergency, Disaster and Critical Care Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Asuka Tsuchiya
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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15
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Bukowski JS, Dembiński Ł, Dziekiewicz M, Banaszkiewicz A. Early Enteral Nutrition in Paediatric Acute Pancreatitis-A Review of Published Studies. Nutrients 2022; 14:3441. [PMID: 36014947 PMCID: PMC9416066 DOI: 10.3390/nu14163441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Nowadays, nutrition is said to be an integral aspect of acute pancreatitis (AP) treatment. Early enteral nutrition (EEN) is safe and beneficial for patients. This was confirmed by clinical experience and can be found in guidelines on managing adults with AP. Furthermore, paediatric recommendations encourage EEN use in AP. However, paediatric guidelines are based exclusively on studies in adults. Therefore, we present a review of published studies on the time of nutritional interventions in children with AP. A search was independently conducted in April 2022 by two of the authors. Only full-text papers published in English involving children between 0-21 were considered. Only four papers met our inclusion criteria: one randomised-control trial (RCT), one prospective study with retrospective chart review, and two retrospective chart reviews. All studies supported EEN and there was no recommendation of any delay in its initiation. The results of all four papers suggested EEN with a regular, normal-fat diet. EEN is safe in children with mild or moderately severe AP and may decrease the length of hospitalisation. Unfortunately, all the conclusions are based on a small amount of heterogeneous data that are mostly retrospective. Future prospective RCTs are needed.
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Affiliation(s)
- Jan Stanisław Bukowski
- Department of Paediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warszawa, Poland
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16
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Soti Khiabani M, Mohammadi MS, Ghoreyshi SA, Rohani P, Alimadad H, Sohoul MH. Acute pancreatitis in 60 Iranian children: do pediatricians follow the new guidelines in diagnosis and management of acute pancreatitis? BMC Pediatr 2022; 22:457. [PMID: 35906562 PMCID: PMC9336120 DOI: 10.1186/s12887-022-03509-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/20/2022] [Indexed: 01/22/2023] Open
Abstract
Background The incidence of acute pancreatitis in children is increasing, but causes and diagnostic and therapeutic methods are various in different centers. The aim of this study was to investigate the common causes and routine diagnostic and therapeutic methods of acute pancreatitis in children in a pediatric gastrointestinal referral center and its accordance with existing guidelines. Methods In this retrospective, cross-sectional study, a total of 60 children with a diagnosis of acute pancreatitis, were studied. Results The most common causes of acute pancreatitis were systemic and metabolic diseases and medications. CT scan was performed for 36% of patients, but 31% of patients, for whom a CT scan was performed had no clear indication of CT scan. Only half of the patients received fluid 1.5 times their maintenance in the first 24 h. Antibiotic therapy was performed for 48% of patients but medical indications for antibiotic treatment were found in only 34% of cases. During the COVID-19 pandemic, the relative incidence of acute pancreatitis was increased. Conclusions In children with systemic and metabolic disease and using anticonvulsant drugs, it is important to consider the incidence of this disease. In clinical education, the risks of radiation due to unnecessary CT scans and inappropriate prescription of antibiotics need to be emphasized. More research should be done to study the association between COVID-19 and acute pancreatitis.
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Affiliation(s)
- Mahsa Soti Khiabani
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran.,Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahya Sadat Mohammadi
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran.,Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Pejman Rohani
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hosein Alimadad
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran. .,Children's Medical Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Hassan Sohoul
- Pediatric Gastroenterology and Hepatology Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Student Research Committee, Department of Clinical Nutrition and Dietetics, Faculty of Nutrition and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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17
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Valverde-López F, Martínez-Cara JG, Redondo-Cerezo E. Acute pancreatitis. Med Clin (Barc) 2022; 158:556-563. [PMID: 35277268 DOI: 10.1016/j.medcli.2021.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 12/26/2021] [Accepted: 12/29/2021] [Indexed: 12/15/2022]
Abstract
Acute pancreatitis is nowadays one of the most common diseases among gastroenterology disorders, being gallstones and alcohol the main etiologies. Diagnostic criteria and indications of different imaging techniques are well defined, so that abdominal ultrasound is useful for etiological diagnosis whereas computarized tomography is better for risk stratification and local complications assessment. Goal directed fludtherapy, early starting of oral feeding and pain management are the mainstay of early treatment in acute pancreatitis. Antibiotics are useful when infected necrosis or extra pancreatic infections are documented or suspected but no as prophylaxis in sterile necrotizing pancreatitis. Minimally invasive approaches have emerged in the last decade for walled off necrosis management, improving complication rates, quality of life and length of hospital stay when compared with open surgery.
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Affiliation(s)
| | | | - Eduardo Redondo-Cerezo
- Servicio de Aparato Digestivo. Hospital Universitario Virgen de las Nieves, Granada, España
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18
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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19
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Effects of immediate or early oral feeding on acute pancreatitis: A systematic review and meta-analysis. Pancreatology 2022; 22:175-184. [PMID: 34876385 DOI: 10.1016/j.pan.2021.11.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The timing of oral refeeding can affect length of stay (LOS) and recovery of acute pancreatitis (AP). However, the optimal timing for oral refeeding is still controversial for AP. This meta-analysis investigated the effects of immediate or early versus delayed oral feeding on mild and moderate AP, regardless of improvement in clinical signs or laboratory indicators. METHODS This systematic review and meta-analysis of randomized controlled trials (RCTs) based on data from Embase, Cochrane Library, PubMed, Web of science, and CBM before August 2021. Two researchers independently used Stata16 to extract and analyse study data. Random effect model was performed for meta-analysis to calculate the risk ratio (RR) and standardized mean difference (SMD). RESULTS 8 RCTs were selected, including 748 patients with mild to moderate AP. Patients in IOR (Immediate or early Oral Refeeding) group had less costs [SMD -0.83, 95%CI (-1.17, -0.5), P < 0.001] and shorter LOS [SMD -1.01, 95%CI (-1.17, -0.85), P < 0.001] than the DOR (Delayed Oral Refeeding) group patients. However, there was no difference in mortality [RR 0.54, 95%CI (0.11, 2.62), P = 0.44], pain relapse rate [RR 0.58, 95%CI (0.25, 1.35), P = 0.27], feeding intolerance rate [RR 0.61, 95%CI (0.28, 1.3), P = 0.2], AP progression rate [RR 0.21, 95%CI (0.04, 1.07), P = 0.06] and overall complications rate [RR 0.41, 95%CI (0.17, 1.01), P = 0.05] between the IOR and DOR groups. CONCLUSIONS Limited data suggest that IOR could reduce LOS and costs without increasing adverse events in mild to moderate AP.
