NUTRITION THERAPY IN ACUTE PANCREATITIS Gila Greenbaum, Dietetic Intern, Sodexo 2014

RBMC Guidelines  There are currently no guidelines in place at the facility for nutrition therapy in AP  This research can help create standards of care

Objectives I. Define acute pancreatitis (AP) II. Differentiate between mild vs. severe AP (SAP) III. Review research to determine recommended nutrition therapy (NT) for AP: I. Timing: when to initiate feedings II. Diet: how to initiate feedings III. Enteral vs. Parenteral Nutrition IV. Review current guidelines: ACG, ASPEN, ESPEN

What would you do? A patient is admitted with acute pancreatitis. After 24 hours, her amylase and lipase remain slightly elevated, but she no longer has abdominal pain or n/v. Would you initiate a diet or keep her NPO status? If you will start a diet, what diet would it be? Why?

What is AP?  Inflammatory disorder  Digestive enzymes damage the pancreas  Primary causes: alcohol abuse, gallstones Signs & SymptomsLab Tests Abdominal pain, tenderness  WBC Nausea, vomiting  Amylase Fever  Lipase

Mild vs. Severe AP MILDSEVERE 80% of cases20% of cases Self-limiting: resolves within 48 hours to 5 days Local or regional complications, e.g. necrosis, fluid collections, develop after 48 hours Absence of organ failure and/or pancreatic necrosis Presence of SIRS, sepsis, persistent organ failure (MODS) and/or death occurring past 48 hours AlcoholGallstones

How to diagnose mild vs. severe AP?  Ranson’s Criteria: Clinical signs ≥3 associated with severe course  Acute Physiology and Chronic Health Evaluation (APACHE) II: physiologic measurements, age, PMH ≥ 8 associated with severe course  CT Severity Index (CTSI): based on extent of inflammation/complications on scan

Goal of Nutrition Therapy in AP  Reduce burden of disease  Maintain positive nitrogen balance without over- stimulating pancreatic fluids  Dietary improvement and/or advancement

What have we done in the past?  Prolonged fasting/NPO until normalization of enzymes, resolution of pain & inflammation  Oral feedings initiated with clear liquid diet  If oral feeding not possible: TPN

What is the recommended NT in AP?  Let’s see what the current research has to say……. I. Timing: when to initiate feedings II. Diet: how to initiate feedings III. Enteral Nutrition (EN) vs. Parenteral Nutrition (PN)

I. Timing: when to initiate feedings 4 studies reviewed in this section: Eckerwall, Clinical Nutrition, 2007 Chebli, Journal of Gastroenterology and Hepatology 2005 Baker, currently ongoing Hegazi, JPEN, 2011

1) Eckerwall, 2007  Immediate feeding vs. traditional fasting  Methods: 60 patients, randomized to fasting or immediate oral feeding group  Findings: (1) No differences between groups concerning pancreatic enzyme levels, pain or GI symptoms (2) LOH shorter in the oral feeding group (4 vs. 6 days)

 Early oral refeeding may stimulate pancreatic secretion, increase inflammation, cause relapse of abdominal pain  Pain relapse during oral refeeding relatively high on day 1-2 since admission  Pain relapse increased hospital stay and overall costs on disease treatment 2) Chebli, 2005

 Does starting EN within 24 hrs reduce infections compared to starting EN and/or oral diet 3-4 days after admission?  208 patients randomized: EN within 24 hours (group A), or oral diet plus EN 72 hours (group B)  Group A: started at 20ml/hr, with goal rate 65ml/hr within 72 hrs  Group B: NPO for 72 hrs, then oral diet and/or EN 3) Baker, ongoing

 Investigated early initiation DJF  Retrospective chart analysis  Nutrition Intervention: 20-25kcal/kg (IBW), 1.5g/kg protein via DJT  Results: (1) Early initiation: reduced mortality, fewer complications (2) Early achievement of feeding goal rate: shorter LOS (9d vs. 19d) 4) Hegazi, 2011

 Most studies: feeding can be initiated within hrs American College of Gastroenterology (ACG) Guidelines (2013)  Timing to initiate feedings remains controversial  Feedings can be started when there is no n/v, and abdominal pain has resolved  Mean time between hospital admission and 1 st meal: 1.5 days --- Recap on Timing ---

2 studies reviewed in this section: Sathiaraj, Aliment Pharmacol Ther, 2008 Jacobsen, Clinical Gastroenterology and Hepatology, 2007 II. Diet: how to initiate feedings

