Clinical Nutrition Pdf 131885

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ARTICLE IN PRESS
Clinical Nutrition (2006) 25, 275–284
http://intl.elsevierhealth.com/journals/clnu
ESPEN GUIDELINES
ESPEN Guidelines on Enteral Nutrition: Pancreas$
a, b c d e f
R. Meier , J. Ockenga , M. Pertkiewicz ,A.Pap, N. Milinic , J. MacFie ,
DGEM:$$C.Lo¨ser, V. Keim
aDepartment of Gastroenterology, Kantonsspital Liestal, Liestal, Switzerland
bDepartment of Gastroenterology, CCM, Charite´-Universita¨tsmedizin Berlin, Berlin, Germany
cDepartment of Nutrition and Surgery, Central Clinical Hospital, Warsaw, Poland
d1st. Department of Gastroenterology, MAV Hospital, Budapest, Hungary
e
Department of Gastroenterology, University Hospital ‘‘Bezanijska kosa,’’ Belgrade, Serbia-Montenegro
fDepartment of Surgery, Scarborough Hospital, Scarborough, UK
Received 21 January 2006; accepted 21 January 2006
KEYWORDS Summary The two major forms of inﬂammatory pancreatic diseases, acute and
Guideline; chronic pancreatitis, require different approaches in nutritional management, which
Clinical practice; are presented in the present guideline. This clinical practice guideline gives
Enteral nutrition; evidence-based recommendations for the use of ONS and TF in these patients. It was
Oral nutritional developed by an interdisciplinary expert group in accordance with ofﬁcially
supplements; accepted standards and is based on all relevant publications since 1985. The
Tube feeding; guideline was discussed and accepted in a consensus conference.
Pancreatitis; In mild acute pancreatitis enteral nutrition (EN) has no positive impact on the
Undernutrition; course of disease and is only recommended in patients who cannot consume normal
Malnutrition food after 5–7 days. In severe necrotising pancreatitis EN is indicated and should be
supplemented by parenteral nutrition if needed. In the majority of patients
continuous TF with peptide-based formulae is possible. The jejunal route is
recommended if gastric feeding is not tolerated.
In chronic pancreatitis more than 80% of patients can be treated adequately with
normal food supplemented by pancreatic enzymes. 10–15% of all patients require
nutritional supplements, and in approximately 5% tube feeding is indicated.
The full version of this article is available at www.espen.org.
&2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.
Abbreviations: EN, enteral nutrition (both oral nutritional supplements and tube feeding); IU, international units; PEG,
percutaneous endoscopic gastrostomy; MCT, medium chain triglycerides; ONS, oral nutritional supplements; TF, tube feeding
$ 77 78
For further information on methodology see Schu¨tz et al. For further information on deﬁnition of terms see Lochs et al.
Corresponding author. Tel.: +41619252187; fax: +41619252804.
E-mail address: remy.meier@ksli.ch (R. Meier).
$$
The authors of the DGEM (German Society for Nutritional Medicine) guidelines on enteral nutrition in pancreatitis are
acknowledged for their contribution to this article.
0261-5614/$-see front matter & 2006 European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2006.01.019
ARTICLE IN PRESS
276 R. Meier et al.
Summary of statements: Acute pancreatitis
Subject Recommendations Grade77 Number
Indications
Mild acute Enteral nutrition is unnecessary, if the patient can B 1.3
pancreatitis consume normal food after 5–7 days.
Enteral nutrition within 5–7 days has no positive A 1.6
impact on the course of disease and is therefore not
recommended.
Give tube feeding, if oral nutrition is not possible due C 1.6
to consistent pain for more than 5 days.
Severe Enteral nutrition is indicated if possible. A 1.3
necrotising Enteral nutrition should be supplemented by C 1.3
pancreatitis parenteral nutrition if needed.
In severe acute pancreatitis with complications 1.8
(ﬁstulas, ascites, pseudocysts) tube feeding can be
performed successfully.
Application Tubefeedingispossibleinthemajorityofpatientsbut A 1.4
may need to be supplemented by the parenteral
route.
Oral feeding (normal food and/or oral nutritional C 1.10
supplements) can be progressively attempted once
gastric outlet obstruction has resolved, provided it
does not result in pain, and complications are under
control. Tube feeding can be gradually withdrawn as
intake improves.
Severe Use continuous enteral nutrition in all patients who C 1.7
pancreatitis tolerate it.
Route Try the jejunal route if gastric feeding is not C 1.4
tolerated.
In case of surgery for pancreatitis an intraoperative C 1.7
jejunostomy for postoperative tube feeding is
feasible.
In gastric outlet obstruction the tube tip should be C 1.8
placed distal to the obstruction. If this is impossible,
parenteral nutrition should be given.
Type of formula Peptide-based formulae can be used safely. A 1.5
Standard formulae can be tried if they are tolerated. C 1.5
Grade: Grade of recommendation; Number: refers to statement number within the text.
