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:
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.
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
Renal Colic Scans with Dr Adrian Goudie
Placebo paradox: Descartes dilemma
Clinical Case 114: Skull and Crackedbones
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
Thanks for this Casey…useful summary of the evidence and may make us -revisit TPN on the ICU for these patients.
Pancreatitis still scares me – not so much the initial management, but the subsequent necrotising process. Had a couple of near misses recently with erosion into gastroduodenal artery…patient goes from sitting up in bed chatting to colour of a piece of paper and systolic of 30mmHg in about 4 minutes. One of the few times could hear blood squirting at eLaparotomy.
Thanks too for the “massive transfusion” summary…>50 units PRCs and over 40 of FFP, plus cryo, pooled platelets etc made me glad had read your summary of transfusion in smaller centres.
Hi Tim
That sounds scary – eroded gastroduodenal art. = never good.
In my world pancreatits is like having an URTI – we see a lot of mild, recurrent, self-limiting EhOH-related pancreatitis – and it can be a bit easy to assume they will all get better quick. I sometimes manage as an outpatient in the mild cases – but it is pertinent to remember that a small percentage will get super-sick with SIRS and ARDS etc
It has been a bit quiet over the last few weeks – because I am working on a few BIG projects – one of which is a more evidence-based “protocol” for massive transfusion – as applied in smaller places…. watch this space
Casey
Do you give light diet or full oral diet.
I have given sandwiches to a pancreatitis patient in ED (on patient request)
they then vomited and the nurses thought I was silly
yehuda
Hi Hoods [local Broome Doc]
IN response to your Qs
– I think clear fluids, small frequent volumes with some carbos in it to “nourish the gut” is my plan – nothing to chunky, protein / fatty. No evidence just opinion. Avoid big feeds as this stimulates the CCK, pancreas, gallbladder circuit of peptides….
– The nurses thought you were silly….? yes, you are. Seen too many med student parties to suggest otherwise. Casey
It always puzzled me that mild or moderate pancreatitis on the ward floor should be let fasting while early and effective enteral nutrition is paramount in severe ones in the ICU.