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20
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Koretz RL. JPEN Journal Club 68. Type I errors. JPEN J Parenter Enteral Nutr 2022; 46:1736-1738. [DOI: 10.1002/jpen.2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Ronald L. Koretz
- Emeritus Professor of Clinical Medicine, Olive View‐UCLA Medical Center, UCLA School of Medicine, Sylmar and Los Angeles California
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21
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Rai A, Anandhi A, Sureshkumar S, Kate V. Hunger-Based Versus Conventional Oral Feeding in Moderate and Severe Acute Pancreatitis: A Randomized Controlled Trial. Dig Dis Sci 2022; 67:2535-2542. [PMID: 33939143 PMCID: PMC8090517 DOI: 10.1007/s10620-021-06992-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/07/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The length of hospitalization is prolonged in patients with acute pancreatitis due to delay in feeding. The present study aimed at evaluating hunger-based early feeding for its efficacy in reducing length of hospitalisation. AIMS AND METHODS This was a parallel arm superiority randomized control trial. Patients with moderate and severe acute pancreatitis were randomised into hunger-based feeding and conventional feeding groups. Patients in hunger-based feeding group commenced feeding once they felt hungry and in conventional feeding group after normalization of biochemical parameters and resolution of symptoms. Patients were followed up till their discharge and were analyzed for length of hospitalisation, fasting duration, feed intolerance, incidence of infective morbidities and invasive procedures. RESULTS Hunger-based feeding and conventional feeding group included 56 and 54 patients, respectively. Hunger-based feeding led to a decrease in length of hospitalization (6.3 days in hunger-based feeding vs 7.3 days in conventional feeding group, P = 0.041) and fasting duration (1.6 days in hunger-based feeding vs 2.7 days in conventional feeding group, P = 0.001).The incidence of feed intolerance (P = 0.098), infective morbidities and invasive non-surgical procedures were similar in both the groups. CONCLUSION Hunger-based feeding significantly reduces length of hospitalization and fasting duration in cases of moderate and severe acute pancreatitis without any significant rise in the incidence of complications. Registration number of Clinical Trails Registry India CTRI/2019/01/017,144.
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Affiliation(s)
- Ashwin Rai
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Amaranathan Anandhi
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Sathasivam Sureshkumar
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
| | - Vikram Kate
- grid.414953.e0000000417678301Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, 605006 India
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22
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Thibault R, Abbasoglu O, Ioannou E, Meija L, Ottens-Oussoren K, Pichard C, Rothenberg E, Rubin D, Siljamäki-Ojansuu U, Vaillant MF, Bischoff SC. ESPEN guideline on hospital nutrition. Clin Nutr 2021; 40:5684-5709. [PMID: 34742138 DOI: 10.1016/j.clnu.2021.09.039] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 12/16/2022]
Abstract
In hospitals through Europe and worldwide, the practices regarding hospital diets are very heterogeneous. Hospital diets are rarely prescribed by physicians, and sometimes the choices of diets are based on arbitrary reasons. Often prescriptions are made independently from the evaluation of nutritional status, and without taking into account the nutritional status. Therapeutic diets (low salt, gluten-free, texture and consistency modified, …) are associated with decreased energy delivery (i.e. underfeeding) and increased risk of malnutrition. The European Society for Clinical Nutrition and Metabolism (ESPEN) proposes here evidence-based recommendations regarding the organization of food catering, the prescriptions and indications of diets, as well as monitoring of food intake at hospital, rehabilitation center, and nursing home, all of these by taking into account the patient perspectives. We propose a systematic approach to adapt the hospital food to the nutritional status and potential food allergy or intolerances. Particular conditions such as patients with dysphagia, older patients, gastrointestinal diseases, abdominal surgery, diabetes, and obesity, are discussed to guide the practitioner toward the best evidence based therapy. The terminology of the different useful diets is defined. The general objectives are to increase the awareness of physicians, dietitians, nurses, kitchen managers, and stakeholders towards the pivotal role of hospital food in hospital care, to contribute to patient safety within nutritional care, to improve coverage of nutritional needs by hospital food, and reduce the risk of malnutrition and its related complications.
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Affiliation(s)
- Ronan Thibault
- Unité de Nutrition, CHU Rennes, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer Institute, NuMeCan, Rennes, France.
| | - Osman Abbasoglu
- Department of Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elina Ioannou
- Department of Nutrition, Limassol General Hospital, Cyprus
| | - Laila Meija
- Riga Stradins University, Pauls Stradins Clinical University Hospital, Latvia
| | - Karen Ottens-Oussoren
- Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Claude Pichard
- Unité de Nutrition, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabet Rothenberg
- Faculty of Health Sciences Kristianstad University Kristianstad Sweden, Sweden
| | - Diana Rubin
- Vivantes Netzwerk für Gesundheit GmbH, Humboldt Klinikum und Klinikum Spandau, Berlin, Germany
| | | | | | - Stephan C Bischoff
- University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany
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23
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Schorn S, Demir IE, Friess H. [Treatment of acute pancreatitis from the viewpoint of surgery]. Chirurg 2021; 93:913-922. [PMID: 34783867 DOI: 10.1007/s00104-021-01532-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 10/19/2022]
Abstract
The role of surgery in the treatment of acute pancreatitis has clearly changed over the years. In the 1990s a clear reduction in hospital mortality was achieved through surgery, whereas the value of surgery (open, in general) has slipped into the background due to the improvement in intensive care medicine in general and the development of minimally invasive treatment options. Nowadays, patients with acute pancreatitis are only operated on after exhaustion of intensive medical care treatment and minimally invasive interventions or when complications occur that cannot be treated in any other way (e.g. hollow organ perforation). This article provides an overview of the currently used treatment measures.
