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REVIEW ARTICLE

Nutrition Management on Acute Pancreatitis
Ralph Girson Gunarsa*, Rino Alvani Gani **, Ari Fahrial Syam ***
* Department of Internal Medicine, Faculty of Medicine University of Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta ** Division of Hepatology Department of Internal Medicine, Faculty of Medicine University of Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta *** Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine University of Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta

Abstract

Pancreatitis is an inflammatory process in pancreas. Clinical manifestation of acute pancreatitis can be mild to severe. Mortality rate is high in severe acute pancreatitis. Etiology of acute pancreatitis generally remains obscured. Supportive management is important in acute pancreatitis. Nutrition is important part in acute pancreatitis. Patient should not be given enteral nutrition temporarily and meanwhile parenteral nutrition must provide sufficient amount of calories and nutritional requirements. Immune nutrition should also be considered. In mild acute pancreatitis, oral realimentard th tion can be started in 3 -7 day. In severe acute pancreatitis with prolonged fasting, gradual enteral nutrition via nasoenteral tube is recommended
Keywords: nutrition, acute pancreatitis, enteral nutrition
Introduction
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Pancreatitis is an inflammatory process in pancreas. Pancreatitis can be classified as acute pancreatitis 1 and chronic pancreatitis. Acute pancreatitis is one of 2 gastrointestinal emergencies. In the United States there are 185,000 annual incidence of acute pancreatitis. Common etiologic factors of acute pancreatitis in United States are idiopathic, alcoholism, and gallstones. In Asia, most common factor is 2,3,4 Ascaris lumbricoides (10-20%). Most of acute pancreatitis occured in young adult, more likely due 3 to alcoholism. Acute pancreatitis can be mild to severe. Complication in severe pancreatitis is common. Multi organ dysfunction leading to death is not rare in severe acute pancreatitis. Mortality rate in mild acute pancreatitis is 10%, and in severe acute pancreatitis 2 the mortality rate increased to 80%. Assessment of severity acute pancreatitis should be done as the patient hospitalized, as the management is different in severe and in mild pancreatitis. Acute pancreatitis management mostly are supportive care. Management patient with severe acute pancreatitis, should be in intensive care unit. Supportive medical management were fluid and nutritional balance, pain relief and complication management. Adequate nutritional management can
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prevent complication of acute pancreatitis.
Patophysiology

Pancreas is retroperitoneal organ, locates behind great curve between stomach and duodenum. Pancreas is exocrine and endocrine organs, which endocrine cells produce hormone (insulin, glucagons, somatostatin, pancreatic polypeptide). Asinus cells produce enzyme, secreted through pancreatic duct, and in sphincter of 1,4,7 Oddi at duodenum. Pancreatic enzyme were amylolysis, lipolysis, and proteolysis. These enzymes were produce in inactive form (preenzyme). Autodigestive process is prevented in normal condition by two reasons, first these preenzyme were inactive and second, there are 7 protease inhibitor. Secretion is regulated by nerve system (parasymphatic, vagal nerve) and hormone 1,4,7 system (secretin, cholestocine).
Acute Pancreatitis

Acute pancreatitis is a clinical syndrome includes acute abdominal pain with elevated enzyme serum; caused by necroinflammation response in 4 pancreas. Acute pancreatitis can be mild to severe (necrotizing pancreatitis). Three or more from Ran-

