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Nutrition Support in Acute Pancreatitis: A Systematic Review of the Literature
Stephen A. McClave, MD*,
Wei-Kuo Chang, MD ,
Rupinder Dhaliwal, RD and
Daren K. Heyland, MD
From the * Department of Medicine, University of
Louisville School of Medicine, Louisville, Kentucky;
Tri-Service General Hospital, Taipei, Taiwan,
Republic of China; and Queens University,
Kingston, Ontario, Canada
Correspondence: Stephen A. McClave, MD, Professor of Medicine, Division of
Gastroenterology/Hepatology, University of Louisville School of Medicine,
Louisville, KY 40202. Electronic mail may be sent to
Stephen.McClave{at}louisville.edu.
Background: Failure to use the gastrointestinal (GI) tract in
patients with acute pancreatitis may exacerbate the stress response and
disease severity, leading to greater incidence of complications and prolonged
hospitalization. The objectives of this study were to determine the optimum
route for nutrition support, whether nutrition therapy is better than no
artificial nutrition support, whether specific additives to enteral or
parenteral therapy can further enhance their efficacy, and whether
methodologic differences in delivery of enteral nutrition (EN) influence
tolerance. Methods: A computerized search was performed of MEDLINE,
Cochrane database, EMBASE, and reference lists of pertinent review articles
for prospective randomized trials in adult patients with acute pancreatitis
that evaluated interventions with nutrition therapy. Primary outcome data and
surrogate endpoint parameters (for nutrition indices, stress markers, and
measures of the inflammatory/immune response) were extracted in duplicate
independently. Where appropriate, meta-analysis was performed by
random-effects model. Results: From 119 articles screened, 27
randomized controlled trials were included and analyzed. In patients admitted
for acute pancreatitis, meta-analysis of 7 trials showed that use of EN was
associated with a significant reduction in infectious morbidity (risk ratio
[RR] = 0.46; 95% confidence interval [CI], 0.29 – 0.74; p =
.001) and hospital length of stay (LOS; weighted mean difference [WMD] =
–3.94; 95% CI, –5.86 to –2.02; p < .0001), a
trend toward reduced organ failure (RR = 0.59; 95% CI, 0.28–1.27;
p = .18), with no effect on mortality (RR = 0.88; 95% CI,
0.43–1.79; p = .72) when compared with use of parenteral
nutrition (PN). Results from individual studies suggest that EN in comparison
to PN reduces oxidative stress, hastens resolution of the disease process, and
costs less. Insufficient data exist to determine whether EN improves outcome
over standard therapy (no artificial nutrition support) in patients admitted
for acute pancreatitis. However, in those patients requiring surgery for
complications of acute pancreatitis, meta-analysis of 2 trials indicates that
provision of EN postoperatively may reduce mortality (RR = 0.26; 95% CI, 0.06
– 1.09; p = .06) compared with standard therapy. PN provided
early within 24 hours of admission was shown to worsen outcome, whereas PN
provided later after full-volume resuscitation appeared to improve outcome
when compared with standard therapy. In early individual studies, specific
supplements added to EN, such as arginine, glutamine,  -3
polyunsaturated fatty acids, and probiotics, may be associated with a positive
impact on patient outcome in acute pancreatitis, compared with EN alone
without the supplements, but studies are too few to make strong treatment
recommendations. Supplementation of PN with parenteral glutamine was shown to
reduce oxidative stress and improve patient outcome (reduced duration of
nutrition therapy and decreased hospital LOS) compared with PN alone in
patients with acute pancreatis. A wide range of tolerance to EN exists,
irrespective of known influences such as mode (continuous vs bolus)
and level of infusion within the GI tract (gastric vs postpyloric).
Conclusions: Patients with acute severe pancreatitis should begin EN
early because such therapy modulates the stress response, promotes more rapid
resolution of the disease process, and results in better outcome. In this
sense, EN is the preferred route and has eclipsed PN as the new "gold
standard" of nutrition therapy. When PN is used, it should be initiated
after 5 days. The favorable effect of both EN and PN on patient outcome may be
further enhanced by supplementation with modulators of inflammation and
systemic immunity. Individual variability allows for a wide range of tolerance
to EN, even in severe pancreatitis.
Journal of Parenteral and Enteral Nutrition, Vol. 30, No. 2,
143-156 (2006)
DOI: 10.1177/0148607106030002143
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