Western-type diet influences mortality from necrotising pancreatitis and demonstrates a central role for butyrate.

OBJECTIVE: The gut microbiota are the main source of infections in necrotising pancreatitis. We investigated the effect of disruption of the intestinal microbiota by a Western-type diet on mortality and bacterial dissemination in necrotising pancreatitis and its reversal by butyrate supplementation. DESIGN: C57BL/6 mice were fed either standard chow or a Western-type diet for 4 weeks and were then subjected to taurocholate-induced necrotising pancreatitis. Blood and pancreas were collected for bacteriology and immune analysis. The cecum microbiota composition of mice was analysed using 16S rRNA gene amplicon sequencing and cecal content metabolites were analysed by targeted (ie, butyrate) and untargeted metabolomics. Prevention of necrotising pancreatitis in this model was compared between faecal microbiota transplantation (FMT) from healthy mice, antibiotic decontamination against Gram-negative bacteria and oral or systemic butyrate administration. Additionally, the faecal microbiota of patients with pancreatitis and healthy subjects were analysed. RESULTS: Mortality, systemic inflammation and bacterial dissemination were increased in mice fed Western diet and their gut microbiota were characterised by a loss of diversity, a bloom of Escherichia coli and an altered metabolic profile with butyrate depletion. While antibiotic decontamination decreased mortality, Gram-positive dissemination was increased. Both oral and systemic butyrate supplementation decreased mortality, bacterial dissemination, and reversed the microbiota alterations. Paradoxically, mortality and bacterial dissemination were increased with FMT administration. Finally, patients with acute pancreatitis demonstrated an increase in Proteobacteria and a decrease of butyrate producers compared with healthy subjects. CONCLUSION: Butyrate depletion and its repletion appear to play a central role in disease progression towards necrotising pancreatitis.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Severe acute pancreatitis / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Pancreatitis aguda grave

Severe acute pancreatitis (SAP) causes local and systemic complications leading to high catabolic, hypermetabolic and hyperdynamic stress states with marked morbidity and mortality. In the last decade, nutritional support has become a key element in the treatment of SAP. Thus, specialized nutrition is indicated from admission, with enteral nutrition being preferred to parenteral nutrition. Enteral nutrition should be initiated early using infusion through the jejunum beyond the ligament of Treitz to minimize pancreatic stress. There are no specific studies that establish the type of diet to be used but experts recommend the use of polymeric diets. Parenteral nutrition, without a specific formula, is indicated in patients with SAP who are intolerant to enteral nutrition or when the clinical signs of pancreatitis are exacerbated or aggravated by enteral nutrition. Evenso, a minimal level of enteral infusion should be maintained to preserve the trophic effect of the intestinal mucosa. In the last few years, several studies of the administration of immunomodulatory diets in patients with SAP have been carried out to demonstrate their effects on the course of the disease. However, there are few clear recommendations on the prognostic benefits of pharmaconutrient enriched diets in these patients. There is substantial scientific evidence suggesting that the only clear indication for pharmaconutrition in patients with SAP is parenteral glutamine administration, which is recommended by all clinical guidelines with distinct grades of evidence (AU)

La pancreatitis aguda grave es una patología que cursa con complicaciones locales y sistémicas que condicionan una situación de estrés altamente catabólica, hipermetabólica e hiperdinámica con marcada morbimortalidad. En la última década, el soporte nutricional se ha convertido en uno de los puntos clave en el tratamiento de la pancreatitis aguda grave. Así, hay indicación de nutrición especializada desde el ingreso, siendo de elección la nutrición enteral sobre la nutrición parenteral administrada de forma precoz más allá del ligamento de treitz, para provocar el mínimo estímulo pancreático. No hay estudios específicos que nos aclaren cuál es el tipo de dieta a administrar, pero los expertos recomiendan la utilización de dietas poliméricas. La nutrición parenteral, sin una fórmula concreta, quedaría indicada en los pacientes con pancreatitis aguda grave que presentan intolerancia a la nutrición enteral o cuando se agravan los signos clínicos de pancreatitis al administrar la dieta enteral. Aun así, se recomienda mantener una mínima perfusión de nutrición enteral para preservar el efecto trófico de la mucosa intestinal. En los últimos años se han realizado numerosos trabajos referentes a la administración de dietas inmunomoduladoras en pacientes con pancreatitis aguda grave, con la finalidad de objetivar cambios en su evolución. Sin embargo, hay pocas recomendaciones claras en cuanto a los beneficios pronósticos de la administración de dietas enriquecidas en fármaco nutrientes, específicamente en pacientes con pancreatitis aguda grave. Sustentada por una evidencia científica relevante, el aporte de glutamina por vía parenteral en pacientes con pancreatitis aguda grave parece ser la única indicación clara de fármaco nutrición en pancreatitis aguda grave recomendando su uso todas las guías de referencia para la práctica clínica con diferentes grados de evidencia (AU)