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Affiliation(s)
| | | | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Medizinische Fakultät, Technische Universität München, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, München, Deutschland.
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24
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Ramírez-Maldonado E, López Gordo S, Pueyo EM, Sánchez-García A, Mayol S, González S, Elvira J, Memba R, Fondevila C, Jorba R. Immediate Oral Refeeding in Patients With Mild and Moderate Acute Pancreatitis: A Multicenter, Randomized Controlled Trial (PADI trial). Ann Surg 2021; 274:255-263. [PMID: 33196485 DOI: 10.1097/sla.0000000000004596] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To establish the optimal time to start oral refeeding in mild and moderate acute pancreatitis (AP) to reduce hospital length-of-stay (LOS) and complications. SUMMARY BACKGROUND DATA Oral diet is essential in mild and moderate AP. The greatest benefits are obtained if refeeding starts early; however, the definition of "early" remains controversial. METHODS This multicenter, randomized, controlled trial (NCT03829085) included patients with a diagnosis of mild or moderate AP admitted consecutively to 4 hospitals from 2017 to 2019. Patients were randomized into 2 treatment groups: immediate oral refeeding (IORF) and conventional oral refeeding (CORF). The IORF group (low-fat-solid diet initiated immediately after hospital admission) was compared to CORF group (progressive oral diet was restarted when clinical and laboratory parameters had improved) in terms of LOS (primary endpoint), pain relapse, diet intolerance, complications, and, hospital costs. RESULTS One hundred and thirty one patients were included for randomization. The mean LOS for the IORF and CORF groups was 3.4 (SD ± 1.7) and 8.8 (SD ± 7.9) days, respectively (P < 0.001). In the CORF group alone, pain relapse rate was 16%. There were fewer complications (8% vs 26%) and health costs were twice as low, with a savings of 1325.7€/patient in the IORF than CORF group. CONCLUSIONS IORF is safe and feasible in mild and moderate AP, resulting in significantly shorter LOS and cost savings, without causing adverse effects or complications.
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Affiliation(s)
- Elena Ramírez-Maldonado
- General and Digestive Surgery Department, Consorci Sanitari Garraf, Sant Pere de Ribes, Barcelona, Spain
- General and Digestive Surgery Department, Hospital Clínic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Sandra López Gordo
- General and Digestive Surgery Department, Consorci Sanitari Garraf, Sant Pere de Ribes, Barcelona, Spain
| | - Eva M Pueyo
- General and Digestive Surgery Department, Moisès Broggi Hospital, CSI, Barcelona, Spain
| | - Ariadna Sánchez-García
- Gastroenterology Department, Hospital Clinic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Susana Mayol
- General and Digestive Surgery Department, Consorci Sanitari Garraf, Sant Pere de Ribes, Barcelona, Spain
| | - Sergio González
- General and Digestive Surgery Department, Moisès Broggi Hospital, CSI, Barcelona, Spain
| | - Jordi Elvira
- General and Digestive Surgery Department, University Hospital of Tarragona Joan XXIII, Rovira i Virgili University, Tarragona, Spain
| | - Robert Memba
- General and Digestive Surgery Department, University Hospital of Tarragona Joan XXIII, Rovira i Virgili University, Tarragona, Spain
| | - Constantino Fondevila
- General and Digestive Surgery Department, Hospital Clínic, IDIBAPS, CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Rosa Jorba
- General and Digestive Surgery Department, University Hospital of Tarragona Joan XXIII, Rovira i Virgili University, Tarragona, Spain
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25
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Yang AL. Nutrition and Acute Pancreatitis. J Clin Med 2021; 10:jcm10040836. [PMID: 33670647 PMCID: PMC7922255 DOI: 10.3390/jcm10040836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/12/2022] Open
Abstract
Acute pancreatitis (AP) is an acute inflammatory process of the pancreas that is characterized by severe abdominal pain, elevated pancreatic enzymes, and pancreatic changes on abdominal imaging. AP is, by nature, an inflammatory process that leads to protein catabolism and an increased metabolic rate, highlighting the strong need for early nutritional support in the initial management of the disease process. The goal of nutritional support in acute pancreatitis is to correct the negative nitrogen balance to reduce inflammation and improve outcomes. Many trials and multiple systemic reviews and meta-analyses have examined the best modality, timing, and composition of nutritional support for acute pancreatitis. Early enteral nutrition has emerged as an important aspect of the clinical management of AP. This narrative review aimed to provide an overview of the clinical management of nutrition in acute pancreatitis based on the currently available data.
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Affiliation(s)
- Allison L Yang
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY 10065, USA
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26
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Pothoulakis I, Nawaz H, Paragomi P, Jeong K, Talukdar R, Kochhar R, Goenka MK, Gulla A, Singh VK, Gonzalez JA, Ferreira M, Barbu ST, Stevens T, Gutierrez SC, Zarnescu NO, Capurso G, Easler J, Triantafyllou K, Pelaez‐Luna M, Thakkar S, Ocampo C, de‐Madaria E, Wu BU, Cote GA, Abebe K, Tang G, Lahooti A, Phillips AE, Papachristou GI. Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study. United European Gastroenterol J 2021; 9:54-62. [PMID: 32883182 PMCID: PMC8259260 DOI: 10.1177/2050640620957243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/06/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied. OBJECTIVE We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis. METHODS Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance. RESULTS Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83-5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01-2.69) were independent risk factors for oral feeding intolerance. CONCLUSION Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.