The Indonesian Journal of Gastroenterology, Hepatology, and

Prolonged fasting is generally needed in severe acute pancreatitis. Goal in nutrition management in acute pancreatitis is to fulfil energy requirement. Mc Clave et al studied group of patients with nasojejunal tube compare to total parenteral nutrition. and hypocalcemia.000 mg/day. niacin 50 mg/day. liquid diet can be switched to more solid form. Parenteral nutrition can increase the risk of catheter related sepsis. Nutrition management in mild acute pancreatitis is different from moderate severe acute pancreatitis.6. Nutrition is given in small portion and the portion is 6 increased daily. with minimum negative 6 balance. higher catheter related 15 infection. April 2007 be given to maintain electrolyte balance. hydration status and to prevent complication. Parenteral lipid infusion can be given with special precaution since it can worsen hypertrygliceridemia and pancreatitis. nutrition support should Volume 8 . and minimize metabolic disorder. Management Most of mild acute pancreatitis (85%-90%) will have spontaneous remission within 3-7 days. Oral nutrition can be started rd th in 3 -5 day hospitalization. pantotenic acid 100 mg/day. and it is related with it’s 3. there are more complications than mild pancreatitis. Total parenteral nutrition is not recommended in mild acute pancreatitis. In severe acute pancreatitis.Nutrition Management on Acute Pancreatitis son’s Criteria. Fasting in nutrition management is to prevent elevated pancreatic enzymes. vitamin B complex 50 mg/hour. Glutamine deficiency can be corrected by parenteral glutamine infusion.000 mg/day. Parenteral nutrition is not related with elevated enzyme. or 8 or more in APACHE scoring system can be classified as severe pancreatitis. therefore nutrition should be given in low lipid diet. It is rather complicated since oral nutrition can provocate autodigestive in acute 4-7 pancreatitis. Other metabolic conditions in acute pancreatitis are hyperglycemia. Catabolic process is followed by negative balance protein. Mineral compositions are calcium 1. and mild pancreatitis with ileus. nutrition is given through parenteral route or enteral route. if the abdominal pain not worsening while 7 nutrition given orally. Nutrition management in severe acute pancreatitis should be more aggressive than in mild pancreatitis. This condition can lead to negative nitrogen balance.8 therapy. Oral nutrition is started in liquid form. Enteral nutrition is recommended. Total parenteral nutrition is indicated for severe pancreatitis.20 severerity. and bacterial translocation. catheter related sepsis. malnutrition. because secretion of pancreatic enzymes and these active enzymes can be an autodigestive process in pancreas. intestinal atrophy. Nutrition should contain adequate calories and protein as well as electrolyte. this scoring system is useful in classification of acute pancreas and making prognosis. protein. As soon as the patient can tolerate better. vitamin and mineral. vitamin C 1. In mild acute pancreatitis oral nutrition can be given. mineral.500 mg/day. Patient who was given enteral nutrition should receive oral pancreatic enzyme until triglyceride serum 20 level below 500 mg/dL. and differ in mortality rate in mild acute 14 pancreatitis. zinc 50 mg/ day. magnesium 1. Medium chain triglyceride and long chain can prevent gut mucosal atrophy and prevent bacterial translocation from gut. management of mild pancreatitis patient is in the regular ward. Liquid diet can be given intermittent every 2-3 hours. Medical management in mild pancreatitis is different from severe pancreatitis. 9 and vitamin E 200.4. Nutrition management on severe acute pancreatitis In severe acute pancreatitis. although there is no significant difference in mortality and natural illness in acute 17 . there are complications of parenteral nutrition. Route of nutrition can be given enteral or parenteral route. It is suggested that 9 nutrition contain medium chain triglyceride. Since patient cannot be given oral nutrition in longer period. Parenteral nutrition is indicated in severe pancreatitis and mild 5 pancreatitis with ileus. therefore supportive care is most important in patient’s management. and higher cost. Nutrition should give adequate calories. There are few considerations in acute pancreatitis nutrition. There is no evidence that aggressive parenteral nutrition can shorten hospitalisation. There is increasing basal metabolism in acute pancreatitis. In general. There was no difference between these groups. and vitamins. there is increasing basal metabolism rate. the amount can be increased daily. There are also there are differences in nutritional 1.16-19 oral nutrition can be started in 3-5 days. Nutrition should not stimulate autodigestive in pancreas.3. Alcohol and coffee is contraindicated. Abdominal pain is related to triglyceride above 500 mg/dL.10-13. Total parenteral nutrition is not associated with shortening natural course of disease of 10-13 acute pancreatitis. Assessment severity by Ranson or APACHE scoring should be done as soon as the patient hospitalized. Total parenteral nutrition is related with higher insulin requirement. Nutrition management on mild acute pancreatitis Oral nutrition can stimulate abdominal pain in acute pancreatitis. since 8.Number 1. Since etiology acute pancreatitis is idiopathic. and started 50 ml. Oral nutrition in acute pancreatitis is contra indicated. On the other hand.800 iu/d. considering the autodigestive process. One of the supportive cares is nutritional management.