La nutrición enteral puede mejorar la evolución de la pancreatitis aguda grave? / Can enteral nutriton improve the course of severe acute pancreatitis?

La mayoría de los casos de pancreatitis aguda se presentan como formas leves en las que no se recomienda el soporte nutricional a no ser que los pacientes no puedan reanudar su alimentación oral normal después de 5-7 días. Por el contrario, la pancreatitis grave cursa con estrés metabólico y precisa de soporte nutricional precoz. La nutrición enteral, como parte del tratamiento de la pancreatitis aguda, lleva más de una década. Estudios recientes indican que la nutrición enteral puede mejorar la evolución de la pancreatitis aguda grave, reducir las complicaciones y favorecer una recuperación más rápida de la enfermedad. La inmunonutrición y los probióticos combinados con la nutrición enteral son una alternativa promisoria, pero son necesarios estudios multicéntricos bien diseñados para establecer su rol en la pancreatitis aguda.

Most of acute pancreatitis cases present as mild cases for which nutritional support is not recommended provided the patient is able to restart normal oral intake within 5- days. By contrast, severe pancreatitis associates metabolic stress and requires early nutritional support. The application of enteral feeding as part of the treatment of acute pancreatitis goes back more than a decade now. Recent studies show that enteral nutrition may improve the course of severe acute pancreatitis, reduce its complications and promote a quicker improvement from the disease. Inmunonutrition and probiotics combined with enteral nutrition are a potentially promising alternative, but further well-designed multi-centric trials are necessary to prove their role in the treatment of acute pancreatitis.

[Importance of enteral nutrition support in necrotic hemorrhagic pancreatitis]. / Contributii la cunoasterea importantei suportului nutritional enteral în pancreatita acuta necrotico-hemoragica.

UNLABELLED: A clinical retrospec tive study was carried out on a series of 68 cases with acute pancreatitis, admitted in the General Surgery Department, Suceava County Hospital, between 2006-2009. RESULTS: A number of 50 men (73.5%) and 18 women (26.5%), aged between 29 and 69 was studied. Enteral nutrition (EN) with naso-jejunal tube placed by endoscopy was used in 55.8% of cases; naso-gastric tube in 20 patients; total parenteral nutrition (TPN) in 10 patients (14.7%). Average duration of nutrition was 15.5 days. Pancreatic complications were observed in 7 patients (70%) from the TPN group comparatively with only 11 (18.9%) in the EN group. There were no significant differences in mortality but significant in hospital costs. CONCLUSIONS: The EN support should be the preferred way of nutrition support in patients with acute pancreatitis, because it is associated with a lower incidence of infection and a reduced hospitalization.

