Acute pancreatitis (AP) is an acute inflammation process of the pancreas with variable involvement of other tissue or remote organ systems ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndromes with or without accompanying sepsis. Severe acute pancreatitis (SAP) is a common disease with emergency situation involving organ failure and/or local complications such as necrosis, abscess, or pseudocysts having mortality of up to 30 percent. Despite improvements in intensive care treatment during the past few decades, the rate of death from SAP has not significantly declined [
SAP includes a hyper catabolic state leading to protein catabolism and increased resting energy requirements [
PN has been associated with gut mucosal atrophy, overfeeding, hyperglycemia, increased risk of infectious complications, and increased mortality rate [
This study is approved by the Review Board of the Second Affiliated Hospital of Chongqing Medical University, China. Total of 130 patients with severe acute pancreatitis having similar severity index, treated at The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China, between January 1998 and June 2008, were retrospectively selected in to two groups, which include 58 males and 72 females with the median age of 49 ranging from 20 to 85 years old. The diagnostic criteria of severe acute pancreatitis include: clinical features, hyperamylasemia/hyperlipasemia (three times the normal upper limit); radiological evidence of severe acute pancreatitis (contrast enhanced CT scan); evidence of organ failure and/or local complications such as pancreatic necrosis; pseudocyst, abscess; computed tomography severity index (CTSI) equal to or greater than 7; Ranson score
Group I includes 59 patients from January 1998 to December 2001 out of whom 27 were male and 32 were female whose age was between 20 to 82 years old. The median age was 51 years. More detailed characteristics of study patients are presented in Table
Characteristics of study patients.
Group I | Group II |
| |
---|---|---|---|
|
| ||
Age in years (average) | 51 | 52.5 | |
Male | 27 | 31 | |
Female | 32 | 40 | |
Etiology | |||
Gallstones | 25 (49.01%) | 34 (47.88%) | |
Alcohol | 21 (41.17%) | 28 (39.43%) | |
Idiopathic | 3 (5.88%) | 6 (8.45%) | |
Drug Induced | 2 (3.92%) | 3 (4.22%) | |
Duration of symptom of disease at the time of admission (days in mean ± SD and range) | 2.63 ± 0.73 (1–5) | 2.77 ± 1.01 (1–5) | 0.247a |
Markers of disease at the time of admission and during the hospital stay.
Group I | Group II |
| |
---|---|---|---|
Mean ± SD (range) | Mean ± SD (range) | Group I versus Group IIa | |
APACHE-II Score | |||
Day 0 | 12.21 ± 2.57 | 12.47 ± 3.71 | 0.363 |
Day 4 | 11.59 ± 5.12 | 11.45 ± 4.31 | 0.276 |
Day 7 | 11.53 ± 4.49 | 10.29 ± 4.21 | 0.010 |
Day 14 | 10.78 ± 4.77 | 09.07 ± 4.97 | 0.009 |
IL-6 | |||
Day 0 | 434.43 ± 187.29 ng/L | 429.57 ± 179.61 ng/L | 0.755 |
Day 4 | 397.50 ± 124.15 ng/L | 382.21 ± 135.73 ng/L | 0.716 |
Day 7 | 387.50 ± 165.92 ng/L | 285.69 ± 199.17 ng/L | 0.016 |
Day 14 | 385.50 ± 194.52 ng/L | 180.33 ± 143.38 ng/L | 0.006 |
Serum Albumin Level | |||
Day 0 | 28.6 ± 3.7 g/L | 30.03 ± 6.2 g/L | 0.963 |
Day 4 | 29.36 ± 4.6 g/L | 28.8 ± 5.3 g/L | 0.865 |
Day 7 | 29.64 ± 5.1 g/L | 29.3 ± 4.6 g/L | 0.872 |
Day 14 | 29.7 ± 4.2 g/L | 30.01 ± 5.7 g/L | 0.987 |
Group II include 71 patients from January 2002 to June 2008 out of whom 31 were males and 40 were females. The patients were 20 to 85 years in age and the median age was 52.5 years. APACHE II score at the time of admission at hospital was
In this study, the nutritional therapy period is defined as the time from enrolment until the first day the patient received more than 70 per cent of their estimated nutritional requirements through volitional oral intake. PN was the provision of intravenous nutrients with the exception of ≤5% dextrose solutions. EN was defined as the provision of a nutritionally complete formula into gastrointestinal tract through a mechanical tube (gastric or small bowel tubes). EN was delivered into the jejunum distally to the ligament of Treitz. Oral intake was food taken orally by mouth. The proportion of the daily target volume of either PN or EN was calculated by dividing the delivered volume by the target volume.
At the time of hospital admission, there was no significant difference between the two groups of patients in clinical data and APACHE II score (
In both the groups, we analyzed APACHE-II score, IL-6 level, serum protein level, complication rate, mortality, cure rate, length of hospital stay, and average hospital cost. Results for normally distributed outcomes are reported using medians and interquartile ranges (IQRs). A non-parametric Mann-Whitney
In Group I, the APACHE II scores on days 4, 7, and 14 were
Comparison of APACHE II score on days 0, 4, 7, and 14 between Group I and Group II. #
Before the treatment, the IL-6 level was
Comparison of IL-6 level on days 0, 4, 7, and 14 between Group I and Group II. #
14 day after the treatment, the serum albumin in Group I and Group II was
Comparison of serum albumin concentrations on days 0, 4, 7, and 14 between Group I and Group II. *
The complication rate of Group II is 39.4 percent which is significantly less than Group I which has 66.1 percent (
Comparison of complications, mortality, and patients-cured between Group I and Group II. *
The mortality of Group II was 12.7 percent which is significantly less than the mortality of Group I which has mortality 30.5 percent (
Outcome in the two groups.