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Affiliation(s)
- Ioannis Pothoulakis
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
- Department of MedicineMedStar Washington Hospital CenterWashingtonDistrict of ColumbiaUSA
| | - Haq Nawaz
- Department of GastroenterologyEastern Maine Medical CenterBangorMaineUSA
| | - Pedram Paragomi
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Kwonho Jeong
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Rupjyoti Talukdar
- Department of GastroenterologyAsian Gastroenterology InstituteHyderabadIndia
| | - Rakesh Kochhar
- Department of GastroenterologyPostgraduate Institute of Medical Education and ResearchChandigarhIndia
| | | | - Aiste Gulla
- Department of GastroenterologyGeorgetown University HospitalWashingtonDistrict of ColumbiaUSA
- Department of MedicineInstitute of Clinical MedicineVilnius UniversityVilniusLithuania
| | - Vikesh K. Singh
- Department of GastroenterologyJohn Hopkins Medical InstitutionBaltimoreMarylandUSA
| | - Jose A. Gonzalez
- Department of GastroenterologyUniversidad Autonoma de Nueva LeónMonterreyMexico
| | - Miguel Ferreira
- Department of GastroenterologyHospital Nacional de ItaguáItaguaParaguay
| | - Sorin T. Barbu
- Department of SurgeryUniversity of Medicine and Pharmacy “Iuliu Hatieganu”Cluj‐NapocaRomania
| | - Tyler Stevens
- Department of GastroenterologyCleveland Clinic FoundationClevelandOhioUSA
| | - Silvia C. Gutierrez
- Department of GastroenterologyHospital Nacional “Profesor Alejandro Posadas”Buenos AiresArgentina
| | - Narcis O. Zarnescu
- Department of GastroenterologyUniversity Emergency HospitalCarol Davila University of Medicine and PharmacyBucharestRomania
| | - Gabriele Capurso
- Pancreato‐Biliary Endoscopy and Endosonography DivisionPancreas Translational and Clinical Research CenterSan Raffaele Scientific Institute IRCCSMilanItaly
| | - Jeffrey Easler
- Department of GastroenterologyIndiana University School of MedicineIndianapolisIndianaUSA
| | | | - Mario Pelaez‐Luna
- Department of GastroenterologyInstituto Nacional de Ciencias Módicas y Nutrición Salvador Zubirán‐Universidad Autonoma d MexicoMexico CityMexico
| | - Shyam Thakkar
- Department of GastroenterologyAllegheny General HospitalPittsburghPennsylvaniaUSA
| | - Carlos Ocampo
- Department of SurgeryHospital General de Argudos “Dr. Cosme Argerich”Buenos AiresArgentina
| | - Enrique de‐Madaria
- Gastroenterology DepartmentAlicante University General HospitalAlicante Institute for Health and Biomedical Research (ISABIAL)AlicanteSpain
| | - Bechien U. Wu
- Department of GastroenterologyKaiser PermanentePasadenaCaliforniaUSA
| | - Gregory A. Cote
- Department of GastroenterologyMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Kaleab Abebe
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Gong Tang
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Ali Lahooti
- Department of GastroenterologyOhio State University Wexner Medical CenterColumbusOhioUSA
| | - Anna E. Phillips
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
| | - Georgios I. Papachristou
- Department of GastroenterologyUniversity of Pittsburgh Medical CenterPittsburghPennsylvaniaUSA
- Department of GastroenterologyOhio State University Wexner Medical CenterColumbusOhioUSA
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27
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Ledder O, Duvoisin G, Lekar M, Lopez RN, Singh H, Dehlsen K, Lev-Tzion R, Orlanski-Meyer E, Shteyer E, Krishnan U, Gupta N, Lemberg DA, Cohen S, Ooi CY. Early Feeding in Acute Pancreatitis in Children: A Randomized Controlled Trial. Pediatrics 2020; 146:peds.2020-1149. [PMID: 32788268 DOI: 10.1542/peds.2020-1149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Studies have increasingly challenged the traditional management of acute pancreatitis (AP) with bowel rest. However, these studies used a low-fat diet or transgastric feeding and only included adults. Aiming to generate higher-quality prospective pediatric data, we compared the traditional approach of fasting and intravenous fluids and early enteral feeding with standard diet or formula. METHODS Randomized controlled trial of children (2-18 years) with mild-moderate AP. Patients were randomly assigned 1:1 to initial fasting and intravenous fluids or an immediate, unrestricted diet. Pain scores, blood measures, and cross-sectional imaging were recorded throughout admission and follow-up. The primary outcome was time to discharge, and secondary outcomes were clinical and biochemical resolution and local and systemic complication rates. RESULTS Of 33 patients (17 [52%] boys, mean age of 11.5 [±4.8] years), 18 (55%) were randomly assigned to early feeding and 15 (45%) were randomly assigned to initial fasting. We recorded the median (interquartile range [IQR]) time to discharge (2.6 [IQR 2.0 to 4.0] vs 2.9 [IQR 1.8 to 5.6]; P = .95), reduction in serum lipase levels by day 2 (58% [IQR 2% to 85%] vs 48% [IQR 3% to 71%]; P = .65), and readmission rates (1 of 18 [6%] vs 2 of 15 [13%]; P = .22) between the early feeding and fasting cohorts, respectively. Immediate or delayed complication rates did not differ. Patients randomly assigned to early feeding had weight gain of 1.3 kg (IQR 0.29 to 3.6) at follow-up, compared with weight loss of 0.8 kg (IQR -2.1 to 0.7) in fasted patients (P = .028). CONCLUSIONS This is the first randomized controlled trial in pediatric AP. There was no difference between early commencement of a standard oral diet and initial fast in any of the major outcome measures.
