Pancreatitis: to feed or not to feed?

Broome Hospital  – world leaders in rates of pancreatitis.  We see soooo much pancreatitis that it is just hardly worth doing serum markers, they are always up!  This for me is a “diagnose on history” scenario!

So I thought I would look at the literature – and found a few interesting, practice-changing pieces of data when it comes to managing the non-gallstone [AKA alcoholic] pancreatitis.  In fact, we often find stones on USS and then remove the gallbag – only to have recurrence a few weeks later – apparently cholecystectomy is not one of the 12 steps!

So here is a bit of a wrap up on the literature for acute (non-gallstone) pancreatitis:

Well – no. In fact fasting has not been shown to help and probably increases the length of admission.  I was always taught this – feeding can increase enzyme production and cause “auto-digestion” – but according to the recent evidence it just aint so – they get better quicker and don’t suffer worse inflammation / mortality etc.  And if you have a nasogastric tube in – then that is fine – it does not need to be a nasojejunal tube to avoid the dreaded enzymes.  There was a Cochrane review in 2010 which reached the same conclusion – feed them!

In the ICU population the use of TPN IV nutrition has been popular – however it looks like it may actually increase your mortality and infectious complications compared to enteral nutrition – review article here.

When I was at school, the answer was NO – it is a sterile process by the text book.

However things change and IV Abs have been used in the severe, necrotic end of the spectrum of disease with some benefit. A meta-analysis in Annals of Surgery suggested a benefit – but it was not an overwhelming one to my reading.  However this review suggested IV meropenem was a good thing for a necrotic collection

The short answer is – not initially, a delayed surgical strategy seems to be beneficial. Surgery is probably best reserved for the true necrotic collection (necrosectomy) with a washout. BUt I am not a surgeon – so ask you local guy…

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