Acute Pancreatitis
Definition
Acute pancreatitis involves the activation of numerous inflammatory mediators and pancreatic enzymes through a complex process, leading to varying degrees of pancreatic autodigestion and systemic inflammation. The most common causes are gallstones (40%) and alcohol abuse (30%) [1, 2], as well as medications, surgical complications, and hypertriglyceridemia. In approximately 80% of cases, the disease is mild. About 20% of patients develop moderately severe or severe acute pancreatitis, characterized by transient or prolonged organ failure lasting more than 48 hours. Assessing the severity of the disease (using the revised Atlanta Classification [3] or the determinant-based classification [4]) and nutritional status [5] upon hospital admission and during the disease course allows for the most effective treatment approach [6].
Impact on Nutritional Status
Numerous pro-inflammatory mediators increase the basal metabolic rate. Depending on the severity and duration of the disease, the basal metabolic rate is elevated to varying degrees. The primary goal of nutritional therapy is to prevent and/or treat malnutrition by ensuring an adequate supply of macro- and micronutrients. Glucose is a crucial energy source, and insufficient intake increases protein breakdown through gluconeogenesis. Elevated plasma triglyceride levels are common but typically return to normal values after the acute phase. Fluid imbalances are also common but can often be managed with early fluid resuscitation [6].
Nutritional Requirements for Patients with Acute Pancreatitis
Adjustments needed for malnourished patients, physical activity level, and age. Adjusted Body Weight (ADJ) should be used for BMI ≥ 28, otherwise, the weight before hospital admission should be applied.
BW = body weight; d = day
Please fill out the weight
Goals of Nutritional Therapy
- Maintenance/improvement of nutritional status and body functions
- Prevention of malnutrition and nutrient deficiencies
- Correction of electrolyte imbalances
- Early initiation of oral/enteral nutrition to reduce the risk of local infectious complications by maintaining "gut barrier function"
Whenever possible, energy and protein requirements should be met through oral nutrition, regardless of serum lipase levels in patients with mild acute pancreatitis. If, despite fortification, snacks, or oral nutritional supplements, less than 75% of needs are met, complementary enteral nutrition should be escalated by day five. Complementary parenteral nutrition is indicated if less than 75% of requirements are met through oral and/or enteral nutrition.
Oral Nutrition
To maintain the "gut barrier function" and thereby reduce the risk of local infectious complications, oral/enteral nutrition should be initiated as soon as tolerated [6]. In mild acute pancreatitis, low-fat, soft foods can help reintroduce oral intake by managing hyperlipidemia or preventing its worsening, improving digestibility, and reducing abdominal pain [6]. The energy requirements are elevated, and adequate nutrition can reduce gluconeogenesis from body proteins, thereby preventing muscle wasting.
Oral intake may also be resumed within 24 hours after a minimally invasive necrosectomy unless contraindicated (e.g., gastric emptying disorder, hemodynamic instability, sepsis).
Practical Guidelines, if Indicated:
- Low-Fat Diet: Only if indicated, and if pancreatic enzyme replacement is insufficient.
- Fortification: Enrich oral intake with energy (e.g., sugar, protein supplements).
Enteral Nutrition
If oral intake is not feasible (e.g., in hyperlipidemic acute pancreatitis), enteral nutrition should be initiated within 24 to 72 hours. Numerous clinical studies and meta-analyses indicate that enteral nutrition is well-tolerated and safe. Additionally, it has been shown that enteral nutrition significantly reduces complications, multi-organ failure, and mortality compared to parenteral nutrition [6].
High-molecular standard nutrient solutions are generally sufficient. Patients with severe acute pancreatitis and associated malabsorption may benefit from a low-molecular diet [6].
Enteral nutrition can be administered via a nasogastric tube. If contraindicated (e.g., digestive intolerance), a nasojejunal tube is used.
General guidelines for severe acute pancreatitis:
- Intra-abdominal Pressure >15 mmHg: A nasojejunal tube is preferred over a nasogastric tube. It is recommended to start with a rate of 20 mL/h and increase as tolerated. If intra-abdominal pressure continues to rise, the enteral feeding should be reconsidered [6].
- Intra-abdominal Pressure >20 mmHg: Stop enteral nutrition and initiate parenteral nutrition [6].
Parenteral Nutrition
Parenteral nutrition is indicated if enteral nutrition is not tolerated, does not meet requirements, or is contraindicated (e.g., bowel obstruction, abdominal compartment syndrome, prolonged paralytic ileus, mesenteric ischemia, intra-abdominal pressure >20 mmHg) [6]. Whenever possible, a small amount of enteral nutrition (e.g., 10 mL/h) should be administered.
In cases of severe acute pancreatitis with total parenteral nutrition, parenteral administration of L-glutamine at 0.2 g/kg body weight per day is recommended [6].
Monitoring
- In severe pancreatitis with enteral nutrition, intra-abdominal pressure and the clinical condition should be closely monitored [6].
- The severity classification should be regularly reassessed based on clinical progression, using various laboratory values or scoring systems as available [6].
Special Considerations
- Severe acute pancreatitis should always be classified as having a "high" risk for malnutrition [6].
- Ensure adequate fluid replacement, correction of electrolyte imbalances, analgesia, and the initiation of oral/enteral nutrition as soon as tolerated [6].
- Prevent and manage gut barrier dysfunction to reduce the risk of associated bacterial translocation, infections, or necrosis [8].
Medications/Supplements
- L-Glutamine: Administer 0.2 g/kg body weight per day in cases of severe acute pancreatitis combined with total parenteral nutrition [6].
- Pancreatic Enzymes: Indicated in cases of exocrine pancreatic insufficiency [6]. It is often advisable to accompany oral refeeding with enzyme supplementation.
- Probiotics and Immunonutrition: Not recommended due to insufficient scientific evidence [6].
Classification of Severity
Since only patients with moderate or severe pancreatitis require nutritional support, determining the severity is essential. Several classification systems exist. Currently, the revised Atlanta classification (mild, moderate, severe) or the determinant-based classification (mild, moderate, severe, critical) should be applied [9].
Revised Atlanta Criteria [3]
| Classification | Organ Failure | Local or Systemic Complications | |
| Mild | No | No | |
| Moderate | Transient (<48 h) | and/or | Present |
| Severe | Persistent (>48 h) single or multiple |
Typically present |
Determinant-Based Classification [4]
| Classification | (Extra)Pancreatic Necrosis | Organ Failure | |
| Mild | No | and | No |
| Moderate | Sterile | and/or | Transient (<48 h) |
| Severe | Infected | or | Persistent (>48 h) |
| Critical | Infected | and | Persistent (>48 h) |
- Forsmark, C.E., S.S. Vege, and C.M. Wilcox, Acute Pancreatitis. N Engl J Med, 2016. 375(20): p. 1972-1981.
- Forsmark, C.E. and J. Baillie, AGA Institute technical review on acute pancreatitis. Gastroenterology, 2007. 132(5): p. 2022-44.
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- Kondrup, J., et al., Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr, 2003. 22(3): p. 321-36.
- Arvanitakis, M., et al., ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr, 2020. 39(3): p. 612-631.
- Sobotka, L., Basics in clinical nutrition Fifth Edition. 2019.
- Wu, L.M., et al., Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis. Br J Surg, 2014. 101(13): p. 1644-56.
- Beyer, G., et al., S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. Z Gastroenterol, 2022. 60(3): p. 419-521.
Authorship:
Valentina Huwiler, PhD, Ernährungswissenschafterlin, Inselspital Bern
Zeno Stanga, MD, Ernährungsmediziner, Inselspital Bern