Nutrición por sonda nasogástrica en la pancreatitis aguda grave / Nasogastric enteral nutrition in severe acute pancreatitis

Fundamento y objetivo: Valorar la tolerancia a la nutrición por sonda nasogástrica de los pacientes con pancreatitis aguda grave. Pacientes y método: Incluimos a 12 pacientes con pancreatitis aguda grave (3 o más criterios de Ranson; proteína C reactiva > 210 mg/dl) y evolución clínica desfavorable ingresados durante el año 2006. Una vez establecida la gravedad de la pancreatitis, se inició alimentación por sonda nasogástrica (10 F) con dieta polipeptídica pobre en grasas (Dietgrif®) mediante bomba de perfusión continua. Se valoraron la tolerancia a la dieta y las complicaciones. Resultados: La edad media (desviación estándar) de los pacientes (4 mujeres y 8 varones) era de 70 (11) años y la estancia media fue de 86 días (intervalo: 14-405 días). La etiología de la pancreatitis fue biliar en 8 casos, alcohólica en uno y desconocida en 3. Todos los pacientes desarrollaron complicaciones médicas y/o pancreáticas. Siete presentaban necrosis pancreática significativa en la tomografía computarizada. Tres ingresaron en la unidad de cuidados intensivos y 2 fallecieron. Ocho de los 12 pacientes (67%) toleraron perfectamente la dieta por sonda nasogástrica independientemente de sus complicaciones. En 3 hubo que interrumpir inicialmente la dieta por íleo paralítico y precisaron nutrición parenteral total de forma transitoria. Sólo en un caso fue imposible la nutrición enteral debido a estenosis duodenal. Conclusiones: La nutrición por sonda nasogástrica en los pacientes con pancreatitis aguda grave es bien tolerada y podría plantearse como una alternativa a las otras formas de nutrición

Background and objetive: To establish the nasogastric enteral nutrition tolerance in patients with severe acute pancreatitis. Patients and method: A total of 12 patients with severe acute pancreatitis ($ 3 Ranson criteria; C-reactive protein > 210 mg/dl) and adverse clinical course were included during 2006. When we verified the disease severity, nasogastric (10 F) enteral nutrition was initiated. We used a low fat semi-elemental feed (Dietgrif®) in a slow infusion rate. We evaluated the enteral nutrition tolerance and the adverse events. Results: The patient (4 women and 8 men) mean age (standard deviation) was 70 (11) years and the mean hospital stay was 86 days (range: 14-405 days). The etiology of pancreatitis was: gallstones 8, alcohol abuse one and unknown 3. All patients had medical and/or pancreatic complications. Seven had significant pancreatic necrosis detected in the abdominal computed tomography. Three patients were admitted in the critical care unit and 2 died. The nasogastric enteral nutrition was well tolerated in 8 out of 12 patients (67%) regardless of their medical or pancreatic complications. Only in 3 patients we had initially to discontinue the feeding because of ileus and total parenteral nutrition was provisionally necessary. Enteral nutrition was impossible in one patient because of duodenal stenosis. Conclusions: Nasogastric enteral nutrition is well tolerated in patients with severe acute pancreatitis and it is an alternative to others nutritional routes

[Dietary treatment in acute pancreatitis]. / Leczenie iywieniowe w ostrym zapaleniu trzustki.

Proper nourishment is one of the basic elements in treatment patients suffering from acute pancreatitis and that's why it should be introduced in early phase of the disease. Patients suffering from light pancreatitis don't need dietary treatment because regular nourishment being.introduced a few days after the disease has developed itself. The proper supply of nourishing elements is crucial to patients with acute or chronic pancreatities. In this group of patient intravenous feeding or enteral nutrition methods are being used. They work as self sufficient and independent methods or they complete one another. The most recommended is the oligomeric diet with glutamine. Despite constant controversy over nourishment, early enternal nutrition is said to be better than intravenous feeding. Due to protection of intestinal barrier the enternal nutrition decrease the translocation of bacteria and endotoxin and as a result decrease the possibility of pancreaties parenchyma. The analysis of randomized clinical studies shows the improvement of clinical treatment and the improvement of prognosis in the group of patients using enternal nutrition. The number of complications and mortality rate has also decreased in this group. It allows also to shorten the hospitalization and cut the treatment costs. The patients, which do not tolerate internal nutrition or which cannot put up with intestinal entrance are to be fed with intravenous feeding. Presented above positive results of acute panctreatitis treatment, which were achieved after using internal nutrition, are the best basis for introducing this method in clinical practice.

A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis.