Summary of statements: Chronic pancreatitis
Subject Recommendations Grade77 Number
General Adequate nutritional therapy as well as pain C 2.4
treatment may have a positive impact on nutritional
status. Caloric intake is increased after an
attenuation of postprandial pain.
ARTICLE IN PRESS
ESPEN Guidelines on Enteral Nutrition 277
Indications More than 80% of patients can be treated adequately B 2.4
with normal food supplemented by pancreatic
enzymes.
10–15% of all patients require oral nutritional C 2.4
supplements.
Tube feeding is indicated in approximately 5% of C 2.4
patients with chronic pancreatitis.
Speciﬁc Stenosis of duodenum C 2.5
contraindications
Grade: Grade of recommendation; Number: refers to statement number within the text.
1. Acute pancreatitis (AP) tional requirements in such cases by whatever
means are most appropriate.
Preliminary remarks: The management of acute Both speciﬁc and non-speciﬁc metabolic altera-
pancreatitis (AP) differs according to its severity. tions occur in AP 9 (Ib). Basal metabolic rate
Classiﬁed by the Atlanta criteria1 approximately increases due to inﬂammatory stress and pain,
75% of the patients have mild disease with a leading to enhanced total energy expenditure.9 In
mortality rate below 1%.2 Mortality increases up severe necrotising pancreatitis, 80% of all patients
to 20% if the disease progresses to its severe are catabolic9 (Ib), with high energy expenditure
necrotizing form3–8 and in the most severe cases and enhanced protein catabolism10 (IIa). The
mortality can rise to 30–40%.7,8 Severe AP with its negative nitrogen balance can be as much as
related systemic inﬂammatory response (SIR) 40g/day11,12 and can have a deleterious effect on
causes increased metabolic demands and may both nutritional status and disease progression. In
progress to multiorgan disease (MOD). Using ima- onetrial, patients with a negative nitrogen balance
ging methods and laboratory parameters, progres- had a ten-fold higher mortality than those with a
sion can be predicted. Until recently, EN, either normal balance.13 This conclusion has to be treated
orally or by tube, was believed to have a negative with caution since no study has been stratiﬁed
impact on the progression of the disease due to according to disease severity, and the relation
stimulation of exocrine pancreatic secretion and between nitrogen balance and progression might,
the consequent worsening of the autodigestive therefore, merely reﬂect the severity of disease.
processes of the pancreas. Even though nutritional Starvation for more than seven days should
deﬁcits are frequent in severe pancreatitis, nutri- always be avoided, since protein and energy
tion as a part of therapy was neglected for a long catabolism induces undernutrition—and probably
time. Even now, few nutritional studies in this worsens the prognosis. It has been shown, that as
condition have been published. little as ﬁve days of conservative therapy without
nutritional support in previously healthy men
1.1. What inﬂuence does acute pancreatitis suffering from severe pancreatitis results in severe
exert on nutritional status and on energy and undernutrition, water retention and decreased
substrate metabolism? muscle function proportional to decreased protein
stores.14
Mild pancreatitis has little impact on nutritional Hyperlipidaemia occurs frequently in acute pan-
status or metabolism. In severe necrotising 15,16
pancreatitis energy expenditure and protein creatitis. It is not clear whether this is a
catabolism are increased (IIa). consequence of disease or due to pathogenic
factors or a combination of both17 (Ib). The latter
Comment: In mild acute pancreatitis the clinical seems more likely, since serum lipids normalize
course is usually uncomplicated and patients can during recovery from AP. Severe hyperlipidaemia
consume normal food, low in fat (o30% of total itself may be the sole cause of AP. It is a particular
energy intake [vegetable fat are preferred]), with- problem in the most severe cases, reﬂecting severe
in three to seven days. The disease has little impact disturbances of fat metabolism secondary to sepsis
on nutritional status or on energy and substrate and treatment.
metabolism. It is not clear whether this is also true The enhanced metabolic rate and protein cata-
in the presence of pre-existing undernutrition, bolism necessitate an increased energy intake from
although it is probably important to meet nutri- both fat (30%) and carbohydrates (50%). 1.0–1.5g
ARTICLE IN PRESS
278 R. Meier et al.
proteins are usually sufﬁcient. Carbohydrates are syndrome (SIRS) was signiﬁcantly attenuated in all
the favoured source of calories, since administra- enterally fed patients. Sepsis and multiorgan fail-
tion is easy, although hyperglycaemia, secondary to ure as well as incidence of surgery were reduced.
insulin resistance and in some cases islet cell Whereas two patients died in the PN group, no
damage, has to be avoided, placing a limit on the death occurred in the EN group. Major weaknesses
rate of administration of glucose and, in some of this study are the small number of patients with
cases, necessitating the use of insulin10 (IIa). severe pancreatitis and the marked differences in
1.2. Does nutritional status inﬂuence outcome? nutrient intake between the enteral and the
parenteral groups.
