*Dietary Interventions for Pancreatitis DOI: http://dx.doi.org/10.5772/intechopen.107319*


### **Table 7.**

*Consequences of malnutrition.*

### **Figure 4.**

*A schematic overview of the different types of malnutrition.*


### **Table 8.**

*Malnutrition screening and diagnostic assessment tools (used in the USA, Australia, New Zealand, Canada and Europe).*

The employment of a Screening Tool permits to immediately evaluate the nutritional status and to monitor the progression of the disease. Unfortunately, these tools are scarcely used and patients' nutritional treatment is not adequate.

### **1.4 Nutritional treatment of acute pancreatitis**

Acute Pancreatitis is traditionally treated with the suspension of food intake via mouth in order to rest the pancreas. This indication is suggested until pain is resolved or until the normalisation of the flogoses indices and/or until the pancreatic enzymes fall within acceptable normal values. However, the nutritional treatment should be planned and monitored over time, and it should include: (1) accurate evaluation of the severity of the disease; (2) proper assessment of the nutritional state; (3) correct identification of the patients with special nutritional needs. As shown in the previous paragraphs, Acute Pancreatitis may present itself very differently in clinic, thus requiring differentiated nutritional approaches.

### *1.4.1 Energy and protein need in acute pancreatitis*

The Resting Energy Expenditure (REE) in patients with Acute Pancreatitis depends on the severity of the disease. In the most severe cases it is highly increased, thus entailing a high mortality risk linked to increased catabolism. In patients with septic complications the REE may be increased by decreased splanchnic blood flow, acidosis and bacterial translocation, as a result of which the REE assessed via indirect calorimetry (REEm) may exceed up to 110–150% of the energy expenditure theoretically calculated using Harris-Benedict (REEc) formulas. A realistic evaluation at the patient's bed should assess the energy expenditure by means of REEc multiplied by a constant of 1,3 or 1,5, depending on the clinical severity. As a result of this huge energy consumption, skeletal muscle proteolysis might increase up to 80% with nitrogen losses of 20–40 g per day, hence requiring the energy and the protein need to be estimated around, respectively, 25 kcal/kg/die and 1,2–1,5 g/kg/die [24, 27, 28].

### *1.4.2 Oral vs. artificial nutrition in moderate acute pancreatitis*

Oral feeding is recommended when abdominal pain, nausea and vomiting have disappeared and, according to some authors, food intake may also take place regardless of serum lipase concentrations [29]. In this context the ideal diet includes a gradual intake of solid food and calories. Traditional diets with clear liquids and low fats (< 30% of total energy intake) have proved completely ineffective if not worsening in terms of malnutrition [30]. Early oral feeding (within 24–48 hours) should be administered also to patients undergoing minimally invasive necrosectomy, as long as haemodynamically stable, in the absence of septic complications and with normal gastro-enteric function. The use of Oral Nutritional Supplements (ONS) aimed at increasing the caloric-protein content is also recommended for these patients [31].

Being a negative prognostic factor of the disease, hyperlipaemia should be treated early with low-fat diets or, in the most severe cases, with hypolipidaemic drugs including insulin, heparin and plasmapheresis if necessary (**Figure 5**). Careful management of hyperglyceridemia appears to reduce the risk of acute pancreatitis recurrence.

Oral Nutrition has not proved less effective than Enteral Nutrition (EN) in preventing infection or death in these patients. Instead, **Table 9** shows a list of the cases in which EN after placement of nose-gastric probe is recommended.

Despite there being few data comparing it to Oral Nutrition, EN is very likely to improve these patients' prognosis, as we will see later. It should therefore be suggested early even when the development of Pancreatitis is initially uncertain (**Table 10**) [32].

**Figure 5.** *Overview of management of hypertriglyceridemia.*



### **Table 9.**

*Indications for the use of EN during acute pancreatitis.*



**Table 10.**

*Pros and cons on nutrition route in severe acute pancreatitis.*

### *1.4.3 Artificial nutrition in severe acute pancreatitis*

Being the risk of malnutrition in Severe Acute Pancreatitis particularly worrying, Parenteral Nutrition (PN) has been widely considered a first choice therapy in the past, aimed at providing such a caloric-protein intake able to maintain lean mass without stimulating the pancreas [33, 34]. However, more recent data show that PN is associated with higher risk of infections (especially from the venous catheter), besides triggering electrolyte imbalance, leading to – or aggravating – Pancreatitis-induced hyperglycaemia and increasing the risk of multi-organ dysfunction. Since PN administration does not involve enteric transit, the intestinal mucosa is at risk of atrophy, with consequent reduction of its barrier function, especially in the small intestine, thus leading to bacterial translocation [35]. All these phenomena may worsen the clinical picture.