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Affiliation(s)
- Oren Ledder
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel; .,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Giles Duvoisin
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia
| | - Marina Lekar
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Robert N Lopez
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia
| | - Harveen Singh
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia
| | - Kate Dehlsen
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia
| | - Raffi Lev-Tzion
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Esther Orlanski-Meyer
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Eyal Shteyer
- Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Nitin Gupta
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Daniel A Lemberg
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Shlomi Cohen
- Department of Paediatric Gastroenterology, Dana-Dwek Children's Hospital, Tel Aviv, Israel; and.,School of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chee Y Ooi
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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28
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Lozada-Hernández EE, Barrón-González O, Vázquez-Romero S, Cano-Rosas M, Apolinar-Jimenez E. Non-inferiority comparative clinical trial between early oral REFEEDING and usual oral REFEEDING in predicted mild acute biliary pancreatitis. BMC Gastroenterol 2020; 20:228. [PMID: 32677891 PMCID: PMC7364543 DOI: 10.1186/s12876-020-01363-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 07/02/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The aim of the study was to compare the onset of oral feeding in the first 24 h after hospital admission with usual oral refeeding and determine whether the timing of the onset of oral feeding influences the recurrence of pain or alters the blood levels of pancreatic enzymes in patients with predicted mild acute biliary pancreatitis. METHODS This non-inferiority randomized controlled trial was carried out between September 2018 and June 2019 after receiving authorization from the ethics committee for health research. Patients with a diagnosis of predicted mild acute biliary pancreatitis were divided into Group A (early oral refeeding, EOR) and Group B (usual oral refeeding, UOR). Outcome measures included pancreatic lipase levels, the systemic inflammatory response (concentrations of leukocytes), feasibility (evaluated by abdominal pain recurrence), the presence and recurrence of gastrointestinal symptoms and the length of hospital stay. RESULTS Two patients in the EOR group experienced pain relapse (3.2%), and four patients in the UOR group experienced pain relapse (6.77%) after oral refeeding (p = 0.379). The presence of nausea or vomiting after the onset of oral refeeding was not different between the two groups (p = 0.293). The onset of oral refeeding was approximately 48 h later in the UOR group. The length of hospital stay was 5 days in the EOR group and 8 days in the UOR group (p = 0.042), and this difference was also manifested in higher hospital costs in the UOR group (p = 0.0235). CONCLUSION Compared with usual oral refeeding, early oral refeeding is safe in predicted mild acute biliary pancreatitis patients, does not cause adverse gastrointestinal events, and reduces the length of hospital stay and costs. TRIAL REGISTRATION Early oral refeeding in mild acute pancreatitis (EORVsUOR). NCT04168801 , retrospectively registered (November 19, 2019).
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Affiliation(s)
- Edgard Efrén Lozada-Hernández
- Department of Surgery and Clinical Research, Hospital Regional de Alta Especialidad del Bajío, Circuito Quinta los Naranjos # 145 B. Colonia Quinta los Naranjos, León, Guanajuato, Mexico.
| | - Omar Barrón-González
- Department of Surgery, Unidad Médica de Alta Especialidad Bajío, Instituto Mexicano del Seguro Social, León, Guanajuato, Mexico
| | - Santa Vázquez-Romero
- Department of Surgery, Unidad Médica de Alta Especialidad Bajío, Instituto Mexicano del Seguro Social, León, Guanajuato, Mexico
| | - Martin Cano-Rosas
- Department of Surgery, Unidad Médica de Alta Especialidad Bajío, Instituto Mexicano del Seguro Social, León, Guanajuato, Mexico
| | - Evelia Apolinar-Jimenez
- Department of Clinical Nutrition, Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, Mexico
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29
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Efficacy and safety of immediate oral intake in patients with mild acute pancreatitis: A randomized controlled trial. Nutrition 2020; 74:110724. [DOI: 10.1016/j.nut.2020.110724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 12/12/2019] [Accepted: 01/04/2020] [Indexed: 12/14/2022]
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30
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Lakananurak N, Gramlich L. Nutrition management in acute pancreatitis: Clinical practice consideration. World J Clin Cases 2020; 8:1561-1573. [PMID: 32432134 PMCID: PMC7211526 DOI: 10.12998/wjcc.v8.i9.1561] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/07/2020] [Accepted: 04/21/2020] [Indexed: 02/05/2023] Open
Abstract
Acute pancreatitis (AP) is a common gastrointestinal disease and the leading cause of hospital admission and healthcare burden among gastrointestinal disorders in many countries. Patients can present with varying degrees of inflammation and disease severity, ranging from self-limiting mild AP to devastating and fatal severe AP. Many factors contribute to malnutrition in AP, especially abnormal metabolism and catabolism related to inflammation. The concept of "pancreatic rest" is not evidence-based. There is however, emerging evidence that supports the use of oral or enteral nutrition to improve nutrition status and to reduce local and systemic inflammation, complications, and death. In mild disease, patients are generally able to initiate solid oral diet and do not require specialized nutrition care such as enteral or parenteral nutrition. In contrast, nutrition interventions are imperative in moderately severe and severe AP. The current article aims to review the latest evidence and suggest practical nutrition interventions in patients with AP, including nutrition requirements, routes of nutrition treatment, types of formula, and the role of nutritional supplements, such as glutamine, probiotics, omega-3 fatty acids, and antioxidants.
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Affiliation(s)
- Narisorn Lakananurak
- Department of Medicine, University of Alberta, Edmonton T6G 2R3, Alberta, Canada
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton T6G 2R3, Alberta, Canada
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31
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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [PMID: 32008871 DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20% of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Erasme University Hospital ULB, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research. (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology & Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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Abstract
The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.
