PancreatitisManual of Clinical Nutrition Management III- 91 Copyright © 2013 Compass Group, Inc.
then, as symptoms subside, progress to an oral diet (17,18,19). A recent prospective, randomized controlled
double-blind clinical trial demonstrated no difference between symptom relapse in patients with mild
pancreatitis who progressed to a solid food diet as opposed to clear liquids or a reduced-energy solid food
diet (20). The need for gradual diet advancement or reducing fat intake (eg, < 50 g/day) to reduce pancreatic
stimulation appears not to be supported by the evidence (1,17). For patients with severe pancreatitis current
guidelines suggest improved patients outcomes when early enteral nutrition (EN) is initiated over both
continued NPO and parenteral nutrition (17-19). The timing of enteral nutrition support is critical for
improving patient outcomes in severe pancreatitis. EN should be initiated within 48 to 72 hours of admission
after fluid resuscitation and when patients are hemodynamically stable. Enteral nutrition should also be
considered for patients who are malnourished, or have not been able to tolerate oral feedings within 5 to 7
days (17,18). Placement on PN should be reserved for only those patients with severe acute pancreatitis in
whom poor tolerance has been documented with EN intervention or in cases where EN is not feasible due to
access or other medical issues (1,17).
Several factors have been identified that influence tolerance to enteral feedings in patients with acute
pancreatitis (1,17,18). Complications of pancreatitis such as presence of pseudocyst, abscess, or ascites are not
a contraindication to EN (1). EN may be provided as long as tolerance is demonstrated. Evidence of
intolerance to EN (eg, increase in abdominal pain, fever, or WBC count in association with increases in
amylase, lipase) should be routinely evaluated. If intolerance is documented, a change in enteral formula may
be indicated (1). The following Table III- 25 provides guidelines for initiating EN in severe acute pancreatitis.
Table III- 25 : Guidelines for Using Enteral Nutrition in Severe Acute Pancreatitis (17,18)
Tube placement: Nasogastric, nasoduodenal or nasojejunal route are currently recommended
options (17,18). Positioning feeding tube tip just below the Ligament of Treitz
may further improve tolerance (1,16).
Feeding rate: Use continuous infusion over 24 hours per day (17,18)
Formula selection: Use small peptide based medium chain triglyceride formula such as
PeptamenTM or SubdueTM (18,21). Small peptide best tolerated in those with
diarrhea or steatorrhea.
If intolerance to semi-elemental formula documented consider (1):
Use elemental formula. Try an elemental formula that provides < 2 to 3% of total calories from fat such as
VivonexTM, CriticareTM, Vital HNTM; or switch to semi-elemental formula with small peptides and medium-
chain triglycerides such as PeptamenTM or SubdueTM.
Implications of Parenteral Nutrition (PN)
Patients who are placed on PN should be managed using hospital PN protocols and/or guidelines. If
pancreatitis is caused by hypertriglyceridemia (> 1,000 mg/dL) or the patient has a history of hyperlipidemia,
infusion of IV fat emulsion (IVFE) should be used with caution (1). Pancreatitis due to IVFE-induced
hyperlipidemia is rare unless serum triglycerides exceed 1000 mg/dL (1). IVFE is considered safe for use in
patients with pancreatitis without hypertriglyceridemia (17,18). However, IVFE should be withheld from the
PN regimen if serum triglyceride concentrations exceed 400 mg/dL (1). Consider using glutamine at 0.30 g/kg
Ala-Gln dipeptides (17, 18).
Nutrition Approaches and Intervention in Chronic Pancreatitis
Chronic pancreatitis is a chronic, persistent inflammatory state resulting in progressive, irreversible fibrosis
and destruction of the endocrine and exocrine tissue. What differentiates chronic pancreatitis from acute is
evidence of permanent damage to the anatomy or function of the gland (1). The etiologies that can lead to
chronic pancreatitis are nearly identical to those for acute pancreatitis (1). A flare up of chronic pancreatitis is
identical to acute pancreatitis (1), however, after the acute episode patients may go on to have recurrent
abdominal pain complicated by diarrhea, steatorrhea, and weight loss. Chronic pancreatitis causes many
digestive and metabolic disturbances and can compromise the patient’s nutritional status over time.
Malnutrition occurs late in the disesase course and is a result of a reduction in nutrient absorption, and an
increase in metabolic activity (1). Nutrition intervention and management should focus on maintaining the
patient’s weight, nutritional status and controlling abdominal pain through symptom management (1).
Most chronic pancreatitis patients can be managed with dietary recommendations and pancreatic enzyme
supplementation (1,17). Enzyme replacement therapy is used to control malabsorption and to relieve pain, and
should be given with meals and snacks (1,17). There is no evidence to support the contention that a fat-