Gunilla Eckerwall

Early nasogastric feeding in predicted severe acute pancreatitis: a clinical, randomized study.

Objective:To compare the efficacy and safety of early, nasogastric enteral nutrition (EN) with total parenteral nutrition (TPN) in patients with predicted severe acute pancreatitis (SAP). Summary Background Data:In SAP, the magnitude of the inflammatory response as well as increased intestinal permeability correlates with outcome. Enteral feeding has been suggested superior to parenteral feeding due to a proposed beneficial effect on the gut barrier. Methods:Fifty patients who met the inclusion criteria were randomized to TPN or EN groups. The nutritional regimen was started within 24 hours from admission and EN was provided through a nasogastric tube. The observation period was 10 days. Intestinal permeability was measured by excretion of polyethylene glycol (PEG) and concentrations of antiendotoxin core antibodies (Endocab). Interleukins (IL)-6 IL-8, and C-reactive protein (CRP) were used as markers of the systemic inflammatory response. Morbidity and feasibility of the nutritional route were evaluated by the frequency of complications, gastrointestinal symptoms, and abdominal pain. Results:PEG, Endocab, CRP, IL-6, APACHE II score, severity according to the Atlanta classification (22 patients), and gastrointestinal symptoms or abdominal pain did not significantly differ between the groups. The incidence of hyperglycemia was significantly higher in TPN patients (21 of 26 vs. 7 of 23; P < 0.001). Total complications (25 vs. 52; P = 0.04) and pulmonary complications (10 vs. 21; P = 0.04) were significantly more frequent in EN patients, although complications were diagnosed dominantly within the first 3 days. Conclusion:In predicted SAP, nasogastric early EN was feasible and resulted in better control of blood glucose levels, although the overall early complication rate was higher in the EN group. No beneficial effects on intestinal permeability or the inflammatory response were seen by EN treatment.

Incidence, management and recurrence rate of acute pancreatitis.

Background: Acute pancreatitis is a common condition that is still associated with substantial morbidity and mortality rates. Management, outcome and recurrence rate in acute pancreatitis in a clinical setting using a conservative management approach are described. Methods: A total of 1376 consecutive cases representing 2211 hospitalizations due to acute pancreatitis treated at the Dept. of Surgery, Lund University Hospital, Lund, were reviewed retrospectively. Management, outcome and recurrence rate were recorded. Results: Incidence, including recurrences, was 300 per million per year; 21% of patients had recurrent (≥2) attacks. In relapsing disease, two‐thirds of patients had the first attack within 3 months. Mortality decreased over the period studied, but overall it was 4.2%; mortality in relapsing attacks was 2.5%, related to multiple organ dysfunction (MODS) in 67% and occurring within the first week in 36%. Conclusions: Despite a conservative approach in the management of acute pancreatitis, mortality is still substantial, frequently occurs early after admission, is associated with MODS and is also seen in relapsing disease. Early cholecystectomy and bile duct clearance could decrease recurrent attacks of biliary pancreatitis.

Severe Acute Pancreatitis - Outcome following a Primarily Non-Surgical Regime.

Background/Aims: Severe acute pancreatitis (SAP) is associated with a high morbidity and mortality. The aim was to evaluate treatment, risk factors and outcome in SAP in a centre with a restrictive attitude to surgery. Methods: All cases of acute pancreatitis admitted 1994–2003 were analysed retrospectively. SAP was defined as organ failure and/or hospital stay >7 days together with one or more of: C-reactive protein >150 mg/l within 72 h after admission, necrosis on computed tomography and need for treatment in the intensive care unit. Results: 185 (22%) of patients with acute pancreatitis fulfilled the criteria for SAP. 175 patients were included, mean age 61 ± 17 years. Hospital stay was in median 13 days. Forty-six patients had some surgical intervention, in 14 cases directed at the pancreas (8%). Hospital mortality was 9% (n = 16), in 88% (n = 14) associated with multiple organ dysfunction and 50% (n = 8) of the deaths occurred within the first week after admission. Of the parameters registered on admission, age and hypotension (systolic blood pressure <100 mm Hg) were identified as risk factors for death. Conclusion: The present treatment regime for SAP as defined above resulted in a 9% mortality rate, with age and hypotension at admission as predictive factors for death.

Acute pancreatitis - from cellular signalling to complicated clinical course.

Acute pancreatitis (AP) is a common disease that has a mild to moderate course in most cases. During the last decade, a change in diagnostic facilities as well as improved intensive care have influenced both morbidity and mortality in AP. Still, however, a number of controversies and unresolved questions remain regarding AP. These include prognostic factors and how these may be used to improve outcome, diagnostic possibilities, their indications and optimal timing, and the systemic inflammatory reaction (systemic inflammatory response syndrome--SIRS) and its effect on the concomitant course of the disease and potential development of organ failure. The role of the gut has been suggested to be important in severe AP, but has recently been somewhat questioned. Despite extensive research, pharmacological and medical intervention of proven clinical value is scarce. Various aspects on surgical interventions, including endoscopic sphincterotomy, cholecystectomy and necrosectomy, as regards indications and timing, will be reviewed. Last, but not least, are the management of late complications and long-term outcome for patients with especially severe AP.