Enteral Nutritional Support For Pancreatitis: Practice Gap discussion at...
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Glutamine and arginine have been tried as amino acid nutritional supplements to stabilize gut mucosa or promote nutrition, but there is not a lot of evidence that they actually work.
Most studies in children regarding enteral feeding in pancreatitis are fairly small and retrospective, but there is good reason to assume the same beneficial effects would occur as in adults.
The myth from surgical training was that feeding would stimulate hormones and the pancreas, but that is not the case.
For gallstone pancreatitis with persistent obstruction, if you have an ERCP endoscopist at your institution, do laparoscopic cholecystectomy first, and if you cannot get the stone out, then remove it by ERCP postoperatively (the adult approach).
Transcystic stone extraction techniques include flushing the stone out, pushing it back with a Fogarty catheter, or using a basket.
One study showed that operative management of gallstone pancreatitis cut down length of stay by about 2 days compared to waiting for ERCP.
If the common bile duct is dilated, the cystic duct is usually dilated, allowing placement of a choledochoscope through the cystic duct to basket the stone.
Using a basket with fluoroscopy during intraoperative cholangiogram is successful about 90% of the time for stone extraction.
The traditional teaching was to let pancreatitis settle down with an interval before cholecystectomy, but experience shows you probably do not gain with that delay; in fact, if you delay to an intermediate timepoint, you may be in a worse spot.
By the time ERCP is set up for gallstone pancreatitis, the stone has often already passed, which is why there are so many negative ERCPs.
For gallstone pancreatitis after stone passage, cholecystectomy should be performed early in the same hospitalization (within 24-48 hours if clinically improving), even if pancreatitis has not completely resolved.
There is no advantage of nasojejunal versus nasogastric feeds in pancreatitis unless the patient is vomiting and cannot tolerate nasogastric feeds.
A restrictive transfusion policy with hemoglobin threshold of 7 (rather than 9 or 10) will have no difference in mortality.
RBC transfusions may confer increased risk of DVT in pediatric patients (not NICU scenario), per JAMA Surgery paper.
In adults, evidence strongly recommends early feeding (24 to 48 hours) with enteral feedings for acute pancreatitis.
The route of enteral feeding (nasogastric vs nasojejunal) does not seem to make any difference in pancreatitis management.
In adults, enteral feeding in pancreatitis reduces morbidity, infectious complications, and mortality, particularly with severe pancreatitis but even in mild to moderate cases, based on meta-analyses and multiple studies.
There is no benefit to supplemental administration of specific amino acids (glutamine, arginine) in pancreatitis cases.
Studies specifically tracked pain and lipase levels and found they did not particularly correlate with enteral feeding; feeding did not cause these parameters to increase.
SAGES is now recommending a paradigm change: even for a stuck stone in gallstone pancreatitis, try laparoscopic cholecystectomy with intraoperative cholangiogram first, then send for ERCP if needed; pre-operative ERCP is falling by the wayside.
If cholecystectomy is delayed until a month after gallstone pancreatitis, the pancreatitis can recur.
Literature shows that amylase and lipase are not good predictors of severity of pancreatitis.