1. Nutritional Strategies in Acute Pancreatitis Kim Feltner Advisor: Gilbert Boissonneault University of Kentucky

2. Overview  Occurrence and Disease significance  Pathophysiology  Signs and Symptoms  Diagnosis  Treatment Methods

3. Pancreatitis  Incidence ranges from 1-5 cases per 10,000 people each year  In 85-90% of patients, will subside in 3-7 days  Most common causes  Alcohol, gallstones  Others  Hypertriglyceridemia, viral infections (mumps or hepatitis), scorpion bites, some drugs such as valproic acid, sulfonamides, and thiazide diuretics and others

4. Pathophysiology  Autodigestion  Activation of proteolytic enzymes trypsinogen, chymotrypsin, and trypsin occurs in the pancreas instead of activation in the intestinal lumen  These activated proteolytic enzymes digest pancreatic and peripancreatic tissue  More enzymes become activated causing digestion of cellular membranes that cause proteolysis, edema, and interstitial hemorrhage

5. Pathophysiology  Proteases are packaged in precursor form and there are also protease inhibitors in the acinar cell and in the pancreatic secretions preventing autodigestion from occurring  Death of the acinar cells releases enzymes and begins autodigestion  Death of acinar cells caused by:  Duct obstruction or reflux of bile or duodenal contents into pancreas  Certain drugs or alcohol

6. Symptoms  Abdominal pain  Steady and boring located epigastrically may radiate to back, chest, flanks, or lower abdomen  N/V

7. Signs  Low-Grade Fever  Tachycardia  Hypotension  Diminished or absent bowel sounds  Pain may be relieved by bending forward (patient may be curled up)

8. Signs  Turner’s Sign  Discoloration of the flanks reflecting tissue flanks reflecting tissue catabolism of hemoglobin catabolism of hemoglobin  May indicate severe necrotizing pancreatitis necrotizing pancreatitis From Forbes CD, Jackson WF: Color Atlas and Text of Clinical Medicine, 3rd ed. London, Mosby, 2003.

9. Signs  Cullen’s sign   Faint blue discoloration around the umbilicus  Result of hemoperitoneum hemoperitoneumhttp://content.nejm.org.ezproxy.uky.edu/cgi/content/full/340/2/149

10. Diagnosis  CT scan may confirm clinical impression of pancreatitis  Sometimes 3 days after dx to identify necrotizing pancreatitis  CT of abdomen may show gallstones  ERCP if gallstones suspected  Usually not used after first attack unless cholangitis or jaundice

11. Lab Abnormalities  ↑ Serum amylase  ↑ Lipase parallel with amylase  Hyperglycemia  Hypocalcemia  Leukocytosis  ↑ CRP  suggests pancreatic necrosis and also causes ↓ albumin

12. Severity Assessment Ranson’s Criteria  Admission  Age > 55yrs  WBC > 16,000/mm 3  Blood Glucose >200mg/dL  Serum LDH > 350 IU/L  Serum AST > 250 U/L 0-2 criteria  1% mortality 3-4 criteria  16%mortality 5-6 criteria  40% mortality 7-8 criteria  100% mortality  Initial 48 hours  ↓ Hematocrit > 10%  ↑ BUN > 5 mg/dL  Serum calcium < 8mg/dL  Arterial Po 2 < 60mmHg  Base deficit > 4 mEq/L  Est. fluid sequestration > 6 L Development indicates worsening prognosis

13. Treatment  Narcotics for pain  IV fluids for hydration  Normally kept NPO to avoid stimulation of pancreas until free of pain and N/V  If pancreatitis does not subside within a few days  Total Parenteral Nutrition (TPN)  Enteral nutrition

14. Nutritional Strategies  NPO  Nothing by mouth  Fluids replenished by IV  Reduces stimulation of the pancreas to prevent worsening of the disease state  Mild cases may begin oral intake within 3-4 days  Gastric decompression  Nasogastric tube suction to remove the acidic stomach contents and prevent them from reaching the jejunum  Recent studies have really shown no benefit to this therapy

15. Nutritional Strategies  Total Parenteral Nutrition (TPN)  Placement of Central Venous Catheter in order to provide complete nutrition (internal jugular, subclavian)  May be required if an ileus is present or if patient has been NPO for 7-10 days  Very invasive, should not be used very early in pancreatitis  High risk of catheter related infections and sepsis

16. Nutritional Strategies  Enteral Nutrition  Naso-gastric feeding usually preferred (inexpensive and easier-no radiology or endoscopy)  Distal to the ligament of treitz produce no change in complications, mortality, or length of hospital stay  Enteral feeding has been shown to improve the systemic inflammatory response

17. What Next?  After free of pain, N/V, bowel sounds return  Begin with clear liquid diet  Very few calories (Enlive is a supplement to clear liquids to provide more calories)  Low residue food in liquid form to minimize amt of food to be digested in the intestines  Next step up to full liquid diet  All liquids added so some protein and fat are available  Next step up to small meals, low fat, low cholesterol, low triglyceride  May need to provide counseling to patient to avoid recurrent attacks  Avoid alcohol, eat small meals

18. References  Arend W.P., Ausiello D., Goldman L., editors. Cecil Textbook of Medicine. 22nd ed. Philadelphia: W. B. Saunders; 2004. 779-884.  Conn's Current Therapy 2004. 56th ed. Philadelphia: W. B. Saunders; 2004. 563-573.  Fauci B., Hauser K., Jameson L., editors. Principles of Internal Medicine. 15th ed. Vol. 2. New York: McGraw Hill; 2001. 2249-2257.  Green II H.L., Noble J., et al, editors. Textbook of Primary Care Medicine. 3rd ed. St. Louis: Mosby; 2001. 1792-1803.  Heinrich S., Shafer M., Rousson V., Clavien P. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Annals of Surgery. 2005 Feb;243(2):154- 168.  Marik P.E., Zaloga G.P. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. British Medical Journal (2004):1-6.  Mcphee S. J., Papadakis M.A, Tierney, Jr L.M., editors. Current Medical Diagnosis and Treatment. Los Altos: California: Lange Medical Publications; 2005. 671-676.  Radenkovic D., Johnson C. Nutritional support in acute pancreatitis. Nutritonal in Clinical Care. 2004; 7(3):98-103.  Raimondo M., Scolapio J.S. What route to feed patients with severe acute pancreatitis: vein, jejunum, or stomach? The American Journal of Gastroenterology. 2005 Feb;100(2):440  Retally C.A., Skarda S., Garza M.A, Schenker S. The usefulness of laboratory tests in the early assessment of the severity of acute pancreatitis. Critical Reviews in Clinical Laboratory Science. 2003; 40(2):117-149

19. Questions