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Vivian E, Cler L, Conwell D, Coté GA, Dickerman R, Freeman M, Gardner TB, Hawes RH, Kedia P, Krishnamoorthi R, Oduor H, Pandol SJ, Papachristou GI, Ross A, Sethi A, Varadarajulu S, Vege SS, Wassef W, Wilcox CM, Whitcomb DC, Wu BU, Yadav D, Ellison A, Habash S, Rastegari S, Reddy R, Yen T, Brooks MR, Tarnasky P. Acute Pancreatitis Task Force on Quality: Development of Quality Indicators for Acute Pancreatitis Management. Am J Gastroenterol 2019; 114:1322-1342. [PMID: 31205135 DOI: 10.14309/ajg.0000000000000264] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Detailed recommendations and guidelines for acute pancreatitis (AP) management currently exist. However, quality indicators (QIs) are required to measure performance in health care. The goal of the Acute Pancreatitis Task Force on Quality was to formally develop QIs for the management of patients with known or suspected AP using a modified version of the RAND/UCLA Appropriateness Methodology. METHODS A multidisciplinary expert panel composed of physicians (gastroenterologists, hospitalists, and surgeons) who are acknowledged leaders in their specialties and who represent geographic and practice setting diversity was convened. A literature review was conducted, and a list of proposed QIs was developed. In 3 rounds, panelists reviewed literature, modified QIs, and rated them on the basis of scientific evidence, bias, interpretability, validity, necessity, and proposed performance targets. RESULTS Supporting literature and a list of 71 proposed QIs across 10 AP domains (Diagnosis, Etiology, Initial Assessment and Risk Stratification, etc.) were sent to the expert panel to review and independently rate in round 1 (95% of panelists participated). Based on a round 2 face-to-face discussion of QIs (75% participation), 41 QIs were classified as valid. During round 3 (90% participation), panelists rated the 41 valid QIs for necessity and proposed performance thresholds. The final classification determined that 40 QIs were both valid and necessary. DISCUSSION Hospitals and providers managing patients with known or suspected AP should ensure that patients receive high-quality care and desired outcomes according to current evidence-based best practices. This physician-led initiative formally developed 40 QIs and performance threshold targets for AP management. Validated QIs provide a dependable quantitative framework for health systems to monitor the quality of care provided to patients with known or suspected AP.
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Affiliation(s)
| | - Leslie Cler
- Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Darwin Conwell
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Gregory A Coté
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | | | - Robert H Hawes
- Institute for Minimally Invasive Therapy, Florida Hospital, Orlando, Florida, USA
| | | | | | - Hellen Oduor
- Methodist Dallas Medical Center, Dallas, Texas, USA
| | | | | | - Andrew Ross
- Virginia Mason Medical Center, Seattle, Washington, USA
| | - Amrita Sethi
- Columbia University Medical Center, New York Presbyterian, New York, New York, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | | | - Wahid Wassef
- University of Massachusetts Memorial Medical Center, Worchester, Massachusetts, USA
| | - C Mel Wilcox
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - David C Whitcomb
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Bechien U Wu
- Kaiser Permanente Los Angeles, Los Angeles, California, USA
| | - Dhiraj Yadav
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | | | - Samar Habash
- AtlantiCare Regional Medical Center, Atlantic City, New Jersey, USA
| | - Sheila Rastegari
- AtlantiCare Regional Medical Center, Atlantic City, New Jersey, USA
| | - Rathan Reddy
- Methodist Dallas Medical Center, Dallas, Texas, USA
| | - Timothy Yen
- Methodist Dallas Medical Center, Dallas, Texas, USA
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Nutrition in Gastrointestinal Disease: Liver, Pancreatic, and Inflammatory Bowel Disease. J Clin Med 2019; 8:jcm8081098. [PMID: 31349549 PMCID: PMC6723806 DOI: 10.3390/jcm8081098] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/06/2019] [Accepted: 07/15/2019] [Indexed: 12/28/2022] Open
Abstract
Liver, pancreatic, and inflammatory bowel diseases are often associated with nutritional difficulties and necessitate an adequate nutritional therapy in order to support the medical treatment. As most patients with non-alcoholic fatty liver disease are overweight or obese, guidelines recommend weight loss and physical activity to improve liver enzymes and avoid liver cirrhosis. In contrast, patients with alcoholic steatohepatitis or liver cirrhosis have a substantial risk for protein depletion, trace elements deficiency, and thus malnutrition. Patients with chronic pancreatitis and patients with inflammatory bowel disease have a similar risk for malnutrition. Therefore, it clearly is important to screen these patients for malnutrition with established tools and initiate adequate nutritional therapy. If energy and protein intake are insufficient with regular meals, oral nutritional supplements or artificial nutrition, i.e., tube feeding or parenteral nutrition, should be used to avoid or treat malnutrition. However, the oral route should be preferred over enteral or parenteral nutrition. Acute liver failure and acute pancreatitis are emergencies, which require close monitoring for the treatment of metabolic disturbances. In most patients, energy and protein requirements are increased. In acute pancreatitis, the former recommendation of fasting is obsolete. Each disease is discussed in this manuscript and special recommendations are given according to the pathophysiology and clinical routine.
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Zhang J, Zhu S, Tan D, Ma A, Yang Y, Xu J. A meta-analysis of early oral refeeding and quickly increased diet for patients with mild acute pancreatitis. Saudi J Gastroenterol 2019; 25:14-19. [PMID: 30226482 PMCID: PMC6373213 DOI: 10.4103/sjg.sjg_240_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIM The objective of the study is to clarify whether early oral refeeding (EORF) and quickly increasing diet (QID) are of benefit to patients with mild acute pancreatitis compared with a traditional oral refeeding strategy. MATERIALS AND METHODS Studies were searched in PubMed, Cochrane library, ScienceDirect, SpringerLink, China Biology Medicine disc and Embase. A meta-analysis was then performed, using relapse of abdominal pain, nausea/vomiting, and length of hospital stay (LOHS) as the evaluation indices. RESULTS Eight trials met the inclusion criteria. For the oral refeeding time group, EORF could significantly decrease the LOHS (mean deviation [MD] -1.97; 95% confidence interval (CI) -3.32 to -0.62;P = 0.004), and there was no significant difference for relapse of abdominal pain (relative risk [RR] 1.17; 95% CI 0.69-2.00;P = 0.56) or nausea/vomiting (RR 1.30; 95% CI 0.19-8.82;P = 0.79) when compared with conventional oral refeeding. For the oral refeeding material group, there was no significant difference for relapse of abdominal pain (RR 0.86; 95% CI 0.53-1.40;P = 0.54), nausea/vomiting (risk difference -0.01; 95% CI -0.19-0.18;P = 0.94), or LOHS (MD -0.88; 95% CI -2.24-0.48;P = 0.20) between the QID and stepwise increasing diet groups. CONCLUSION Pure EORF or QID caused no damage to patients with mild acute pancreatitis, and EORF could significantly decrease the LOHS.
