Nutrition management in acute pancreatitis: Clinical practice consideration

Table 1 The revised Atlanta 2012 classification for grading severity of acute pancreatitis

Grade of severity	Criteria
Mild	No organ failure
	No local or systemic complications
Moderately severe	Organ failure that resolves within 48 h (transient organ failure) and/or
	Local or systemic complications without persistent organ failure
Severe	Persistent organ failure (> 48 h)
	Single organ failure
	Multiple organ failure

Local complications include acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis. Systemic complications include exacerbation of pre-existing co-morbidity, such as coronary artery disease or chronic lung disease, precipitated by the acute pancreatitis.

Table 2 Modified Marshall scoring system for organ dysfunction

Organ system	Score
	0	1	2	3	4
Respiratory (PaO2/FiO2)	> 400	301-400	201-300	101-200	≤ 100
Renal1
Serum Cr (μmol/L)	≤ 134	134-169	170-310	311-439	> 439
Serum Cr (mg/dL)	< 1.4	1.4-1.8	1.9-3.6	3.6-4.9	> 4.9
Cardiovascular (SBP, mm Hg)2	> 90	< 90, fluid responsive	< 90, not fluid responsive	< 90, pH < 7.3	< 90, pH < 7.2

¹A score for patients with pre-existing chronic renal failure depends on the extent of further deterioration of baseline renal function. No formal correction exists for a baseline serum creatinine ≥ 134 μmol/L or ≥ 1.4 mg/dL.

²Off inotropic support. A score of 2 or more in any system defines the presence of organ failure. Cr: Creatinine; SBP: Systolic blood pressure.

Table 3 Summary of nutrition management in severe acute pancreatitis and areas for future research

Recommendation	Areas for future research
Energy requirement should be measured by IC, or 25 kcal/kg/d may be used	Role of on-demand oral diet
Protein requirements are 1.2-1.5 g/kg/d	Polymeric formula vs elemental/semi- elemental formula
Early EN within 48 h is recommended	Timing and benefits of PN in intestinal failure type I or II
Gastric or Jejunal feeding is acceptable	Role of enteral glutamine, probiotics, omega-3 FAs, antioxidants
Intravenous glutamine may be considered in patients with TPN
PEI should be monitored, especially in alcoholic, severe, and necrotizing pancreatitis

EN: Enteral nutrition; IC: Indirect calorimetry; TPN: Total parenteral nutrition; PEI: Pancreatic exocrine insufficiency; FAs: Fatty acids.