Group I | Group II |
| |
---|---|---|---|
Complication rate | 66.1% | 39.4% | 0.010a |
Mortality | 30.5% | 12.7% | 0.044a |
Cure rate | 59.3% | 81.7% | 0.019a |
Length of hospitalization | 51 ± 8 days | 32 ± 9 days | 0.005b |
Treatment cost | ¥ 45534 ± 3031.5 | ¥ 30869 ± 12794.6 | 0.001b |
In Group II, the cure rate is 81.7 percent which is significantly higher than 59.3 percent in Group I (
The length of hospitalization in Group II was
For the Group II, it is
Severe acute pancreatitis (SAP) is acute pancreatitis associated with complications that are either local (e.g., peripancreatic fluid collection, necrosis, abscess, pseudocyst) or systemic (e.g., organ dysfunction). According to the Atlanta Classification, SAP can be divided into two phases. The first phase of about 7–10 days start with aseptic inflammation, systemic inflammation response syndrome (SIRS), sepsis, multi organs failure (MOF), and even death [
This study compares the result of two groups of SAP patients to explore the nutrition requirements of various stages of SAP and to propose the method of Gradually Combined Treatment of Nutrition Support for SAP.
In the course duration of SAP, the need for nutrients varies with the change of the duration. In order to comply with metabolism of the body in SAP, we should take the right amount of progressive nutrition support. The body’s requirements for the amount of nutrients based on the balance of the body metabolic rate (BMR) and body’s stress response to the inflammation of pancreatitis. At the period of stress response, the body itself is in the stage of macrophages. At this stage, the patients exhibits higher basal metabolic and catabolic rates as well as impaired metabolic capability to use exogenous amino acid and energy. As the disease goes on, the body adapts to the trauma and the tissues and organs are recovered. At this time, the body’s requirements for nutritional substrate are gradually reduced and finally become close to BMR. With the stress response reduced, body’s repair to trauma and anabolic enhanced, exogenous nutritional substrate requirement is gradually increased. In this stage, the energy requirement is equal to acute energy expenditure (AEE).
Till days 3-4 of the onset of SAP, a serious Systemic Inflammatory Response Syndrome (SIRS) may occur. The body is in the high catabolic stage and in stress, which represents macrophages to itself and metabolic disturbance. The principal contraindication of this phase is to improve the intracellular environment and microcirculation. Intravenous perfusion of the high calories and high viscosity nutrients solution will increase the imbalance in the intracellular environment and microcirculation. Therefore the amount of substrate required by nutritional support should be reduced, the amount should be equivalent to half of the BMR, the energy should be supplied by monosaccharide, which mainly provide to the tissue and cells rely solely, such as the brain, RBSs, and others.
After the comprehensive treatment, the maintenance of the intracellular environment and microcirculation of most patients are improved. The differences between decomposition and synthesis of metabolic in the body reduced, the phenomenon of self-macrophages gradually improved, the demand for the non-protein calories began to increase to half of BMR and requires the energy of fats as well as glucose. However, the body is still in the stress state, the intracellular environment has not fully recovered, and cells’ anabolism lack vitality; high nutritional supplements will increase the burden of tissue and organ, leading to variety of metabolic complications. When SAP entered the second stage of about 7–10 days, most patients have successfully recovered through the stress period, the environment and microcirculation improved, assimilation is enhanced, demand of exogenous nutrients substrate increased. After 2 weeks, the energy demand basically reached AEE.
In this study, we analyzed APACHE-II score and IL-6 levels. After being admitted in hospital, APACHE-II score is one of the best predictor to assess the severity of pancreatitis [
Patients with SAP are frequently hypercatabolic; timely institution of feeding is important if malnutrition is to be avoided or treated. Local complications of pancreatitis might cause upper gastrointestinal tract obstruction, making enteral nutrition problematic. There are also concerns that enteral nutrition may exacerbate the severity of SAP through further pancreatic stimulation and enzyme release. These considerations have led to a widespread reliance on parenteral nutrition as the main nutritional support modality in SAP.
Many evidences suggest that there are several potential benefits to enteral nutrition compared with parenteral nutrition including a reduction in microbial translocation, improvements in gut blood flow, and preservation of gut mucosal surface immunity. Furthermore, since altered gut microbiological flora and barrier function may contribute to the development of infected pancreatic necrosis, there are theoretical advantages to enteral feeding in SAP.
About the timing of nutritional support for the patients with SAP, in most of the studies, both parenteral nutrition and enteral nutrition begin within 48 h; parenteral nutrition is started later than enteral nutrition, more likely an assistant method of enteral nutrition [
In severe acute pancreatitis, evaluation of body’s metabolism should be the first consideration and then gradually combined treatment of parenteral nutrition with enteral nutrition should be used as routine therapy. This cannot only improve the natural history of pancreatitis but also can reduce the incidence of complication and mortality.
The authors declare that they have no conflict of interests.