Given these considerations, EN through nose-gastric probe should be carried out early (within 24–72 hours) in haemodynamically stable patients who do not tolerate Oral Nutrition, so as to protect the intestinal mucosa, prevent the proliferation of bacteria and stimulate bowel motility (**Figure 6**) [36, 37]. Many studies and metaanalyses show that EN significantly decreases the rate of infection (with lower levels of cytotoxic CD4 T lymphocytes and C-reactive protein), the risk of multi-organ failure, the necessity for operation and the mortality, compared to PN. Gastric EN does not lead to higher incidence of complications (such as diarrhoea, abdominal distension or increased pain), although the indication to use anti-secretory agents (somatostatin, octreotide) so as to reduce the nutrients-induced secretory action of the pancreas remains questioned.

### **Figure 6.** *Route of nutrition treatment in acute pancreatitis.*

In cases where the enteric function appears uncertain, it is recommendable not to infuse nutrients, but only a 5% low-speed glucosate solution (10–20 ml/hour for 24 hours) through the standard gastric-nose probe. The evaluation of the gastric stagnation or the distension of the loops, in addition to the use of instrumental techniques, will permit to assess the state of the enteric transit. The use of a nasojejunal probe (NJ) is recommended in patients with gastroparesis, gastric obstruction due to oedema or pancreatic pseudocyst. Since the tip of this probe, which is indicated also in case of significant regurgitation, ideally overcomes the Treitz ligament, its insertion may prove difficult, often requiring repeated positioning by endoscopy and resulting in frequent spontaneous displacement. In Severe Necrotizing Pancreatitis or in Nasopharyngeal Disorder precluding NJ placement, some scholars suggest the placement of a percutaneous gastrostomy tube with jejunal extension (PEG-J) in case of EN lasting over 4–6 weeks. These invasive techniques should be used only with complicated patients in whom the prognosis appears to be severely impaired. Finally, jejunostomy should be performed in patients undergoing surgery (**Table 11**) [38].

A possible side effect of EN is the increased Intra-Abdominal Pressure (IAP), due to which the use of boluses is never recommended, especially in case the patient is feverish or reports nausea or vomiting. On the contrary, a low flow of nutrients (20 ml/hour to be increased very slowly depending on the patient's tolerance) can guarantee, especially in the early stages, a progressive normalisation of the intestinal function.

In the most severe cases, measurement of Pulmonary Pressure is recommended. When it reaches or exceeds 15 mmhg, EN should be administered with caution. In


**Table 11.**

*Overall nutritional recommendations for severe acute pancreatitis.*

patients with pressures above 15 mmhg, in which a picture of abdominal hypertension is possible (e.g. no peristalsis, abdominal distension, elevated gastric stagnation, etc.), the development of a picture of Abdominal Compartment Syndrome (ACS) should never be excluded [39]. In this context, the use of a nasojejunal tube for EN should be preferred, although the transition to NP should always be considered. In case of IAP with pressure higher than 20 mmhg, the use of EN should be interrupted for precautionary purposes. Clinical data are reported where early EN was possible in about 30% of cases with excellent clinical results (e.g. open abdomen with rapid fascial closure, low rates of fistulation, reduction of nosocomial infections and lower hospital costs), as long as the medical staff is highly skilled in managing minimal complications and able to monitor and manage the metabolic aspects of the disease. In summary, when nutritional objectives are not attainable with EN alone, a partial or total PN should be ensured especially in hyper-catabolic patients, patients with negative nitrogen balance, patients whose gastro-enteric tract is not usable, or for whom a surgical decompression (open abdomen) is required. In these cases the additional use of glutamine (0.20 g/kg/day) appears to increase albuminaemia, decrease C-reactive protein, reduce the frequency of infections and the risk of death [40].

The use of NP should also be recommended in patients with chylous ascites not responding to a fat-free diet nor to an elemental EN diet.

### *1.4.4 Enteral nutrition formulations*

In patients with AP, a standard polymeric diet shall be used, although some studies express concern about the possibility for these nutritional formulations to induce insufficiency of exocrine pancreas (manifesting with alteration of faecal elastase and faecal fat) especially in cases of Alcoholic or Necrotizing Pancreatitis. However, polymeric diets should always be the first choice [41]. Feeding with semi-elemental diet should be performed only if persistent steatorrhea appears and absence of clostridium-difficile infection can be proved. In case of steatorrhea the use of pancreatic enzymes should be considered. The use of semi-elemental or elemental products is appropriate in cases where, despite the severity of the clinical picture (e.g. necrotizing pancreatitis), total or partial EN is possible [42]. The enteral formulations should be chosen according to the doses of faecal elastase. Despite there being several different techniques, EN in patients with Acute Pancreatitis is mostly performed with nasogastric probe.
