Keywords
acute pancreatitis, enteral nutrition, parenteral nutrition, types of tube feeding, intolerance to oral nutrition.
How to Cite
Tsys, O. V. (2025). NUTRITION IN ACUTE PANCREATITIS: A REVIEW OF CURRENT VIEWS. Herald of Pancreatic Club, 68(3), 31-38. https://doi.org/10.33149/vkp.2025.03.05
Abstract views: 662 PDF Downloads: 223
Abstract
Nutritional support for the treatment of acute pancreatitis (AP) is an issue that is constantly being studied and developed. Nutritional support is important not only for maintaining mucosal permeability but also because AP is a metabolically demanding pathological process that activates an inflammatory cascade that leads to catabolic stress, the formation of reactive oxygen species, and the activation of immune responses that can quickly suppress innate immune regulation and antioxidant capacity.
Traditionally, patients on the standard nutrition protocol start with a hypocaloric liquid diet, and if this first meal is well tolerated, a light diet is gradually introduced, followed by a fuller diet (solid foods with the calorie and fat content of a normal or low-fat diet) until the patient can take a full oral diet. Although this protocol is widely used, in practice, many randomised controlled trials have shown that immediate oral nutrition close to a normal diet is safe in presumed mild pancreatitis and may even lead to a shorter hospital stay.
The first meal that patients with AP receive is crucial in determining whether oral nutrition is tolerated. In line with this goal, the timely administration of low-dose enteral nutrition (EN) is a widely supported approach. All international guidelines state that EN, which is preferable to full parenteral nutrition, should provide nutritional support in severe AP.
Due to slow gastric emptying, patients may not be able to tolerate feeding through a nasogastric tube. Theoretically, feeding through a nasogastric tube can stimulate a more active secretion of pancreatic juice. However, while the placement of a nasogastric tube is a simple procedure, the nasojejunal tube must be placed radiologically or endoscopically, which can cause a delay in the onset of early EN.
A systematic review and meta-analysis of the literature on EN formulas in AP showed that the use of polymeric formulas compared to semi-elemental formulas does not significantly increase the risk of nutritional intolerance, infectious complications, or death in patients with AP.
References
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28. McClave S. A., Taylor B. E., Martindale R. et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016; 40: 159–211. https://doi.org/10.1177/0148607109335234.
29. McClave S. A. Factors that worsen disease severity in acute pancreatitis: implications for more innovative nutrition therapy. Nutr Clin Pract. 2019; 34(Suppl 1): S43–S48. https://doi.org/10.1002/ncp.10371.
30. Meier R., Beglinger C., Layer P. et al. ESPEN guidelines on nutrition in acute pancreatitis. European Society of Parenteral and Enteral Nutrition. Clin Nutr. 2002; 21: 173–183. https://doi.org/10.1054/clnu.2002.0543.
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38. Petrov M. S., Atduev V. A., Zagainov V. E. Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A meta-analysis. Int J Surg. 2008; 6: 119–124. https://doi.org/10.1016/j.ijsu.2008.01.003.
39. Petrov M. S., Loveday B. P., Pylypchuk R. D. et al. Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg. 2009; 96: 1243–1252. https://doi.org/10.1002/bjs.6862.
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41. Poropat G., Giljaca V., Hauser G. et al. Enteral nutrition formulations for acute pancreatitis. Cochrane Database Syst Rev. 2015; (3): CD010605.
42. Pupelis G., Plaudis H., Zeiza K. et al. Oral feeding in necrotizing pancreatitis. Acta ChirBelg. 2014; 114: 34–39.
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45. Roberts K. M., Nahikian-Nelms M., Ukleja A. et al. Nutritional aspects of acute pancreatitis. Gastroenterol Clin North Am. 2018; 47: 77–94. https://doi.org/10.1016/j.gtc.2017.10.002.
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47. Song J., Zhong Y., Lu X. et al. Enteral nutrition provided within 48 hours after admission in severe acute pancreatitis: a systematic review and meta-analysis. Medicine (Baltimore). 2018; 97: ell871. https://doi.org/10.1097/MD.0000000000011871.
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2. Besselink M. G., van Santvoort H. C., Buskens E. et al. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet. 2008; 371(9613): 651–659. https://doi.org/10.1016/S0140-6736(08)60207-X.
3. Bevan M. G., Asrani V., Petrov M. S. The oral refeeding trilemma of acute pancreatitis: what, when and who? Expert Rev Gastroenterol Hepatol. 2015; 9: 1305–1312. https://doi.org/10.1586/17474124.2015.1079125.
4. Bevan M. G., Asrani V. M., Bharmal S. et al. Incidence and predictors of oral feeding intolerance in acute pancreatitis: a systematic review, meta-analysis, and meta-regression. Clin Nutr. 2017; 36: 722–729. https://doi.org/10.1016/j.clnu.2016.06.006.
