Emily Feivor Clinical Research Paper Nut Sci 486 Enteral Nutrition Shows Promising Effects in Severe Acute

Pancreatic Diseased Patients Severe Acute Pancreatic Disease is diagnosed in 20% of all Acute- Pancreatic disease patients, and is primarily caused by excessive intake of alcohol or gallbladder complications. This topic is important because of our high culture influence of alcohol consumption, which puts people at a greater risk of developing pancreatitis. However 10%-20% of cases reported for severe acute pancreatic disease have an unknown cause. This disease is often mis-diagnosed as a common virus because the symptoms include nausea, vomiting, and sudden abdominal pain. However, the pancreas actually becomes inflamed leading to digestive enzymes staring their digestion processes inside of the pancreas rather than waiting to leave to the GI tract. This leads to sepsis and other organ failure due to an up regulation of inflammatory response cells (Young, et al.)4. The severity of the symptoms, including high rate of mortality, makes this a very important disease to treat, not to mention using a method with the most benefit. Nutritional support has greatly improved clinical outcomes and the route of nutrition has been very influential in reducing complications involving infections from the disease. Many studies have been done to determine whether or not enteral or parenteral nutrition is more beneficial in preventing pancreatic infection, and enteral has shown to have the upper hand in regards to hindrance. The purpose of this paper is to give a clear reasoning to why enteral nutrition is more beneficial, and why most treatment centers have chosen this route of nutrition. All studies were conducted on human models and two of the three (1,2)

studies had a group on parenteral nutrition and the other on enteral nutrition. The third, a retrospect study, compared enteral and parenteral nutrition based on severity of the disease and etiology (3). Effects of parenteral nutrition vs. effects of enteral nutrition Randomized trials are beneficial in trying to figure out ways that work and dont necessarily have any impact on the variables outside the control. This study, conducted by Xing-Mao Wu et al, included two groups in which 54 patients given parenteral nutrition and the other group had 53 patients given enteral nutrition- whose main cause of pancreatitis was biliary tract disease (gallstones) with alcoholism following a close second. Both groups had very similar male to female ratios, and they were selected based on having pancreatic necrosis, C-reactive protein level greater than 19.5 mg/dL as well as receiving prophylactic antibiotics. The results were based on four areas: organ failure, surgical interventions, incidence of pancreatic septic necroses, and mortality. In all categories, parenteral nutrition was significantly higher as compared to enteral nutrition (Surgical Intervention: PN-80% EN-22%, Septic Necroses: PN72% EN-23%, Mortality: PN-43% EN-11%). Most significantly there was roughly a 60% decrease in organ failure in the patients given enteral nutrition, primarily because of the reduced cytokine-stress response in cases of acute pancreatitis.1 In a second study Vieira et al 2 also compared parenteral and enteral methods separately (enteral n=15 and parenteral n=16) but this time a much smaller group of only 31 patients who had pancreatic disease- primarily caused by gallstones and alcoholism. They were categorized by prophylactic antibiotic chosen, use or not of somatostatin, nutrition support, length of stay, complications progression of disease, reactivation of the

disease and daily nutritional costs. They were compared based on demography, disease etiology, antibiotic prophylaxis, use or not of somatostatin, nutritional support, complications and disease progression .2. The overall goal of both these groups was to manage the patients progress with efficacy, security, morbidity, mortality, and hospitalization time 2. The study showed no significant difference between groups when it came to severity of the disease, use of nutritional support, antibiotics, surgical intervention or somatostatin. However in regards to complications, the parenteral group saw 68% of patients experienced complications such as infections, as compared to 40% of enteral patients. This is also backed up by a study done by Kalfarentozos et al. when the study found that enteral nutrition had fewer septic complications during pancreatitis therefore lessening mortality rates5. In the case of the Vierira et al. study, no patients died in the enteral nutrition route but 18.75% of patients had died in parenteral feedings, although this was not statistically significant. In reducing septic complications, enteral nutrition has proved to be significant as the best route of feeding, along with it being equally as safe and effective as parenteral nutrition in reducing toxicity6. Enteral Nutrition vs Parenteral Nutrition in regards to disease severity The review study conducted by Shaffer R.S Mok et al., concludes the same results as the studies above in that that enteral nutrition is superior in improving long-term outcomes and mortality in acute pancreatitis patients3. Mok et al,s article looked at many studies that took the severity into consideration to conclude that enteral nutrition would in fact be under-utilized based on the astounding results with acute pancreatitis. Researchers looked at 161 of Cooper University Hospitals patients with acute pancreatitis between the years of 06/2007-01/2010 who had all received supplemental nutrition of either

