Acute Pancreatitis

Nutrition Support
Comprehensive Clinical Case Study
Jenna Godfrey
The Sage Colleges

Objectives
1.

Disease Background

2.

Medical Nutrition Therapy

3.

Literature Review

4.

Clinical Case Overview

5.

Timeline of Events

6.

Nutrition Diagnoses

7.

Interventions vs. Standard Guidelines

8.

Implications and Recommendations for Future Practice

Background
-

Disease Description
-

Inflammation of the pancreas

Premature activation of trypsin

destruction of pancreatic cells
Abdominal pain, N/V, steatorrhea
Mild-moderate vs. severe

Causes
-

Alcoholism: 70-80%
Biliary tract obstruction
CF, renal failure, medications

Complications
-

Shock, sepsis, respiratory failure

Chronic pancreatitis
DM

Medical Nutrition Therapy

- Mild-moderate pancreatitis: NPO initially
-

Gradually progress to oral diet as symptoms subside

-

No difference between progression to solid food vs. clear liquids

-

Significant decrease in LOS for patients receiving solid food as first oral feeding

Fat restriction (<50g) dependent on steatorrhea and abdominal pain

-

High protein

- Severe pancreatitis: initiate EN after fluid resuscitation/hemodynamic stability

-

Indicated for malnourished patients or those who were unable to tolerate oral feedings within 5-7
days

Shown to reduce symptom severity, LOS, GI intolerance, infectious complications, and surgical
interventions

Nutrient Requirements
Indirect Calorimetry
25-35 kcal/kg
1.2-1.5 g/kg
Low fat (<50g)

2012 JPEN Consensus Statement

Methods:
-

Literature review & consensus combined grading system

Results:
-

Nutrition support is not indicated for mild-moderate cases

Nutrition support is indicated if patient is expected to be NPO >5-7 days
Early nutrition support is indicated for severe pancreatitis and can lessen the
development of surgical complications
EN is preferred over PN; continuous over cyclic/bolus
-

NG tubes; MCT oil formula

25-35 kcal/kg & 1.2-1.5 g/kg protein

Why is EN preferred?
- 2010 Cochrane review of 8 trials comparing EN to TPN7
- Decreased RR for death, multiple organ failure, systemic infections, and
surgical interventions
- Reduced LOS by 2.37 days

Why are NG tubes preferred?

-

2013 meta-analysis of 3 trials comparing NG to NJ tube feeding10

- No differences in mortality, aspiration, diarrhea, pain, and meeting
energy needs

Clinical Case Overview

-

69 y/o male

Abdominal pain & N/V

Admit weight: 102.2 kg (225 lbs)

Ht: 183 cm, BMI: 30.5 kg/m2

IBW: 81 kg (Hamwi)

Good skin turgor

NKFA

Diminished BS, tender epigastrium

BP: 149/86, Temp: 98.8, HR: 92

Nonsmoker, no EtOH abuse

PMHx:
-

HTN
Dyslipidemia
CAD
CABG x2

Home Medications:
-

Amlodipine: Ca channel blocker

Atorvastatin: dyslipidemia
Lisinopril: ACE inhibitor
Ecotrin: NSAID

Glucose

190

Blood Urea Nitrogen

30

Creatinine

1.7

ALT & AST

186 & 161

Lactic Acid

2.6

Lipase

6,227

Estimated needs:
- 2,025-2,430 kcal/day (25-30 kcal/kg
IBW)
- 97-122g protein/day (1.2-1.5 g/kg
IBW)
- 2,430-2,835 mL fluids/day (30-35
mL/kg IBW)

Timeline of Inpatient Medical Course

2/7
Admitted
on 2/3
102.2 kg
NPO

2/18
Cholecystectomy
NPO

2/29
Full liquids
Probiotics
PERT

2/9
Aspiration
Intubation

Self-extubated

NPO

NPO

2/22
Clear
liquids

2/24
TF initiation
@ 10 mL/hr

2/11
Clear
liquids

2/15
GERD

2/27
NG tube pulled
out

NPO

3/3
Transferred
to rehab
unit

3/5
Dental
soft

Clear liquid

3/6
BMs

93.8 kg
D/C on
3/10

Nutritional Recommendations/Interventions
-

Diet advancement to low-fat

Ensure Clear

EN formula: Vital 1.5 @ 65 mL/hr

Snack orders

Mighty Shakes

Diet education

Actual Interventions

Standard Guidelines

Patient was kept NPO initially for 8 days.

Initiating enteral nutrition support early in cases of severe acute pancreatitis is

indicated. Regardless of disease severity, enteral nutrition support should be
initiated if the patient is expected to be NPO for greater than 5-7 days.6,7

NPO with TF initiation 21 days after

admission: Vital 1.2 @ 10 mL/hr through
nasogastric route. Subsequently increased
to 20 mL/hr 2 days later before
discontinued.