and decreased of leukocyte ability in neutralizing bacteria or fungal.5 peripancreatic abscess. protein. and vitamin E were given. nutrition can be switch to normal nutrition.5 mg/kg/day total protein was given. After two days of fasting condition. Nutrition management is important part of supportive management. Nutrition composition is the same as in mild acute pancreatitis. Tube is placed within day 3-4 after hospitalization. glutamine. In abscess peripancreas. vitamins. and less infection 24 complication.10 same bacteria were found more than in the gut. If well-tolerated. showed in animal study that enteral 11 nutrition can prevent bacterial translocation from gut. 2-3 PUFA (polyunsaturated fatty acid). The assumption was parenteral nutrition were related with mucosal atrophy. protein 22.15. Immunonutrition in severe pancreatitis showed promising result. in meta-analysis study. All these would increase risk of bacterial translocation. Another assumption was parenteral nutrition is related to disability of T/B lymphocyte. Kalafarentzoz et al. liquid diet can be switched gradually to soft diet and finally to regular food. Acute and chronic pancreatitis.16 difference in complications of pancreatitis.17. Nasoenteral tube is placed with fluoroscopy guided or by endoscopic procedure.18 g DHA. Additional immunonutrition should also be considered. Patient with mild pancreatitis were not undergone these procedure since oral nutrition is started on day 2 after hospitalisation. Then. supportive nutrition should be more aggressive. Ari Fahrial Syam pancreatitis. and 3. Hauser SL. 16. 1. and low lipid. They concluded that enteral nutrition 13. elevated protein serum level. Arginin. found that glutamine in nutrition parenteral could shorten fasting phase. investigated 22 patients who had fasted 48 hours since admission. Non invasive procedure is more preferred. glutamine also activation in immune cells. changed chemotaxis. References 1. mineral. Kotani et al. Therefore.19 Approximately 1. He concluded that enteral nutrition should be recommended because of less complication and less 22 cost compare to total parenteral group. Jameson JL editors. Jejunostomi is recommended only if the patient would undergo abdominal surgery. Fauci AS.2-1. osmolarity 400 mosm/L. infections complication is higher in parenteral nutrition than 16 in enteral group. Enteral nutrition is also recommended in chronic pancreatitis. and 7 lymphocyte. Recommendation is based on 10. and gut associated lymphoid tissue (GALT). Glutamine is an amino acid which has many function and found in many organs.18. and . Conclusions Acute pancreatitis is an inflammatory in pancreas. oral nutrition is contra indicated. catheter related sepsis.5 g/kg protein. enterocyte. In: Braunwald E. N-3 PUFA had anti atherogenic effect and lower cytokine proinflammatory. nutrition can be increased slowly until fulfilled nutrition requirement. Oral nutrition can be started in day 3-7 with composition of high carbohydrate. Marik et al. An animal study showed glutamine might prevent pancreatic asinus atrophy. in a randomised prospective study showed that less complication in nasojejunal nutrition 21 than in parenteral group. immunonutrition should be given 20 10-30 ml/hour continuously to jejunum. 18 12. Kasper DL. Hepatology. Rino Alvani Gani .Ralph Girson . phagocytosis. assessment of severity is highly recommended in management of acute pancreatitis. 1. combination 20 of enteral and parenteral nutrition is recommended. Toskes PP. and patient were sent home after 4 days. If enteral nutrition cannot be tolerate by the patient. Oral nutrition must be started in liquid and small portion.3 g. Olah et al recommend enteral nutrition with commercial enteral formula. medium protein.66 g EPA. appropriate route and timing of nutrition. Harisson’s principles of internal The Indonesian Journal of Gastroenterology. patient fasted for 48 hours. given by enteral or parenteral. and 2 g/kg/day lipid.95 g linoleic acid containing N-3 PUFA gave better result compared to standard enteral 23 nutrition. and triglyceride. In paralytic ileus. Assi et al. N-3 PUFA contained in fish oil 3. Nasoenteral tube was placed by endoscopic procedure and guided by fluoroscopy. As the patient tolerates enteral nutrition. 1. enteral nutrition is recommended. Enteral nutrition is given with nasoenteral tube or jejunostomy. anti oxidant effect. Management of acute pancreatitis is mostly supportive management. Greenberger NJ. Nutrition recommendations are 25-35 kcal/kg/day calories. Its composition is as same as with mild pancreatitis with consideration of lipid emulsion cannot be given 19 in patients with hypertriglyceridemia. glutamine should be considered in acute pancreatitis. In mild acute pancreatitis. Glutamine deficiency is related with bacterial translocation.19 could prevent sepsis and complication. Longo DL. Nutritional management should be given appropriately according to severity of pancreatitis. Nasojejunal tube is placed by endoscopic procedure. In acute severe pancreatitis. Ockenga et al. 1 kkal/ml. Nutritional management should considered adequate amount of calories.4. 19 polymer enteral nutrition can be given. placed by endoscopic procedure or surgical. and should fulfil adequate calories. If patient could tolerate oral nutrition. In severe pancreatitis. ESPEN recommendation in acute pancreatitis suggested that patient should fast in day 2-5. a 25 kcal/kg/day of total calories and 1.5 g/500ml. Nutrition is given by jejunostomy. These complications are sepsis. thus.

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