5. Bouffard Y. H., Delafosse B. X., Annat G. et al. Energy expenditure during severe acute pancreatitis. JPEN J Parenter Enteral Nutr. 1989; 13: 26–29. https://doi.org/10.1177/014860718901300126.
6. Cassim M. M., Allardyce D. B. Pancreatic secretion in response to jejunal feeding of elemental diet. Ann Surg. 1974; 180: 228–231. https://doi.org/10.1097/00000658-197408000-00017.
7. Chang Y. S., Fu H. Q., Xiao Y. et al. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a meta-analysis. Crit Care. 2013; 17: RU8. https://doi.org/10.1186/cc12790.
8. Crockett S. D., Wani S., Gardner Т. et al. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology. 2018; 154: 1096–1101. https://doi.org/10.1053/j.gastro.2018.01.032.
9. Dickerson R. N., Vehe K. L., Mullen J. et al. Resting energy expenditure in patients with pancreatitis. Crit Care Med. 1991; 19: 484–490. https://doi.org/10.1097/00003246-199104000-00005.
10. Dungan K. M., Braithwaite S. S., Preiser J. C. Stress hyperglycaemia. Lancet. 2009; 373(9677): 1798–1807. https://doi.org/10.1016/S0140-6736(09)60553-5.
11. Eatock F. C., Brombacher G. D., Steven A. et al. Nasogastric feeding in severe acute pancreatitis may be practical and safe. Int J Pancreatol. 2000; 28: 23–29. https://doi.org/10.1385/IJGC:28:1:23.
12. Eatock F. C., Chong P., Menezes N. et al. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005; 100: 432–439. https://doi.org/10.1111/j.1572-0241.2005.40587.x.
13. Eckerwall G. E., Tingstedt B. B., Bergenzaun P. et al. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery: a randomized clinical study. Clin Nutr. 2007; 26: 758–763. https://doi.org/10.1016/j.clnu.2007.04.007.
14. Endo A., Shiraishi A., Fushimi K. et al. Comparative effectiveness of elemental formula in the early enteral nutrition management of acute pancreatitis: a retrospective cohort study. Ann Intensive Care. 2018; 8: 69. https://doi.org/10.1186/s13613-018-0414-6.
15. Feller J.H., Brown R.A., Toussaint G. et al. Changing methods in the treatment of severe pancreatitis. Am J Surg. 1974; 127: 196–201. https://doi.org/10.1016/0002-9610(74)90157-3.
16. Grant J.P., Davey-McCrae J., Snyder P.J. Effect of enteral nutrition on human pancreatic secretions. JPEN J Parenter Enteral Nutr. 1987; 11: 302–304. https://doi.org/10.1177/0148607187011003302.
17. Greenberg J. A., Hsu J., Bawazeer M. et al. Clinical practice guideline: management of acute pancreatitis. Can J Surg. 2016; 59: 128–140. https://doi.org/10.1503/cjs.015015.
18. Guo Z. Z., Wang P., Yi Z. et al. The crosstalk between gut inflammation and gastrointestinal disorders during acute pancreatitis. Curr Pharm Des. 2014; 20: 1051–1062. https://doi.org/10.2174/13816128113199990414.
19. Hill G. L., Jonathan E., Rhoads Lecture. Body composition research: implications for the practice of clinical nutrition. JPEN J Parenter Enteral Nutr. 1992; 16: 197–218. https://doi.org/10.1177/0148607192016003197.
20. Italian Association for the Study of the Pancreas, Pezzilli R., Zerbi A., Campra D. et al. Consensus guidelines on severe acute pancreatitis. Dig Liver Dis. 2015; 47: 532–543. https://doi.org/10.1016/j.dld.2015.03.022.
21. Kang W., Gomez F. E., Lan J. et al. Parenteral nutrition impairs gut-associated lymphoid tissue and mucosal immunity by reducing lymphotoxin beta receptor expression. Ann Surg. 2006; 244: 392–399. https://doi.org/10.1097/01.sla.0000234797.42935.46.
22. Kotani J., Usami M., Nomura H. et al. Enteral nutrition prevents bacterial translocation but does not improve survival during acute pancreatitis. Arch Surg. 1999; 134: 287–292. https://doi.org/10.1001/archsurg.134.3.287.
23. Kumar A., Singh N., Prakash S. et al. Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol. 2006; 40: 431–434. https://doi.org/10.1097/00004836-200605000-00013.
24. Larino-Noia J., Lindkvist B., Iglesias-Garcia J. et al. Early and/or immediately full caloric diet versus standard refeeding in mild acute pancreatitis: a randomized open-label trial. Pancreatology. 2014; 14: 167–173. https://doi.org/10.1016/j.pan.2014.02.008.
