Observation Often the Best Approach in Acute Pancreatitis

From the Mayo Clinic Advances and Controversies in Clinical Nutrition

KEY BISCAYNE, Fla—Acute pancreatitis is one of the handful of diseases in which the best therapy may be no therapy. Unlike chronic pancreatitis, which causes structural or functional changes in the pancreas, when inflammation of the pancreatic gland (ie, acute pancreatitis) resolves, the organ is left with no disease sequelae.

Louis R. Lambiase, MD, associate professor of medicine and chief of the Division of Gastroenterology at the University of Florida, Jacksonville, said at the Mayo Clinic’s 16th Annual Advances and Controversies in Clinical Nutrition meeting that most patients with acute pancreatitis do well, and 85% will not need nutritional support.

“With those patients you just wait and see until their belly pain gets better, until their bowel function returns, then you feed them. That requires no support for 2 to 3 days. Then there are patients who are very ill, usually in the intensive care unit, and they need nutritional support. They have increased energy, nitrogen, and protein requirements, and they also have decreased vitamins. Those people do need support.”

The major risk factors for acute pancreatitis include hypotension, respiratory failure, hypocalcemia, and elevated serum lactate dehydrogenase and C-reactive protein levels. The recommended treatment in most cases is to put the pancreas at rest, correct hypovolemia, and relieve the pain. In some cases, antibiotics and intravenous (IV) hyperalimentation may be indicated.

For patients with severe acute pancreatitis, IV or parenteral nutrition support is necessary. “The problem is that treating patients with parenteral nutrition seems to increase the infection rate. Those people have problems with sepsis and complications,” Dr Lambiase explained. “And the thought was that because pancreatitis predisposes you to having more infection, because the gut wall becomes thin and bacteria tend to migrate into the body through it, perhaps feeding orally or with a tube will decrease this. Several studies have been presented that showed that putting food into the gut of rats with pancreatitis decreased the amount of bacteria in the body.”

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Subsequent research showed that patients fed through a tube, as opposed to intravenously, had fewer complications. A summary of studies presented by Dr Lambiase suggests that there were fewer infections and less need for surgery in patients fed with a tube versus intravenously. Nevertheless, he told , there are still concerns with this method.

“The first is that it is difficult to get all the nutrition required through a tube into the intestine, because the intestines don’t work all that well in patients with pancreatitis. Also, some enzymes may be secreted a little more from the pancreas. The pancreatitis actually may get worse if you feed people with tube feeding, although that’s not clear. At the end of the day, probably tube feeding is better, but we may have to switch to intravenous feeding.”

Although there is no specific treatment for pancreatitis, patients who are fed do better, because they heal faster, he concluded.