Nutrition in Acute Pancreatitis
報告者：臺北醫學大學•市立萬芳醫院
報告日期：民國 91 年 7 月 4 日
葉文慧 營養師
以下為內文：
♣The pancreas is an elongated, flattened gland that lies in the upper abdomen behind the stomach.
The head of the pancreas is in the right upper quadrant below the liver within the curvature of the
duodenum and the tapering tail slants upward to the hilum of the spleen.
♣This organ has both an endocrine and exocrine function.
Endocrine---pancreatic cells manufacture glucagon, insulin, and somatostatin for absorption into blood.
Exocrine----other cells secrete enzymes and other substances directly into the intestinal lumen to help
in digestion proteins, fats, and carbohydrate.
♣The important of nutrition
In Acute pancreatitis---Nutrition is important in moderate-to-severe disease because the disease process often is
complicated and prolonged, precluding eating.
♣75-85% patient：Alcohol abuse and Biliary tract disease
others：metabolic, traumatic, operative, infectious and pharmacologic
（Table72.1）
♣Typically present
1.Acute abdominal pain
2.↑ pancreatic enzyme in serum（amylase）
♣Range：interstitial pancreatitis necrotizing pancreatitis
♣Toxicity and complication
burn
protein and fluid loss
 1.third-space loss
2.escape of enzyme into the circulation B other systemic complication
↓
A hypovolemia and hopotension
↓
C pancreatic and peripancreatic necrosis （lipase）
B： 1.Renal insufficiency
2.Respiratory distress syndrome
3.Sepsis（Leukocytosis, fever）
♣Mild acute interstitial pancreatitis
Character：abdominal pain, nausea, vomiting, anorexia
Mortality：No or Low（<2%）
Complication（Local）：third-space losses
（systemic）：respiratory or renal failure（uncommon）
Recovery：several days
Treatment：simple medical treatment, parenteral nutrition is rarely needed.
♣Severe necrotizing pancreatitis
Character：end-organ failure
Mortality：if necrotic tissue is infection, mortality rate approximate 30%
Recovery：a prolonged, complicated clinical course
Treatment：As soon as PN support when pancreatitis is recognized
♣Clinical Predictor of Severity
＃Criteria：Name（Ranson, Bank, Agarwal and Pitchumoni, and Imrie）
disadvantage：need 48 hours
＃Ranson criteria： use age, laboratory measurements (at admission and 48 hr) and further clinical
Mortality： ≤2 signs  0
3-5 signs  10-20%
≥6 signs  >50%
≥3 signs have a high risk of developing pancreatic necrosis and systemic complications
＃other named criteria：simpler. Use development of cardiac, pulmonary, renal, metabolic,
hematologic and neurologic complication within the first 48 hours
Mortality：one or more complication identifies  a high risk of complications and death
＃APACHE-П score： can use repeatedly at any time
Mortality： ≤9 score survival
≥13 score  high probability of death
Suggest ≥10 score into ICU  PN support
＃First Computed tomography（CT）
Balthazar and Ramson（grsdes A to E）
A：normal pancrease
B：focal or diffuse enlargement
C to E：pancreatic enlargement
C：with mild peripancreatic inflammation
D：with fluid in the anterior pararenal space
A and B：excellent
C：pancreatic necrosis and 10% infection
D and E：infection is 50% and mortality 15%
E：with fluid collections in more than one area
♣Treatment
＃Food and drink are withheld
NG decompression（in moderate-to-severe acute pancreatitis）
＃In mild pancreatitis：
Pain control, IV fluid, NPO
Not need PN if patient can eat in 5-7 days
＃In moderate-to-severe pancreatitis：
Nutrition support must be a routine part of medical management, to prevent inanition（TPN）
REE
PN support use ：as soon as the cardiorespiratory system are stable
＃PN include：
1.hypertonic dextrose
2.solution of crystalline amino acids
3.fat emulsion to prevent fatty acid deficiency（expect hyperlipidemia-induced pancreatitis）
4.daily requirements of electrolytes, vitamins and trace elements
5.insulin
6.proton pump inhibitors（omeprazole）or H2-blockers
--After paralytic ileus has subsided and in patient requiring surgery, use oral low-fat feeding
to instead PN（because TPN complication）
TPN has advantage----maintaining ”pancreatic rest”
＃EN has many advantages over TPN：
1.maintenance of intestinal integrity and the gut mucosal barrier
2.lower cost
3.elimination complication of PN
＃Elemental diet----jejunal feeding
♣Refeeding
When to begin oral feeding, what to feed, how often to feed？
＃criteria of initiate oral feeding
1.absence of abdominal pain and tenderness
2. ↓ amylase level to near-normal levels
3.absence of complication
＃↓ 100-300mL no calorie liquid （every 4 hours in first 24 hours）
↓ same volume nutrient liquid
↓ 3-4 days
↓ soft diet
All diet contain ≥50% carbohydrate calorie
↓ solid diet
from 160 to 640 kcal/meal
＃Rate of pancreatic enzyme secretion V.S nutrition composition of meal（Figure 72.1）
Rate of delivery of calorie to the duodenum （Figure 72.2）