Nutritional strategies in severe acute pancreatitis: a systematic review of the evidence.

Nutrition in severe acute pancreatitis is a critical aspect in the management of this condition. This review aims to systematically review the evidence available to inform the use of nutritional support in severe acute pancreatitis. High quality (level 1) evidence supports naso-jejunal enteral nutrition (NJ-EN) over parenteral nutrition (PN) reducing infectious morbidity and showing a trend towards reduced organ failure although there is no detectable difference in mortality. Trial data may underestimate benefit as patients are often recruited with predicted rather than proven severe disease. NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often impractical and naso-gastric (NG) feeding seems to be equivalent in terms of safety and outcomes whilst being more practical (level 2 evidence). Regarding feed supplementation, probiotic feed supplementation is not beneficial (level 1 evidence) the and may cause harm with excess mortality (level 2 evidence). No evidence exists to confirm benefit of the addition of prokinetics in severe acute pancreatitis (SAP) although their use is proven in other critically ill patients. Level 2 evidence does not currently support the use of combination immuno-nutrition though further work on individual agents may provide differing results. Level 2 evidence does not support intravenous supplementation of anti-oxidants and has demonstrated that these too may cause harm.

[1]  M. Fink.  Gastrointestinal mucosal injury in experimental models of shock, trauma, and sepsis , 1991, Critical care medicine.

[2]  R. Brown,et al.  Changing methods in the treatment of severe pancreatitis. , 1974, American journal of surgery.

[3]  D. Heyland,et al.  Nutrition support in acute pancreatitis: a systematic review of the literature. , 2006, JPEN. Journal of parenteral and enteral nutrition.

[4]  C. McKay,et al.  A Randomized Study of Early Nasogastric versus Nasojejunal Feeding in Severe Acute Pancreatitis , 2005, The American Journal of Gastroenterology.

[5]  T. Myrhöj,et al.  Neostigmine in postoperative intestinal paralysis , 1988, Diseases of the colon and rectum.

[6]  J. Leslie.  Alvimopan for the Management of Postoperative Ileus , 2005, The Annals of pharmacotherapy.

[7]  L. Gramlich,et al.  Acute pancreatitis: Practical considerations in nutrition support , 2007, Current gastroenterology reports.

[8]  M. Boermeester,et al.  Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial , 2008, The Lancet.

[9]  J. Windsor,et al.  Early ascorbic acid depletion is related to the severity of acute pancreatitis , 1999, The British journal of surgery.

[10]  Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis , 1998 .

[11]  Yue Han,et al.  Expression of tumor necrosis factor and its receptor in gallstone and gallbladder carcinoma tissue. , 2004, Hepatobiliary & pancreatic diseases international : HBPD INT.

[12]  A. Siriwardena,et al.  Intravenous n‐acetylcysteine, ascorbic acid and selenium‐based anti‐oxidant therapy in severe acute pancreatitis , 2003, Scandinavian journal of gastroenterology.

[13]  K. Fearon,et al.  Glutamine-supplemented total parenteral nutrition reduces blood mononuclear cell interleukin-8 release in severe acute pancreatitis. , 1998, Nutrition.

[14]  R. Charnley,et al.  Acute pancreatitis and the influence of socioeconomic deprivation , 2009, The British journal of surgery.

[15]  Kehu Yang,et al.  Probiotics in patients with severe acute pancreatitis: a meta-analysis , 2008, Langenbeck's Archives of Surgery.

[16]  Javier Targarona Modena,et al.  Total enteral nutrition as prophylactic therapy for pancreatic necrosis infection in severe acute pancreatitis. , 2006 .

[17]  D. J. Bryg,et al.  An immune‐enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients , 2000, Critical care medicine.

[18]  D. Talwar,et al.  Relationship of carotenoid and vitamins A and E with the acute inflammatory response in acute pancreatitis , 2000, The British journal of surgery.

[19]  E. Aly,et al.  UK guidelines for the management of acute pancreatitis , 2005 .

[20]  J. Baillie.  AGA Institute medical position statement on acute pancreatitis. , 2007, Gastroenterology.

[21]  Bei Sun,et al.  Role of individually staged nutritional support in the management of severe acute pancreatitis. , 2004, Hepatobiliary & pancreatic diseases international : HBPD INT.

[22]  S. O'keefe,et al.  Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. , 2002 .

[23]  J. Windsor,et al.  Nasogastric tube feeding in predicted severe acute pancreatitis. A systematic review of the literature to determine safety and tolerance. , 2008, JOP : Journal of the pancreas.

[24]  A. Siriwardena,et al.  Randomised, double blind, placebo controlled trial of intravenous antioxidant (n-acetylcysteine, selenium, vitamin C) therapy in severe acute pancreatitis , 2007, Gut.

[25]  N. Emelyanov,et al.  A Randomized Controlled Trial of Enteral versus Parenteral Feeding in Patients with Predicted Severe Acute Pancreatitis Shows a Significant Reduction in Mortality and in Infected Pancreatic Complications with Total Enteral Nutrition , 2007, Digestive Surgery.

[26]  H. O. Oudemans-van Straaten,et al.  Neostigmine resolves critical illness-related colonic ileus in intensive care patients with multiple organ failure – a prospective, double-blind, placebo-controlled trial , 2001, Intensive Care Medicine.

[27]  J. Xiong,et al.  Clinical study on nutrition support in patients with severe acute pancreatitis. , 2003, World journal of gastroenterology.

[28]  R. Carter,et al.  Nasogastric feeding in severe acute pancreatitis may be practical and safe , 2000, International journal of pancreatology : official journal of the International Association of Pancreatology.

[29]  W. Du,et al.  Therapeutic efficacy of high-dose vitamin C on acute pancreatitis and its potential mechanisms. , 2003, World journal of gastroenterology.

[30]  O. Simonsen,et al.  Negative effect of Metoclopramide in postoperative adynamic ileus. A prospective, randomized, double blind study , 1986, The British journal of surgery.

[31]  M. Rowe,et al.  Pathogenesis of pancreatic sepsis. , 1993, American journal of surgery.

[32]  S. Wexner,et al.  Does metoclopramide reduce the length of ileus after colorectal surgery? , 1991, Diseases of the colon and rectum.

[33]  M. Petrov,et al.  Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A meta-analysis. , 2008, International journal of surgery.

[34]  P. Calder,et al.  A Randomised Clinical Trial to Assess the Effect of Total Enteral and Total Parenteral Nutritional Support on Metabolic, Inflammatory and Oxidative Markers in Patients with Predicted Severe Acute Pancreatitis (APACHE II >6) (R. Gupta et al., Southampton) , 2003, Pancreatology.

[35]  A. Lavrentieva,et al.  Nutrition support in acute pancreatitis. , 2008, JOP : Journal of the pancreas.

[36]  W. Shi,et al.  Prokinetic effect of erythromycin after colorectal surgery , 2000, Diseases of the colon and rectum.

[37]  F. Cerra,et al.  Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial. , 1995, Critical care medicine.

[38]  D. Hailey,et al.  2004 MacLean-Mueller prize enteral or parenteral nutrition for severe pancreatitis: a randomized controlled trial and health technology assessment. , 2005, Canadian journal of surgery. Journal canadien de chirurgie.

[39]  T. Sundqvist,et al.  Serum amino acid profile in patients with acute pancreatitis , 2008, Amino Acids.