Introduction:
Acute and chronic pancreatitis is the most prevalent disease of the pancreas. Even though they are benign, they are associated with a considerable risk of malnutrition and may necessitate nutritional support. The treatment of acute pancreatitis is entirely symptomatic, as there is no appropriate treatment to avoid the activation of inflammatory and proteolytic cascades. This dangerous cycle of cell signaling is thought to be predominantly activated by gram-negative bacterial infection. The gastrointestinal tract represents the most likely speculative source of bacterial infection. Bacterial translocation is triggered by increased gut permeability, which causes macromolecules like bacteria, endotoxins, and antigens to migrate from the gastrointestinal tract to the portal system, mesenteric lymph nodes, liver, spleen, and pancreas. This cascade stimulates macrophages, circulatory neutrophils, and granulocytes, triggering the production of pro-inflammatory cytokines and inflammatory responses. This inflammatory response, which is originally part of the host's defense mechanisms, becomes overly active and can become self-destructive. Unbalanced inflammatory mediator production may result in systemic inflammatory response syndrome (SIRS), infectious pancreatic necrosis, and multi-organ failure.
What Is Severe Acute Pancreatitis?
Severe acute pancreatitis (SAP) is a common septic syndrome caused by a breakdown of the gut barrier. As a result, one of the primary therapeutic objectives of SAP is to retain gut integrity to prevent the translocation of bacteria and endotoxins and to strengthen the gut immune system. Several recent clinical approaches have been developed to prevent or reduce bacterial translocation. Enteral feeding with or without immunonutrition and the use of probiotics during treatment are advised in patients with severe acute pancreatitis.
What Is Enteral Nutrition?
Enteral nutrition is administering complete nutrition preparations into the digestive tract orally or through tubes.
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Indications Include - Situations that result in or may cause a nutritional deficit while maintaining the functional integrity of the digestive tract, like intestinal diseases, digestive system surgeries, consciousness modifications, hypercatabolic states, and lack of appetite.
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Contraindications include - Mechanical blockage of the intestine.
In most cases, enteral nutrition is identified as a viable replacement for total parenteral nutrition since it retains the function of the intestines, induces very little metabolic imbalance, creates fewer problems for patients, and is less expensive. Enteral nutrition is most commonly administered through nasogastric, naso-enteric, or gastrostomy tubes.
What Are the Complications Associated with Nasogastric Feeding?
Several issues can arise when a patient is artificially fed through a nasogastric tube:
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Gastrointestinal problems such as (diarrhea, constipation, nausea, and vomiting).
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Tube-related problems such as (nasal ulcers, tube clogging, and tube dislodgement).
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Respiratory problems such as (pulmonary aspiration).
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Metabolic problems such as (hyperglycemia, hyper or dehydration, and electrolytic alterations).
The complications attributed to enteral nutrition can be avoided by properly positioning the tube and selecting an appropriate nutritional preparation in combination with a patient care plan.
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Enteral Nutrition Versus Parenteral Nutrition:
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Persistent parenteral feeding has several negative side effects, including atrophy and increased intestinal mucosa permeability. Moreover, an absence of peristaltic stimulation induces hypomotility of the gut, and bowel contents stagnation alters the intestinal microflora significantly.
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Because nutrients are taken up directly from the intestinal lumen, enteral feeding restricts the atrophic changes. Furthermore, because the nutrients are hyperosmolar, enteral feeding promotes gut motility. These pathophysiological mechanisms safeguard against abnormal intestinal flora overgrowth and increased intestinal permeability of the intestines, potentially reducing bacterial translocation.
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Marik and Zaloga found that using enteral nutrition caused a significant decrease in infectious complications and duration of hospital stay, along with reduced organ failure. However, this study failed to demonstrate that enteral feeding could lower mortality.
What Is the Time of Feeding for Patients with Severe Acute Pancreatitis?
The use of enteral feeding as soon as possible (in less than 24 hours) in acute pancreatitis patients. The trophic impact of luminal nutrients with the onset of early enteral nutrition has been identified to have a favorable impact on the maintenance of both structure and function of the mucosa in terms of maintaining the integrity of epithelial cell junctions, stimulating brush border enzymes, and preventing bacterial translocation, as well as the benefit of significantly reduced multiorgan failure and infections and mortality.
What Is the Management of Severe Acute Pancreatitis?
Management of severe acute pancreatitis and management recommendations
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Enteral vs. Parenteral Nutrition - Enteral nutrition is recommended.
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Feeding Schedule - Early feeding in less than 48 hours is recommended.
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Gastric vs. Jejunal Tube Feeding Route - Both are recommended.
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Feeding Composition - Complete solid oral diet as accepted by the patient; the elemental formula has no advantages for tube feeding.
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Insufficiency of the Pancreas - The benefit of replacement is confined to severe or necrotizing pancreatitis.
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Prebiotics and Probiotics - Inadequate data to support widespread use.
What Are the Tube-Related Complications of Nasogastric Feeding?
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The most serious complication of tube feeding is the aspiration of the pulmonary contents, which has a mortality rate ranging from 17 percent to 62 percent.
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The administration of drugs in solid form (crushed pills and capsules) through tubes results in a high frequency of tube clogging. Preventing the habit of crushing pills and replacing them with liquid medications would reduce the occurrence of this complication.
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The most common complication was accidental tube dislodgement accidentally by the patient itself, which affected up to 48 percent of patients. The first reason for discontinuing enteral nutrition and placing new tubes was patient manipulation and removal of the tube by the patient.
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Hyperglycemia occurs in 34.5 percent of patients, especially if the patient has diabetes.
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Electrolytic changes frequently took place in enteral nutrition patients. The number of episodes of these complications increased as the timeframe of enteral nutrition increased.
Conclusion:
Current findings suggest that enteral nutrition administration effectively treats severe acute pancreatitis (SAP). Enteral nutrition decreases mortality, infectious complications, and multi-organ failure. In SAP, feeding through the nasogastric tube is probably equally effective as nasojejunal feeding in terms of the enteral feeding route. However, some patients with SAP develop gastrointestinal dysfunction and are susceptible to enteral nutrition intolerance, which causes enteral nutrition to be suspended or terminated.