It is recommended to meet energy (25-35 kcal/kg) and protein (1.2-1.5 g/kg)

requirements through nutrition support.6
Nasogastric tube feeding is comparable to nasojejunal tube feeding with no
significant differences in safety and tolerance.10
Elemental formulas are not significantly superior to standard formulas for patients
with acute pancreatitis.11
Research shows no benefit from the use of immunonutrition or probiotics in EN
formulas for the treatment of acute pancreatitis.12
Formulas enriched with MCT oil may promote better tolerance.6

Actual Interventions

Standard Guidelines

Advancement to clear liquids for first oral feedings.

Advancement to solid foods as first oral feeding has no

difference in symptom recurrence compared to liquids in mild
cases of acute pancreatitis. Research suggests that solid foods
introduced as first oral feedings may reduce length of stay.9

Supplementation with probiotics (lactobacillus

acidophilus).

Probiotic use in the treatment of infection necrosis in cases of

severe acute pancreatitis shows no benefit.13

Advancement to dental soft diet.

Education on Pancreatitis Nutrition Therapy.

A low-fat diet is recommended in patients recuperating from

acute pancreatitis.8

Nutrition Diagnoses
Initial Assessment: Inadequate protein/energy intake related to decreased ability
to consume sufficient protein/energy due to N/V and altered GI function as
evidenced by severe gallstone pancreatitis complicated by respiratory failure,
reported poor appetite, NPO status x6 days, and pt meeting 0% of estimated
needs.

Final Assessment? Malnutrition related to decreased ability to consume sufficient

protein/energy due to severe gallstone pancreatitis as evidenced by NPO status
x16 days, limited clear liquid diet x8 days, and unintended weight loss of 18.5 lbs
(8.2%) in past 37 days.

Implications & Recommendations for Future Practice

-

Limitations of the RD

Need better communication within healthcare team, especially in severe cases

Nutrition support guidelines should be shared with MDs

Recommend:
-

More prompt and aggressive nutrition support intervention

Trial of first oral feeding as solid foods rather than liquids

Progression to low-fat diet as tolerated

No evidence to support probiotic supplementation

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Escott-Stump, S. Nutrition and Diagnosis-Related Care. 8th ed. Wolters Kluwer; 2015: 514-521.
Rettally CA, Skarda S, Garza MA, Schenker S. The usefulness of laboratory tests in the early assessment of severity of acute pancreatitis. Crit Rev Clin Lab Sci. 2003;40
(2):117-149.
Clemens DL, Schneider KJ, Arkfeld CK, Grode JR, Wells MA, Singh S. Alcoholic pancreatitis: New insights into the pathogenesis and treatment. World Journal of
Gastrointestinal Pathophysiology. 2016;7(1):48-58. doi:10.4291/wjgp.v7.i1.48.
Eisner T. Acute Pancreatitis. Medline Plus. NIH U.S. National Library of Medicine. Updated 2/11/2014. https://www.nlm.nih.gov/medlineplus/ency/article/000287.
htm
Wang G-J, Gao C-F, Wei D, Wang C, Ding S-Q. Acute pancreatitis: Etiology and common pathogenesis. World Journal of Gastroenterology: WJG. 2009;15(12):14271430. doi:10.3748/wjg.15.1427.
Mirtallo J, Forbes A, McClave S, Jensen G, Waitzberg D, Davies A. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral
Nutr. 2012;36(3):284-291.
Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database of Systematic Reviews. 2010.
Doi: 10.1002/14651858.CD002837.pub2.
Spanier BWM, Bruno MJ, Mathus-Vliegen EMH. Enteral Nutrition and Acute Pancreatitis: A Review. Gastroenterology Research and Practice. 2010;2011. Doi: 10.1155
/2011/857949
Moraes JM, Felga GE, Chebli LA, Franco MB, Gomes CA, Gaburri PD, Zanini A, Chebli JM. A full solid diet as the initial meal in mild acute pancreatitis is safe and
result in a shorter length of hospitalization. J Clin Gastroenterol. 2010;44(7):517-522.
Chang Y, Fu H, Xiao Y, Liu J. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. Critical Care. 2013;17(3):R118. doi:10.1186
/cc12790.
Petrov MS, Loveday BPT, Pylypchuk RD, McIlroy K, Phillips ARJ, Windsor JA. Systematic review and meta-analysis of enteral nutrition formulations in acute
pancreatitis. Br J Surg. 2009;96:1243-1252
Poropat G, Giljaca V, Hauser G, Stimac D. Enteral nutrition formulations for acute pancreatitis. Cochrane Database of Systematic Reviews. 2015. DOI: 10.1002
/14651858.CD010605.pub2.
Sun S, Yang K, He-Jinjui Tian X, Ma B, Jiang L. Probiotics in patients with severe acute pancreatitis: A meta-analysis.Langenbecks Arch Surg. 2009;394:171-177.
Vital AF 1.2 Cal. Features. Abott Nutrition. < http://abbottnutrition.com/brands/products/vital-af-1_2-cal>

Questions?