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Affiliation(s)
- Jiran Zhang
- Department of Emergency, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou 225001, Jiangsu Province, China
| | - Sha Zhu
- Department of Operating Room, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou 225001, Jiangsu Province, China
| | - Dingyu Tan
- Department of Emergency, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou 225001, Jiangsu Province, China
| | - Aiwen Ma
- Department of Emergency, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou 225001, Jiangsu Province, China
| | - Yan Yang
- Department of Emergency, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou 225001, Jiangsu Province, China
| | - Jiyang Xu
- Department of Emergency, Clinical Medical College of Yangzhou University, Subei People's Hospital, Yangzhou 225001, Jiangsu Province, China,Address for correspondence: Prof. Jiyang Xu, Clinical Medical College of Yangzhou University, Subei People's Hospital, Nantong West Road, 98Yangzhou 225001, Jiangsu Province, China. E-mail:
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Valverde-López F, Wilcox CM, Redondo-Cerezo E. Evaluation and management of acute pancreatitis in Spain. GASTROENTEROLOGIA Y HEPATOLOGIA 2018; 41:618-628. [PMID: 30149943 DOI: 10.1016/j.gastrohep.2018.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/04/2018] [Accepted: 06/19/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The aim of this systematic review is to summarize epidemiological data and areas of future acute pancreatitis research in Spain. METHODS We conduct an independent search in PubMed and Web of Science and analyse articles by Spanish researchers from 2008 to 2018. RESULTS We identified an overall incidence of 72/100,000 person-years, with biliary pancreatitis as the most common etiology. BISAP was useful but suboptimal for predicting severity and some biomarkers such as Oleic acid chlorohydrin have shown promising results. The modified determinant-based classification can help to classify patients admitted to intensive care units. Ringer's lactate solution is currently the fluid of choice and classic surgery has been surpassed by minimally-invasive approaches. Starting a full-caloric diet is safe when bowel sounds are present. DISCUSSION There are numerous well-defined research fields in Spain. Future multicentre studies should focus on management, predicting severity and cost-effectiveness.
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Affiliation(s)
- Francisco Valverde-López
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain.
| | - C Mel Wilcox
- Division of Gastroenterology and Hepatology and Pancreaticobiliary Center, University of Alabama at Birmingham, USA
| | - Eduardo Redondo-Cerezo
- Department of Gastroenterology and Hepatology, "Virgen de las Nieves" University Hospital, Complejo Hospitalario Universitario de Granada, Granada, Spain
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Abstract
OBJECTIVES Clinical trials on tube feedings (TFs) have not been sufficiently powered to change practice patterns in acute pancreatitis (AP). We aimed to describe the use, duration, and resource utilization of TF in AP patients at an expert US center. METHODS Of 423 AP patients prospectively enrolled at the University of Pittsburgh Medical Center from 2004 to 2014, 139 (33%) received TF. Data on TF were assessed in 100 (72%) of 139 patients with complete data available. RESULTS Patients on TF were more likely to be male, be obese, have alcohol etiology, and have moderately severe (34% vs 19%) or severe AP (62% vs. 3%) (P < 0.05). Tube feedings were started after a median of 5 days (interquartile range, 3-8 days) from admission and were administered for a median of 39 days (interquartile range, 19-58 days). A nasojejunal route (95%) with an oligomeric formula (92%) was the preferred TF strategy. Feeding tube complications led to at least 1 endoscopic tube replacement in 42% of patients and to an unexpected health care visit in 29% of those discharged on TF (16/55 patients). CONCLUSIONS Tube feedings form an important component in the management of patients with moderately severe and severe AP. Further studies should define the optimal utilization of TF and ways to reduce TF-related complications.
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Kothari D, Babineau M, Hall M, Freedman SD, Shapiro NI, Sheth SG. Preventing Hospitalization in Mild Acute Pancreatitis Using a Clinical Pathway in the Emergency Department. J Clin Gastroenterol 2018; 52:734-741. [PMID: 29095424 DOI: 10.1097/mcg.0000000000000954] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
GOALS We created an observation pathway with close outpatient follow-up for patients with mild acute pancreatitis (AP) to determine its effect on admission rates, length of stay (LOS), and costs. BACKGROUND AP is a common reason for hospitalization costing $2.6 billion annually. Majority have mild disease and improve quickly but have unnecessarily long hospital stays. STUDY We performed a pilot prospective cohort study in patients with AP at a tertiary-care center. In total, 90 patients with AP were divided into 2 groups: observation cohort and admitted cohort. Exclusion criteria from observation included end-organ damage, pancreatic complications, and/or severe cardiac, liver, and renal disease. Patients in observation received protocolized hydration and periodic reassessment in the emergency department and were discharged with outpatient follow-up. Using similar exclusion criteria, we compared outcomes with a preintervention cohort composed of 184 patients admitted for mild AP in 2015. Our primary outcome was admission rate, and secondary outcomes were LOS, patient charges, and 30-day readmission. RESULTS Admitted and preintervention cohorts had longer LOS compared with the observation cohort (89.7 vs. 22.6 h, P<0.01 and 72.0 vs. 22.6 h, P<0.01). The observation cohort admission rate was 22.2% lower than the preintervention cohort (P<0.01) and had 43% lower patient charges ($5281 vs. $9279, P<0.01). Moreover there were significantly fewer imaging studies performed (25 vs. 49 images, P=0.03) in the observation cohort. There were no differences in readmission rates and mortality. CONCLUSIONS In this feasibility study, we demonstrate that a robust pathway can prevent hospitalization in those with AP and may reduce resource utilization without a detrimental impact on safety.