BACKGROUND & AIMS: Patients recovering from mild acute pancreatitis typically receive a clear liquid diet (CLD) when ready to initiate oral nutrition. Patient discharge then depends on their successful advancement to solid food. We hypothesized that initiating oral nutrition with a low-fat solid diet (LFSD) after mild pancreatitis would be well tolerated and would result in a shorter length of hospitalization (LOH). METHODS: Patients with mild pancreatitis were randomized to a CLD or LFSD when they were ready to resume oral nutrition. Decisions about diet advancement and hospital discharge were at the discretion of the medical team, without input from study team members. Patients were monitored daily for recurrence of pain, need to stop feeding, post-refeeding LOH (primary end point), and for 28 days post-refeeding to capture re-admission rates. RESULTS: We randomized 121 patients: 66 to CLD and 55 to LFSD. The number of patients requiring cessation of feeding because of pain or nausea was similar in both groups (6% for CLD, 11% for LFSD; P = .51). The median LOH after refeeding was identical in both groups (1-day interquartile range, 1-2; P = .77). Patients in the LFSD arm consumed significantly more calories and grams of fat than those in the CLD arm during their first meal and on study day 1. There was no difference in the 28-day re-admission rates between the 2 arms. CONCLUSIONS: Initiating oral nutrition after mild acute pancreatitis with an LFSD appeared safe and provided more calories than a CLD, but did not result in a shorter LOH.

Nutrition support in severe acute pancreatitis.

Nutritional support can improve the outcome from severe acute pancreatitis in two ways: first by providing the building blocks for tissue repair and recovery, and second, by modulating the inflammatory response and preventing organ failure, both of which are responsible for most of the morbidity and mortality associated with the disease. This review discusses the evidence on which these statements are based.

Nutrición artificial en la pancreatitis aguda / Artificial nutrition in acute pancreatitis

La pancreatitis aguda es una patología cuya etiología más frecuente es la litiasis biliar y la ingesta de alcohol. Si bien en el 80% de los pacientes suele tener un curso clínico leve, un 20% de los pacientes presenta una pancreatitis grave que se acompaña de necrosis pancreática, absceso o seudoquiste, con disfunción multiorgánica y una respuesta hipermetabólica exacerbada, siendo estos pacientes los que van a requerir un tratamiento más complejo con soporte nutricional intensivo. En esta puesta al día revisamos la fisiopatología y la nutrición artificial en la pancreatitis aguda, de forma que los estudios clínicos publicados en los últimos años nos proporcionan una evidencia científica suficiente para aconsejar en la pancreatitis aguda la utilización de la nutrición enteral sobre la nutrición parenteral, al presentar menor tasa de complicaciones globales y sepsis, con un coste inferior de la nutrición enteral respecto a la nutrición parenteral (AU)

The most frequent etiologies of acute pancreatitis are gallstones and alcohol consumption. Although the clinical course is mild in 80% of patients, severe pancreatitis accompanied by pancreatic necrosis, abscess or pseudocyst, with multiple organ dysfunction and an exaggerated hypermetabolic response, develop in 20% and it is these patients who will require more complex treatment with intensive nutritional support. The present update reviews the physiopathology of artificial nutrition in acute pancreatitis. The clinical studies published in the last few years provide sufficient scientific evidence to allow the use of enteral nutrition to be recommended over parenteral nutrition in acute pancreatitis due to the lower rate of overall complications and sepsis and reduced cost associated with this treatment modality (AU)

Safety and efficacy of conservative management in acute severe pancreatitis.

Acute severe pancreatitis represents a disease with multiple complications and a high mortality rate. The clinical evolution is related to the acute systemic inflammatory response syndrome, due mainly to inflammatory mediators and pancreatic enzymes and to the infectious complications representing a peak in the incidence of death. This study aims to retrospectively analyse the outcome of patients diagnosed with acute severe pancreatitis, conservatively treated versus those surgically managed. This study includes 151 patients, each having been diagnosed with acute severe pancreatitis (CT using Balthazar's) distributed in term of age, sex and severity parameters. The conservative treatment has included antibiotics, and anti-inflammatory drugs. The imaging and biological parameters were further statistically analysed. The clinical-biological evolution has been paralleled by the CT severity index. The conservatively treated group had a better clinical-biological outcome (p<0.05), when compared with the surgically treated group. Morbidity was significantly higher in the group exposed to surgical treatment. Conservative treatment should be the first option in acute severe pancreatitis management.

