Acute Pancreatitis

• Causes of acute pancreatitis

  • Gallstones
  • Alcohol
  • Idiopathic/no cause
  • Autoimmune causes
  • Hypercalcaemia
  • Drugs
• How does acute pancreatitis present?

  • Characterised by abdominal pain, serum amylase and/or lipase at least 3x higher than normal upper limit, and imaging findings (CT, MRI, US)
• What is severe acute pancreatitis (SAP)?

  Occurs in the late phase of acute pancreatitis, and can present as or lead to organ failure for more than 48hrs
• What are the two types of acute pancreatitis?

  1. Oedematous
  2. Necrotizing
• What is the nutritional status of acute pancreatitis like?

  Patients with alcohol-induced acute pancreatitis may have pre-existing malnutrition, otherwise tend to be well-nourished
• How does severe acute pancreatitis affect nutritional status?

  Negatively affects nutritional status due to organ failure which will require intensive care and many interventions as treatment
• Severe acute pancreatitis is a catabolic condition, which means greater severity will lead to greater losses of muscle and nutrition stores in the body
• Complications of severe acute pancreatitis that affect nutrition


  • Hyperglycaemia
  • Malabsorption
  • Delayed gastric emptying
• Even once nutrition provision is commenced, likely as EN, nutritional status is still at risk of declining
• A 2021 study found patients with severe acute pancreatitis had a mean weight loss of 14% from pre-morbidity to discharge, which is clinically significant and suggestive of malnutrition
• The extent of necrosis and resection of the pancreas needed in severe acute pancreatitis also influences long-term nutritional status
• Pancreatic exocrine insufficiency (PEI)

  Occurs with significant resection of the pancreatic head, requires long-term pancreatic enzyme replacement therapy (PERT)
• Type 3c diabetes mellitus

  Occurs with resection/damage to the tail of the pancreas, leads to endocrine insufficiency
• Short-term nutritional management of severe acute pancreatitis

  1. Offer enteral nutrition within 72hrs of presentation

  Why?

  • Reduce risk of gut atrophy, bacterial translocation, and infected necrosis
  • Stimulate intestinal motility and maintain gut mucosal integrity
• A 2010 Cochrane review found enteral nutrition significantly reduced mortality, multiple organ failure, systemic infection and the need for operative interventions compared to TPN
• Delays in feeding due to investigations and procedures are common in clinical practice
• Complications that can affect delivery and tolerance of enteral nutrition in severe acute pancreatitis


  • Delayed gastric emptying
  • Nausea and vomiting
  • High nasogastric aspirates
  • Paralytic ileus
  • Antibiotic-related diarrhoea
• Mode of feeding: nasogastric (NG) vs nasojejunal (NJ) feeding?

  ESPEN guidelines 2022 recommend NG unless the patient has digestive intolerance, then NJ should be used
• A 2020 Cochrane review found little to no difference in outcomes for severe acute pancreatitis patients between NG and NJ feeding routes
• Enteral nutrition formulation


  ESPEN recommend a standard polymeric feed, but in severe acute pancreatitis malabsorption may indicate a semi-elemental formula
• A 2015 Cochrane review found no significant benefit of different enteral nutrition formulations in severe acute pancreatitis
• Oral intake in severe acute pancreatitis

  • Soft/liquid based diets may reduce pancreatic stimulation, but need to ensure they meet full nutritional requirements
  • Pancreatic rest may be required in more severe cases, with restriction of oral intake and initiation of enteral nutrition
• Opiates are usually used for pain management, but can cause constipation and nausea which impacts nutrition
• Long-term nutritional management of severe acute pancreatitis


  1. Management of endocrine insufficiency (type 3c diabetes)

  2. Management of exocrine insufficiency (pancreatic enzyme replacement therapy)
• Type 3c diabetes


  Patients may become prone to sudden hypoglycaemia due to lack of glucagon, requires insulin management
• Pancreatic exocrine insufficiency (PEI)


  Impacts absorption of fat, leading to malabsorption, steatorrhea, abdominal bloating, flatulence, weight loss, and fat-soluble vitamin deficiencies
• Management of PEI


  • Pancreatic enzyme replacement therapy (PERT)
  • Avoidance of low-fat diets which exacerbate malnutrition
  • Moderate fat advice for malnourished patients requiring long-term nutrition support
• Routine supplementation of vitamin D is required, as well as routine monitoring of vitamin D and parathyroid hormone status in patients with PEI
• What is the nutritional status of acute pancreatitis patients like? 


  Patients with high alcohol intake may have pre-existing malnutrition

  Otherwise most patients well-nourished