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.