Nutrición basada en la evidencia en la pancreatitis aguda y la enfermedad hepática crónica estable / Evidence-based nutrition in acute pancreatitis and stable chronic liver disease

La pancreatitis aguda es una enfermedad que, por definición, genera un aumento del catabolismo. Esta reacción metabólica, junto con la anorexia que produce la enfermedad, genera, secundariamente a la desnutrición, un claro aumento de la morbimortalidad. La desnutrición acompaña a casi un 70% de los pacientes con cirrosis, con el consiguiente aumento de complicaciones. El objetivo fue realizar una revisión para valorar la utilidad de la nutrición parenteral total y/o la nutrición enteral sobre la evolución de la pancreatitis aguda y el paciente con hepatopatía crónica estable. Con respecto a los pacientes con pancreatitis aguda, parecen existir ventajas en la administración de nutrición enteral sobre la parenteral en variables clínicas (infecciones, intervenciones quirúrgicas y estancia media) (A-B); no obstante, es necesario diseñar nuevos estudios con estratificación de los pacientes en función de la gravedad de la pancreatitis y probablemente de su etiología. La suplementación con glutamina puede ser eficaz en disminuir estancias y días de soporte (B). Con respecto a los pacientes con hepatopatía crónica estable, no existe ningún trabajo que demuestre la superioridad de la nutrición enteral sobre la parenteral, o viceversa, en variables clínicas relevantes (mortalidad, estancia, etc.). Sólo existe un trabajo que ha mostrado que la nutrición enteral es superior que la ingesta oral en disminución de la mortalidad (B). La necesidad de mejorar los diseños y realizar estudios en función de los diferentes tipos de hepatopatías crónicas y gravedad de la hepatopatía es un área prioritaria de investigación (AU)

Acute pancreatitis is a disease that, by definition, generates an increase in metabolism. This metabolic reaction, together with the anorexia produced by the disease, clearly increases morbidity and mortality secondary to malnutrition. Malnutrition affects almost 70% of patients with cirrhosis, with a consequent increase in complications. The present review aims to evaluate the utility of the use of total parenteral nutrition (TPN) and/or enteral nutrition (EN) in patients with acute pancreatitis and in those with stable chronic liver disease. In patients with acute pancreatitis, the administration of enteral nutrition seems to confer advantages over parenteral nutrition in clinical variables (infections, surgical interventions, and mean length of hospital stay) (A-B); nevertheless, further studies stratifying patients according to the severity of pancreatitis and probably its etiology should be designed. Glutamine supplementation can be effective in reducing length of hospital stay and duration of nutritional support (B). In patients with stable chronic liver disease, there are no studies that demonstrate the superiority of EN over PN, or vice versa, in relevant clinical variables (mortality, length of hospital stay, etc.). There is only one study that has demonstrated that EN is superior to oral intake in reducing mortality (B). Improved study designs and the need to perform studies according to the type and severity of liver disease should be a research priority (AU)

Pancreatitis aguda: de la evidencia al caso real / Acute Pancreatitis: from the evidence to the reality

Pancreatitis is classified as acute or chronic.Usually, acute pancreatitis is a consequence of gallstones or is idiopathic...Since the early 20th century, Moynihan described the acute pancreatitis as the most terrible intraabdominal calamity, and subsequently emphasized the prevalent role of surgical tyreatment to remove the toxins accumulated in the abdominal cavity. Likewise this treatment modality was adapted by most surgeons and it was maintained during 20 years as the key to optimal management...A opatient with acute pancreatitis was studied along, the evidence available was revised and also its real applicability since the retrospective analysis of the case, in a pathogenesis with several diagnostic and therapeutic guidelines determined by their usefulness but not because of evidence and viceversa enhanced by this one but with a difficult application