 Tolerance of soft diet (SD) vs. clear liquid diet (CLD) in feeding initiation  Methods: 101 patients randomized to CLD (458kcal/d, 11g fat/d) or SD (1040kcal/d, 20g fat/d)  Findings: SD patients had decreased LOH post feeding (4 vs. 6d), reduced total LOHS (5 vs. 8d), no differences in pain 1) Sathiaraj, 2008

 Low fat solid diet (LFSD) vs. CLD  Patients fed within 1-3 days post admission  Results: (1) LFSD was well tolerated, (2) Did NOT result in shorter LOH  Significance: LFSD can be considered for patients who desire greater dietary choice when initiating feeding after mild AP 2) Jacobsen, 2007

 SD and LF solid diet are tolerated compared with CLD ACG Guidelines (2013):  Appropriate diet when initiating feedings: low fat low residue (soft) diet --- Recap on Diet ---

1 study reviewed in this section: Hegazi, J Parenter Enteral Nutr, 2011 III. Enteral vs. Parenteral Nutrition

Nutrition Support

New Research: EN vs. PN EN: Encourages gut function, reduces bacterial overgrowth, fewer overall infections and complications  EN vs. PN: fewer days of nutritional support 2. Progressed to full oral feeding 1 day earlier  Cost savings: PN ($3294/pt) vs. EN ($761/pt)

 PN offers nutrients without pancreatic stimulation  PN associated with infections, metabolic complications  Pancreatic stimulation minimized during EN using mid to distal jejunum (40-60cm distal to the ligament of Treitz) Hegazi, 2011

--- Recap on Enteral vs. Parenteral ---  Most research: EN has eclipsed PN as the new "gold standard" of NT in AP ACG Guidelines (2013)  PN should be avoided in SAP unless EN not possible (e.g. paralytic ileus) or tolerated

ESPEN Guidelines  EN has no positive impact on mild AP, only recommended for patients NPO > 5 days  EN is recommended for SAP  Only supplement with PN if needed  EN should be continuous, peptide-based formula

ASPEN Guidelines  Energy Requirements: Calories: 25–35 kcal/kg/d Protein: 1.2–1.5 g/kg/d  Mild-moderate AP: 1. NPO, gradual advancement to oral diet within 3-4d 2. Only consider nutrition support if NPO > 5d  EN: preferred over PN, initiate first if feasible  EN Formula: small peptide-based MCT, continuous feeding  PN used only if EN not tolerated/indicated

Summary I. Timing: remains controversial, within hours, with no n/v or abdominal pain II. Diet: low fat low residue diet (usually with mild to moderate AP) III. EN preferred over PN when possible (usually with SAP)

Back to the case study……. A patient is admitted with acute pancreatitis. After 24 hours, her amylase and lipase remain slightly elevated, but she no longer has abdominal pain or n/v. Would you initiate a diet or keep her NPO status? If you will start a diet, what diet would it be? Based on the current research and guidelines, is your answer different from your initial answer?

References 1. Eckerwall et al. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery—A randomized clinical study. Clinical Nutrition, Vol 26, Issue 6, , Siow. Enteral Versus Parenteral Nutrition for Acute Pancreatitis. Critical Care Nurse, 28, 19-30, Mirtallo et al. International Consensus Guidelines for Nutrition Therapy in Pancreatitis. JPEN J Parenter Enteral Nutr 36, , Chebli et al. Oral refeeding in patients with mild acute pancreatitis: Prevalence and risk factors of relapsing abdominal pain. Journal of Gastroenterology and Hepatology, Vol 20, 9, 1385–1389, Tenner et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol, 108, , Sathiaraj et al. Clinical trial: oral feedings with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis. Aliment Pharmacol Ther, 28, , 2008.

References cont. 7. Jacobsen et al. A Prospective, Randomized Trial of Clear Liquids Versus Low-Fat Solid Diet as the Initial Meal in Mild Acute Pancreatitis. Clinical Gastroenterology and Hepatology, 5, , Hegazi et al. Early Jejunal Feeding Initiation and Clinical Outcomes In Patients with Severe Acute Pancreatitis. J Parenter Enteral Nutr Vol. 35, 1, 91-96, Baker et al. Pancreatitis, very early compared with normal start of enteral feeding (PYTHON trial): design and rationale of a randomized controlled multicenter trial. Trials 12, 73, Eckerwall et al. Early Nasogastric Feeding in Predicted Severe Acute Pancreatitis, A Clinical, Randomized Study. Annals of Surgery, Vol 244, 6, , Ioannidis et al. Nutrition Support in Acute Pancreatitis. J Pancreas, 9, 4, , Takeda et al. JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis. J Hepatobiliary Pancreat Surg, 13, 42-47, Meier et al. Nutrition in Pancreatitis. Best Pract Res Clin Gastroenterol, 20, 3, , 2006.

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