Enteral Nutrition and Severe Acute Pancreatitis

Hegazi R, Rana A, Graham T, Rolniak S, Conta P, Kandil H, O’Kefe J. Early jejunal feeding initiation and clinical outcomes in patients with severe pancreatitis. JPEN. 2011;35:91-96.

Pancreatitis is often mild and self-limiting. However, in 20–30% of cases, it can cause systemic inflammatory distress syndrome (SIRS), multi-organ failure, and a mortality rate of 15–40%. In this “severe group,” pancreatitis is a very catabolic condition; therefore, nutrition support has been a cornerstone of therapy. The question always asked is how to “feed” the patient while “resting” the pancreas. Previous trials have demonstrated that enteral nutrition (EN) is superior to parenteral nutrition (PN) in the setting of acute pancreatitis because of reduced associated infectious complications and cost. This current study wanted to determine if the time to initiation of EN and the time to reach target nutrition goals impacted clinical outcomes in patients with severe acute pancreatitis (SAP).

A retrospective chart review was performed on 17 patients in an ICU with a diagnosis of SAP who were referred to a nutrition support team. These patients had at least one system in organ failure and an APACHE II score of >8. Patients were divided into 3 groups: A — never reached goal nutrition needs; B — reached goal nutrition needs after >3 days; and C — reached goal nutrition needs in ±3 days. APACHE II scores were similar among the 3 groups. Nasojejunal (NJ) feeding tubes were placed endoscopically. Patients were fed using a semi-elemental tube feeding. ICU stay was significantly higher in group A (45.3 days) as compared to group B (19 days) and C (13 days) (p=.035). The percentage of patients with overall complications (e.g., sepsis, pancreatic necrosis, multiple organ failure) was similar among the 3 groups. The overall mortality rate was similar in the 3 groups (24%). There was a significant difference in the time to EN initiation between the survivors (8+/-3 days)(n=13) and non-survivors (17+/-13 days)(n=4) (p<.05) The average BMI in survivors was 34.2 and in non-survivors 44.8. Overall, it appears that patients with SAP benefit from early EN use by NJ feeding. Significantly obese patients appear to have reduced survival.

This study underscores the importance of early EN use in patients with SAP. These patients were able to get a NJ tube placed endoscopically in a time-efficient manner in order to begin EN therapy. In this patient group, severe obesity was associated with a decrease in survival. More work on obese patients is required to understand why this group has an increased incidence of death.

TPN and Vitamin D

Thompson P, Duerksen DR. Vitamin D deficiency in patients receiving home parenteral nutrition. JPEN. 2011;35:499-504.

Vitamin D is obtained through oral ingestion and by conversion of vitamin D in the skin from exposure to sunlight. Recently, it has been demonstrated that the daily recommendation for vitamin D intake is low for the general population. Patients on home parenteral nutrition (HPN) have very limited oral vitamin D intake or absorption. These patients often do not get outside into the sun for the time period necessary for adequate ultraviolet light exposure. They obtain most of their vitamin D (200 IU) from the multivitamin supplementation they receive in their PN prescription. The accepted method for monitoring a patient’s vitamin D status is through serum 25(OH)D serum levels.

Twenty-two long-term HPN patients had their vitamin D levels checked by 25(OH)D status. Most of the patients had been on HPN for >1 year. Their most common diagnosis for receiving HPN was gastrointestinal dysmotility (45%), malabsorption (36%), and GI obstruction (18%).Vitamin D insufficiency was defined as a serum level of 25(OH)D between 50 and 75 nmol/L, and deficiency was defined as a serum level <50 nmol/L. The mean 25(OH)D level was 42+/-22 nmol/l. Sixty-eight percent of the patients in this study had vitamin D insufficiency, and 27% had vitamin D deficiency. There did not appear to be a seasonal variation in vitamin D status. There appeared to be no correlation of small intestinal length and vitamin D status in patients with a diagnosis of short bowel syndrome.

One complication of patients on long-term HPN is metabolic bone disease (MBD). The etiology of this complication is multifactorial, with vitamin D as only one component of this complex problem. Intake of calcium, magnesium, and phosphorous, in addition to fluoride exposure, aluminum exposure, metabolic acidosis, and other factors, plays a role in the development of MBD. More work needs to be done to understand the optimal IV dose of vitamin D that is required in patients on long-term HPN. In addition, consideration needs to be given to the other factors listed previously as to their role in causing or worsening MBD in long-term HPN patients.