Nutrition in acute pancreatitis - influence on gut barrier and inflammatory response

Sammanfattning: Acute pancreatitis (AP) is associated with metabolic changes, acute inflammatory response and increased gut permeability. In AP, traditional treatment has been initial fasting on purpose to avoid activation of proteolytic enzymes and pancreatic enzyme secretion. However, enteral feeding has been suggested superior to fasting due to a proposed beneficial effect on the gut barrier function. The aim was to evaluate the present nutritional regime and the effects of enteral nutrition, oral nutrition or cellulose derivatives during AP. In the first study, 99 cases of severe AP were analyzed retrospectively and fluid resuscitation and nutritional support were evaluated. In the second study 50 patients with predicted severe AP were randomized to total parental nutrition or enteral nutrition. In study III, sixty patients were randomized to fasting or immediate oral feeding. In the last study, oral pre-treatment with cellulose derivatives or antioxidants were evaluated in experimental pancreatitis. Interleukines, CRP and leucocytes measured acute inflammatory response. Gut barrier function was determined by excretion of polyethylene glycol, endogenous endotoxin-core antibodies, Ussing chamber experiments and bacterial counts. Complications, abdominal pain, hyperglycemia and length of hospital stay, evaluated clinical outcome. The nutritional regime in severe AP included a moderate and hypocaloric initial fluid resuscitation, total parental nutrition as the preferred route for nutritional support, non-strict glucose control and associated mortality of 17%, indicating several modes of improving outcome. Nasogastric, early enteral nutrition was feasible and resulted in better blood glucose control. No beneficial effects on intestinal permeability or the inflammatory response were seen. In mild AP immediate oral feeding was feasible and may accelerate recovery without exacerbation of the disease process. In experimental acute pancreatits, pre-treatment with cellulose derivatives restored enteric microbial ecology, but did not influence on intestinal permeability.