Although not investigated in this context, severe A further trial by Powell et al.22 (Ib) could not
undernutrition is likely to affect outcome nega- conﬁrm these ﬁndings. They compared early TF in
tively. patients with severe AP to patients without nutri-
Comment: Since there are no studies addressing tional support. One possible explanation could be
this issue, the question cannot be properly an- the different patient populations studied. In the
swered for AP. It has to be considered that under- Windsor group the mean APACHE II was 8 in the EN
groupand9.5inthePNgroup.21InthePowellseries
nutrition is a well-known risk factor for more APACHE II scores were 13 or more.22
complications and higher morbidity in other dis- In a randomised prospective controlled trial,
eases. It also has to be considered that under- comparing EN (TF) vs. PN in patients with severe
nutrition is known to occur in 50–80% of chronic pancreatitis Kalfarentzos et al.23 (Ib) scored less
alcoholics and that alcohol is a major aetiological than half of those studied, but, in the remainder,
factor in acute pancreatitis (30–40% of patients).18
Overweight, with a high body mass index is also mean APACHE II scores were 12.7 in the EN group
associated with a poorer prognosis. and11.8inthePNgroup.ENwaswelltoleratedand
was associated with fewer septic and other
1.3. Is EN indicated in acute pancreatitis? complications than PN as well as cost were more
In mild acute pancreatitis EN is unnecessary, if than three times less.
the patient can consume normal food after ﬁve In recent years it has become clear, that PN
to seven days (B). related complications have often been the conse-
In severe necrotising pancreatitis, EN is in- quence of overfeeding or even just catheter
sepsis.24 Van den Berghe et al. showed, irrespective
dicated if possible (A). This should be supple- of the route of nutritional support, that the control
mented by parenteral nutrition if needed (C). of hyperglycemia with insulin reduced mortality in
Comment: Parenteral nutrition (PN) has been the critically ill patients.25 Hyperglycaemia may occur
standard way of meeting nutritional requirements with EN as well as PN.
since it avoids pancreatic stimulation and improves Several studies in patients with trauma, thermal
nutritional status. A positive beneﬁt has, however, injury and major gastrointestinal surgery have
not yet been conﬁrmed in trials. There are two shown a reduction in septic complication with
investigations in mild to moderate pancreatitis EN26,27 (Ib) which also helps to maintain mucosal
19
comparing parenteral to no nutritional support function and limit absorption of endotoxins and
(Ib) or to TF20 (Ib). In the trial by Sax et al. no cytokines from the gut.28,29 In animals with induced
difference in mortality or complication rate be- pancreatitis, EN prevented bacterial transloca-
tween the two regimens could be demonstrated.19 tion,30 but whether this occurs in patients with AP
Catheter induced septicaemias as well as hypergly- is still unclear.31
caemia occurred signiﬁcantly more often in the PN Recent evidence has encouraged a much greater
group. McClave et al., in a prospective randomised use of EN than PN in severe acute pancreatitis,
controlled study, compared early EN via a jejunal whenever possible. EN, by down-regulating
tube to PN in patients with mild to moderate splanchnic cytokine production and modulating
pancreatitis.20 Early EN was initiated within 48h the acute phase response, reduces catabolism and
after admission to hospital. No difference in the preserves protein.21
investigated parameters was found, although PN Abou-Assi et al.32 studied 156 patients with AP
was found to be four times more expensive. All over 12 months. During the ﬁrst 48h all patients
patients in both groups survived. were treated with i.v. ﬂuid and analgesics. 87% of
Windsor et al.21 (Ib) compared PN with EN in patients had mild, 10% moderate, and 3% severe
patients with mild to moderate (total peripheral PN disease. Those who improved went on to normal
vs. ONS) and severe pancreatitis (total central PN food as soon as possible. The non-responders
vs. TF). The systemic inﬂammatory response were randomized to receive nutrients either by a

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...Article in press clinical nutrition http intl elsevierhealth com journals clnu espen guidelines on enteral pancreas a b c d e f r meier j ockenga m pertkiewicz pap n milinic macfie dgem lo ser v keim adepartment of gastroenterology kantonsspital liestal switzerland bdepartment ccm charite universita tsmedizin berlin germany cdepartment and surgery central hospital warsaw poland dst department mav budapest hungary university bezanijska kosa belgrade serbia montenegro fdepartment scarborough uk received january accepted keywords summary the two major forms inammatory pancreatic diseases acute guideline chronic pancreatitis require different approaches nutritional management which practice are presented present this gives evidence based recommendations for use ons tf these patients it was oral developed by an interdisciplinary expert group accordance with ofcially supplements standards is all relevant publications since tube feeding discussed consensus conference mild en has no positive i...

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