enteral of parenteral, and whose primary cause directed from gallstone (n=50) and alcohol induced (n=36) which was a significant portion of the sample population. The researchers were looking at patients who shared the same demographics, weight, albumin and prealbumin levels, and looked at the demands of protein for each individual. After patients were divided based on demographics, weight, etc, they were divided into subgroups based on the severity of the disease and etiology, which was determined by the BISAP score (0 being the least and 5 being most severe). From these subgroups containing a total of 161 patients, 37 patients received EN while 124 patients were supplemented via PN. When looking at the method of nutrition, it was shown that PN increased the pancreatic secretion, which intensifies the process of auto digestion in acute pancreatitis. EN, however, was noted to lessen disease progression and its complications as supported by eight review articles studied by Mok et al. whom concluded a 6% decrease in mortality rates in EN vs PN patients. Further studies looked at in this article also support that EN lessons multiple organ failure and septic complications. With this in mind, it is strongly advised to use enteral feeding over parenteral nutrition to ensure optimal health and wellbeing of a patient with acute pancreatitis3. Although all three studies showed the advantage of enteral nutrition in patients with acute pancreatitis reducing sepsis, only articles 2 &3 showed EN improving the rate of infection, multiple organ failure, and decreased mortality rates. There are some considerations that should be taken into account; both review studies (1 and 2) had relatively small population sizes and did not separate patients based on the severity of the disease like third article (3). By dividing the patients up based on the state of their disease, it can play a factor to how they are able to respond to treatments, surgeries,

nutrition routes, etc, and plays a vast role in justifying what works and what doesnt. However, based on article threes limited sample size, acute pancreatitis may have failed to show even stronger significant differences to make the study more significant. A larger study sample could have given the researchers more of a defined and persuasive answer to why EN should be used over PN in patients with acute pancreatitis. Conclusion In conclusion all three studies (1-3) have strong evidence that enteral nutrition does indeed help in the prevention of sepsis, and two studies (1,3) show improvements in reducing mortality, morbidity, increasing surgical interventions, decreasing multiple organ systems affected, as well as overall infections. One study (3) shows the results based on separation of disease severity, while the two others (1,2) base it off of randomized studies of two groups. All studies have evidence supported by other credible sources finding the same results after similar studies (4,5,6) as well as one study observing results of 8 significant studies on EN impacting MOS, mortality, surgical intervention, infections, and sepsis (3). It is conclusive that EN does in fact favor the patient when it comes to preventing sepsis and overall wellbeing of a patient suffering from acute pancreatitis and should be used over PN when administering nutritional supplementation (1,2,3). For future research, I feel it is important to indeed find the source of the disease, and group patients using BISAP to accurately justify disease severity using a large sample size. Concluding results based on the etiology and severity, researchers would be able to depict exact data results, and accumulate strong supporting evidence if and why enteral nutrition is indeed beneficial to a patient with acute pancreatitis. This would be significant in the field of dietetics when administering a route

of nutrition. The goal of a dietician is to obtain the highest quality of life, and knowing exactly how that can be obtained to reduce side effects of acute pancreatitis, is significant and worthwhile information.

1) Wu, Xing-Mao, Kai-Qiang Ji, Hai-Yuan Wang, Guo-Fu Li, Bin Zang, and Wei-Min Chen. "Total Enteral Nutrition In Prevention Of Pancreatic Necrotic Infection In Severe Acute Pancreatitis." Pancreas 39.2 (2010): 248-251. Print. 2) Vieira, Josiel Paiva, Gutemberg Fernandes de Arajo, Jos Raimundo Arajo de Azevedo, Alberto Goldenberg, and Marcelo Moura Linhares. "Parenteral Nutrition Versus Enteral Nutrition In Severe Acute Pancreatitis." Acta Cirurgica Brasileira 25.5 (2010): 449-454. Print. 3) Mok, Shaffer R.S., Patricia Henry, Punitha Shivaprasad, and Thomas A Judge. "The difference in enteral nutrition (EN) versus total parenteral nutrition (TPN) in acute pancreatitis by etiology and disease severity." Health-Internal Medicine 4.4 (2012): 242248. Print. 4) Contin Educ Anaesth Crit Care Pain (2008) 8 (4): 125-128. 5) Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg. 1997;84(12):1665-9. 6) McClave SA, Greene LM, Snider HL, Makk LJ, Cheadle WG, Owens NA, Dukes LG, Goldsmith LJ. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enteral Nutr. 1997:21(1):14-20).