25. Lherm T., Monet C., Nougiere B. et al. Seven cases of fungemia with Saccharomyces boulardii in critically ill patients. Intensive Care Med. 2002; 28: 797–801. https://doi.org/10.1007/s00134-002-1267-9.
26. McArdle A. H., Echave W., Brown R. et al. Effect of elemental diet on pancreatic secretion. Am J Surg. 1974; 128: 690–692. https://doi.org/10.1016/s0002-9610(74)80031-0.
27. McClave S. A., Chang W. K., Dhaliwal R. et al. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006; 30: 143–156. https://doi.org/10.1177/0148607106030002143.
28. McClave S. A., Taylor B. E., Martindale R. et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016; 40: 159–211. https://doi.org/10.1177/0148607109335234.
29. McClave S. A. Factors that worsen disease severity in acute pancreatitis: implications for more innovative nutrition therapy. Nutr Clin Pract. 2019; 34(Suppl 1): S43–S48. https://doi.org/10.1002/ncp.10371.
30. Meier R., Beglinger C., Layer P. et al. ESPEN guidelines on nutrition in acute pancreatitis. European Society of Parenteral and Enteral Nutrition. Clin Nutr. 2002; 21: 173–183. https://doi.org/10.1054/clnu.2002.0543.
31. Meier R., Ockenga J., Pertkiewicz M. et al. ESPEN guidelines on enteral nutrition: pancreas. Clin Nutr. 2006; 25: 275–284. https://doi.org/10.1016/j.clnu.2006.01.019.
32. Mirtallo J. M., Forbes A., McClave S. A. et al. International consensus guidelines for nutrition therapy in pancreatitis. JPEN J Parenter Enteral Nutr. 2012; 36: 284–291. https://doi.org/10.1177/0148607112440823.
33. Moraes J. M., Felga G. E., Chebli L. et al. A full solid diet as the initial meal in mild acute pancreatitis is safe and results in a shorter length of hospitalization: results from a prospective, randomized, controlled, double-blind clinical trial. J Clin Gastroenterol. 2010; 44: 517–522. https://doi.org/10.1097/MCG.0b013e3181c986b3.
34. Neviackas J. A., Kerstein M. D. Pancreatic enzyme response with an elemental diet. Surg Gynecol Obstet. 1976; 142: 71–74.
35. Pagliari D., Saviano A., Newton E. E. et al. Gut microbiota-immune system crosstalk and pancreatic disorders. Mediators Inflamm. 2018; 2018: 7946431. https://doi.org/10.1155/2018/7946431.
36. Pan L. L., Li J., Shamoon M. et al. Recent advances on nutrition in treatment of acute pancreatitis. Front Immunol. 2017; 8: 762. https://doi.org/10.3389/fimmu.2018.00849.
37. Pendharkar S. A., Plank L. D., Windsor J. et al. Quality of life in a randomized trial of nasogastric tube feeding in acute pancreatitis. JPEN J Parenter Enteral Nutr. 2016; 40: 693–698. https://doi.org/10.1177/0148607115574290.
38. Petrov M. S., Atduev V. A., Zagainov V. E. Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A meta-analysis. Int J Surg. 2008; 6: 119–124. https://doi.org/10.1016/j.ijsu.2008.01.003.
39. Petrov M. S., Loveday B. P., Pylypchuk R. D. et al. Systematic review and meta-analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg. 2009; 96: 1243–1252. https://doi.org/10.1002/bjs.6862.
40. Petrov M. S., van Santvoort H. C., Besselink M. G. et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch Surg. 2008; 143: 1111–1117. https://doi.org/10.1001/archsurg.143.11.1111.
41. Poropat G., Giljaca V., Hauser G. et al. Enteral nutrition formulations for acute pancreatitis. Cochrane Database Syst Rev. 2015; (3): CD010605.
42. Pupelis G., Plaudis H., Zeiza K. et al. Oral feeding in necrotizing pancreatitis. Acta ChirBelg. 2014; 114: 34–39.
43. Ragins H., Levenson S. M., Signer R. et al. Intrajejunal administration of an elemental diet at neutral pH avoids pancreatic stimulation. Studies in dog and man. Am J Surg. 1973; 126: 606–614.
44. Rinninella E., Annetta M. G., Serricchio M. et al. Nutritional support in acute pancreatitis: from physiopathology to practice. An evidence-based approach. Eur Rev Med Pharmacol Sci. 2017; 21: 421–432.
45. Roberts K. M., Nahikian-Nelms M., Ukleja A. et al. Nutritional aspects of acute pancreatitis. Gastroenterol Clin North Am. 2018; 47: 77–94. https://doi.org/10.1016/j.gtc.2017.10.002.
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