P.O.Box 2345, Beijing 100023,China World J Gastroenterol 2003;9(9):2105-2108
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CLINICAL RESEARCH
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Clinical study on nutrition support in patients with severe acute
pancreatitis
Gang Zhao, Chun-You Wang, Fang Wang, Jiong-Xin Xiong
Gang Zhao, Chun-You Wang, Jiong-Xin Xiong, Pancreatic Surgery
Center, Union Hospital, Tongji Medical College, Huazhong University
of Science and Technology, Wuhan 430022, Hubei Province, China
Fang Wang, Department of Pharmacology, Tongji Medical College,
Huazhong University of Science and Technology, Wuhan 430030,
Hubei Province, China
Correspondence to: Dr. Gang Zhao, Pancreatic Surgery Center,
Union Hospital, Tongji Medical College, Huazhong University of
Science and Technology, Wuhan 430022, Hubei Province, China.
zhaogang1427@yahoo.com.cn
Telephone: +86-27-85726273
Received: 2003-03-20 Accepted: 2003-04-22
Abstract
AIM: To investigate the effect of nutritional support therapy
on severe acute pancreatitis (SAP).
METHODS: A total of 96 patients with severe acute pancreatitis
were divided randomly into control and treatment groups.
The former group received total parenteral nutrition (TPN)
via central venous infusion, while parenteral nutrition (PN)
and enteral nutrition (EN) therapies were applied in different
phases for the latter group. The nutrition status, acute phase
responses, pancreas lesions, enteric mucosa penetrability
and immune functions were monitored.
RESULTS: Body weight and prealbumin concentration were
increased in treatment group, compared to those in the control
group, but albumin concentration did not change significantly.
Acute physiology and chronic health evaluation II (APACHE II)
scores decreased after 7 d of treatment, whereas the scores of
the control group decreased on the 11
th
day. Concentrations of
tumor necrosis factor-
(TNF-
), interleukine-6 (IL-6) and
serum C reactive protein (CRP) dropped earlier in the
treatment group (on the 4
th
day) than that in the control group
(on the 7
th
day). No difference was observed in pancreatic
lesions between the control and treatment groups.
Concentration of endotoxin and lactulose/manicol (L:M) ratio
of urine did not change in treatment group, but those in the
control group were elevated markedly. Compared with the
treatment group, CD4:CD8 T cells ratio and immunoglobulin G
(IgG) concentration in the control group decreased significantly.
CONCLUSION: Compared to TPN, the combined therapy
of EN and PN could improve the nutrition status and moderate
the acute phase response obviously. Moreover, the integrity
of enteric mucosa and immune function were protected more
effectively in treatment group than in the control one. On
the other hand, EN did not simulate the excretion of pancreas
and avoid exaggerating the inflammation of pancreas. Thus,
appropriate application of PN and EN appears to be more
effective for patients with SAP.
Zhao G, Wang CY, Wang F, Xiong JX. Clinical study on nutrition
support in patients with severe acute pancreatitis. World J
Gastroenterol 2003; 9(9): 2105-2108
http://www.wjgnet.com/1007-9327/9/2105.asp
INTRODUCTION
Severe acute pancreatitis (SAP) is characterized by a diffuse
inflammatory process of the pancreas with variable involvement
of adjacent tissues and dysfunction of remote organs
[1]
. The
metabolic alterations of SAP are involved in a classical stress
state, as proposed for sepsis, including hyperdynamic changes,
hypermetabolism and hypercatabolism. Thus, artificial
nutritional support should be a suitable treatment
[2-4]
. The clinical
nutritional management of pancreatitis has changed from total
parenteral nutrition (TPN) to enteral nutrition (EN). However,
it remains to be clarified whether EN is the best approach or
not
[5-8]
. The purpose of this observation was to evaluate different
nutrition therapies for SAP.
MATERIALS AND METHODS
Patients
A total of 96 patients with SAP admitted to the Pancreatic
Surgery Center of Union Hospital (Wuhan, China) between
February 2000 and October 2002 were recruited to the
randomized study. The severity of pancreatitis was defined
according to the Atlanta classification system for acute
pancreatitis. Criteria for this observation were the acute
physiology and chronic health evaluation II (APACH II) score
higher than 8, and no indication for operation temporarily
[9, 10]
.
These patients consisted of 58 males and 38 females with a
mean age of 47.8 years (range 24-68 years). After 48 hours of
common management including active liquid resuscitation and
organ function protection
[11,12]
, the patients were divided
randomly into control and treatment groups. No significant
differences of male:female ratio (15.6:16.7) and average age
(48.2 and 46.7) were found between the two groups.
Study protocol
The 41 patients in control group were commenced on TPN via
central venous infusion. In the treatment group, PN and EN
were carried out by three stages for 55 patients. At first, the
patients of treatment group only received glutamine-
supplemented PN. When the paralysis was relieved, EN and
PN were applied at the same time. EN was administrated via a
nasojejunal feeding tube under endoscopy or X-ray. Following
the study period, the volume and speed of enteral feeding were
adjusted depending on the individual tolerance. Deficiency of
energy was compensated through glutamine-supplemented PN.
At last, the enteric feeding reached approximately 2 000 ml in
5-7 d, and PN was ceased.
Nutrition formulas
Conventional TPN was based on an amino acid solution
providing 0.25 g nitrogen/(kg·d)
with lipid emulsion and
glucose. Half of the non-protein calories were provided by
lipid. The total calorie was 30 kcal/(kg·d) and the calorie to
nitrogen ratio was 120:1 in each patient. Electrolytes, trace
elements and vitamins were added to maintain requirements
[13]
.
PN in treatment group was based on the same elements as
TPN but with supplement of 0.22 g glutamine/kg. EN formula
was Peptide-2000 (Nutricia, Holland) semi-elementary diet
Study 