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Affiliation(s)
| | - Matthew Babineau
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Lebanon, NH
| | - Matthew Hall
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sunil G Sheth
- Department of Medicine, Division of Gastroenterology
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Nutritional Considerations in Pediatric Pancreatitis: A Position Paper from the NASPGHAN Pancreas Committee and ESPGHAN Cystic Fibrosis/Pancreas Working Group. J Pediatr Gastroenterol Nutr 2018; 67:131-143. [PMID: 29927872 PMCID: PMC6020697 DOI: 10.1097/mpg.0000000000002023] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Wide variations exist in how physicians manage the nutritional aspects of children affected by acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic (CP) pancreatitis. Better consensus for optimal management is needed. METHODS This consensus statement on nutrition in pediatric pancreatic diseases was developed through a joint ESPGHAN-NASPGHAN working group that performed an evidence-based search of the literature on nutrition in AP, ARP, and CP with a focus on pediatrics. The literature was summarized, quality of evidence reviewed, and expert recommendations developed. The authorship met to discuss the evidence and statements. Voting on recommendations occurred over 2 rounds based on feedback. A consensus of at least 75% was required to approve a recommendation. Areas requiring further research were identified. RESULTS AND DISCUSSION The literature on nutrition in pediatric pancreatitis is limited. Children with mild AP benefit from starting an early nutritional regimen in the course of the attack. Early nutrition should be attempted in severe AP when possible; enteral nutrition is preferred over parenteral nutrition. Children with ARP are likely to tolerate and benefit from a regular diet. Children with CP need ongoing assessment for growth and nutritional deficiencies, exocrine and endocrine insufficiencies. CONCLUSIONS This document presents the first authoritative recommendations on nutritional considerations in pediatric pancreatitis. Future research should address the gaps in knowledge particularly relating to optimal nutrition for AP in children, role of diet or dietary supplements on recurrent attacks of pancreatitis and pain episodes, monitoring practices to detect early growth and nutritional deficiencies in CP and identifying risk factors that predispose children to these deficiencies.
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Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial Medical Treatment of Acute Pancreatitis: American Gastroenterological Association Institute Technical Review. Gastroenterology 2018; 154:1103-1139. [PMID: 29421596 DOI: 10.1053/j.gastro.2018.01.031] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Santhi Swaroop Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Matthew J DiMagno
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Chris E Forsmark
- Division of Gastroenterology, University of Florida, Gainesville, Florida
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada
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Affiliation(s)
- Ronald L Koretz
- 1 Olive View-UCLA Medical Center, David Geffen-UCLA School of Medicine, Sylmar and Los Angeles, California, USA
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Incidence and predictors of oral feeding intolerance in acute pancreatitis: A systematic review, meta-analysis, and meta-regression. Clin Nutr 2017; 36:722-729. [DOI: 10.1016/j.clnu.2016.06.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/07/2016] [Indexed: 12/26/2022]
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Lodewijkx PJ, Besselink MG, Witteman BJ, Schepers NJ, Gooszen HG, van Santvoort HC, Bakker OJ. Nutrition in acute pancreatitis: a critical review. Expert Rev Gastroenterol Hepatol 2017; 10:571-80. [PMID: 26823272 DOI: 10.1586/17474124.2016.1141048] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.
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Affiliation(s)
- Piet J Lodewijkx
- a Department of Surgery , Jeroen Bosch hospital , s-Hertogenbosch , The Netherlands
| | - Marc G Besselink
- b Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
| | - Ben J Witteman
- c Department of Gastroenterology and Hepatology , Hospital Gelderse Vallei Ede , Ede , The Netherlands
| | - Nicolien J Schepers
- d Department of Gastroenterology and Hepatology , Erasmus MC University Medical Center , Rotterdam , The Netherlands.,e Department of Gastroenterology and Hepatology , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Hein G Gooszen
- f Department of Operating Theatres and Evidence Based Surgery , Radboud University Medical Center , Nijmegen , The Netherlands
| | | | - Olaf J Bakker
- g Department of Surgery , University Medical Center Utrecht , Utrecht , The Netherlands
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Bevan MG, Asrani V, Petrov MS. The oral refeeding trilemma of acute pancreatitis: what, when and who? Expert Rev Gastroenterol Hepatol 2016; 9:1305-12. [PMID: 26289104 DOI: 10.1586/17474124.2015.1079125] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Tolerance of oral refeeding is an essential goal of nutritional management of acute pancreatitis. However, oral feeding intolerance remains one of the most common complications in patients with this disease. It often results in longer periods of hospitalization, increased treatment costs, increased risk of readmission, and reduced quality of life. The traditional practice involves keeping patients nil by mouth followed by gradual stepwise reintroduction of food. However, it does not have a solid evidence base and, hence, there is increasing interest in determining alternative strategies that may be beneficial in reducing the occurrence of oral feeding intolerance. This review focuses on the randomized controlled trials that investigated the key questions informing the nutritional management of acute pancreatitis: when to feed, what to feed and who is in charge of the decision-making.
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Affiliation(s)
- Melody G Bevan
- a Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Varsha Asrani
- a Department of Surgery, University of Auckland, Auckland, New Zealand
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Horibe M, Nishizawa T, Suzuki H, Minami K, Yahagi N, Iwasaki E, Kanai T. Timing of oral refeeding in acute pancreatitis: A systematic review and meta-analysis. United European Gastroenterol J 2015; 4:725-732. [PMID: 28408989 DOI: 10.1177/2050640615612368] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 09/21/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIM The optimal timing of oral refeeding in acute pancreatitis is unclear. This study aimed to perform a systematic review with meta-analysis of randomized controlled trials (RCTs) that compared early oral refeeding with standard oral refeeding in acute pancreatitis. METHODS PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify RCTs eligible for inclusion in the systematic review. The weighted mean differences (WMDs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Five eligible RCTs were included. Compared with standard oral refeeding, early oral refeeding significantly decreased the length of hospital stay (WMD: -2.22, 95%CI: -3.37 to -1.08, p = 0.0001). Although there was heterogeneity (I2 = 56%, p = 0.06), subgroup analysis of the refeeding criteria (immediate group and hungry group) eliminated the heterogeneity. There was no significant difference between the early refeeding group and standard refeeding groups with respect abdominal pain and distension (OR 1.14; 95%CI 0.65-1.99 and OR 1.53; 95%CI 0.81-2.90). CONCLUSIONS Compared with standard oral refeeding, early oral refeeding safely reduced the length of hospital stay in patients with acute pancreatitis.
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Affiliation(s)
- Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Toshihiro Nishizawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine.,Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School Of Medicine
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine
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Abstract
The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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