胰腺炎的營養(yǎng)治療課件

NutritioninAcutePancreatitis“AnEvidenceBasedApproach”

NutritioninAcutePancreatWhichpatientsbenefitsfromnutritionalsupportinacutepancreatitis?Allpatientswithacutepancreatitis?

(Mildpancreatitisisdifferentfromseverepancreatitis)Enteralorparenteral?Whereistheevidence?WhichpatientsbenefitsfromnSeverity(Clinical,laboratoryandradiologicalsigns)

NutritionalstatusOutcomepredictors-Mildform(~80%)

-Severeform(~20%)

Outcomepredictors-MildformSeverityassesmentMildform (~80%)

-Ransonsigns3

-CRP<120mg/l

-APACHEIIscore8

-Balthazar‘s-CT-score3

Severeform (~20%)

-Ransoncirteria>3

-CRP>120mg/l

-APACHEIIscore>8

-Balthazar‘s-CT-score>3Severityassesment1068patients,meanage52.8yrs,589edematousAP,479severeAPMORTALITY:total7.8%,mild

aP1%,severeaP16.1%SeverityandoutcomeMortalitycanincreasetoupto40%ifsepsisandMOFoccur1068patients,meanage52.8yESPENGuidelines

EnteralNutrition: ClinicalNutritionVol25(2),April2006ParenteralNutrition: ClinicalNutritionVol28,July2009

/education/

guidelines.htmESPENGuidelines

EnteralNutriSeverityofacutepancreatitiscanbeassessedadequately

Forartificialnutritionalinterventionsmildpancreatitishastobeseparatedfromseverepancreatitis

Nutritionalstatushastobeassessedonadmissionandduringthecourseofthedisease

RecommentationIRecommentationIMaingoalsfornutritioninacutepancreatitisToprovidecalorieswithENorPNtoreverseproteincatabolismwithoutstimulationoftheexocrinepancreaticsecretionToimproveortoavoidnutritionaldepletionToreducemorbidityandmortalityMaingoalsfornutritioninacHowshouldnutritionalsupportbedone?Parenteralorenteral?Gastralorjejunal?HowshouldnutritionalsupportENvsPNandacutepancreatitisMildtomoderatepancreatitisEarlyEN(ED,NJ)vsPNPRCTN=32

EN PN

n=16 n=16Caloricgoal(day4) 72% 86%Daystonormalamylase1.5Daystodietbymouth 1.1LOH(days) 9.71.311.92.6LenghofICUstay(days)1.3%Nosocomialinfection12.58.512.58.5Mortality(%) 0.00.0Cost(US$) 76150.33294551.9*McClaveetal,JPEN,1997

*p<0.05ENvsPNandacutepancreatitiIsthesituationdifferent

inmildtomoderateorseverepancreatitis?Isthesituationdifferent

inENvsPNandacutepancreatitis

Severepancreatitis

EN(SED,NJ)vsPN

PRCT

N=38

EN PN

n=18 n=20LOH(d) 40(25-83) 39(22-73)LOICU(d) 10(5-21) 12(5-24)Complication-septic(Tot.nb) 5(6) 10(15)*-Hyperglycaemia 49-Pancr.necrosis 1 4Pneumonia 24Costs 3timeshigherKalfarentzosetal,BJSurg,1997ENvsPNandacutepancreatitiENvsPNandacutepancreatitis

Severepancreatitis

EN(NJ[Hypocaloric])vsPN

PRCT

N=156

Enroledpatients87%mild10%moderate3%severe75%improvedon48hbowelrestandiv.fluidsdischargedwithin4daysRestrandomizedtojejunalENorPNAbou-Assi,etal,AmJGastroenterology,2002ENvsPNandacutepancreatitiResultsoftherandomizedpatients

n=27n=26Ranson‘sCriteria2.5(0.5)3.1(0.6)Nutr.Goal88%*54%Hyperglycemia(MOF)14pt.*(8)4pt.(7)CatheterSepsis9pt.*1pt.Death6pt.8pt.Durationoffeeding(d)10.8*6.7Hosp.Days18.4(2.9)*15.2(2.6)Hosp.Costs(USdollar)lowerinEN(saving2360.-)*p<0.03Abou-Assi,etal,AmJGastroenterology,2002PNENResultsoftherandomizedpatiMcClaveetal,JPEN,2006EarlyENvsPNinacutepancreatitisInfectiouscompliations

RR0.46CI:0.29-0.74p=0.001McClaveetal,JPEN,2006EarlyMcClaveetal,JPEN,2006EarlyENvsPNinacutepancreatitisLengthofhospitalstay-3.9dCI:-5.9--2.0p=0.0001McClaveetal,JPEN,2006EarlyMcClaveetal,JPEN,2006EarlyENvsPNinacutepancreatitisMortalityRR0.88CI:0.43-1.79p=0.72McClaveetal,JPEN,2006EarlyEarlyENvsPNinsevereacutepancreatitis(Meta-Analysis) OutcomeMortality RR 0.40(CI:0.2-0.8)Infectednecrosis RR 0.43(CI:0.2-0.9)TotalinfectionsRR 0.48(CI:0.3-0.8)MOF RR0.44(CI:0.3-0.7)NeedforsurgeryRR0.37(CI:0.2-0.6)Jafrietal,Gastroenterology2008,A1417trials,146patientsEN,167PNEarlyENvsPNinsevereacuteENvsPNandsevereacutepancreatitis

EN(SED,NJ)vsPN

PRCT

ScreenedpatientsN=466,severepacreatitisN=70

EN PN

n=35 n=35Pancreaticinfections 7 160.02Extrapancreaticinfections4 110.04Singleorganfailure4 100.08Multipleorganfailure 7120.02Death 2 120.01Petrovetal,DigSurg,2006PvalueComplicationsENvsPNandsevereacutepancENvsPNandsevereacutepancreatitis149patientsFirst48h:CTNecrosis

CRP>195mg/L107Patients

54TPN

~115kJ/KG/d

1,2gN

250ml20%Intralipid

53TEN

~115kJ/KG/d

1,5gN

SurvimedjejunalAPACHEII16±4

CRP218±8APACHEII14±2

CRP211±9Wuetal,Pancreas2010ENvsPNandsevereacutepancENvsPNandsevereacutepancreatitisWuetal,Pancreas2010ENvsPNandsevereacutepancENvsPNandsevereacutepancreatitis

Enteralnutrition(N=25)TPN(N=25)PvalueInfection

16(64.0%)

15(60.0%)1.000ICUstay(days;medianandrange)

10(0-44)

15(0-60)0.625Hospitalstay(days;medianandrange)

42(15-108)

36(20-77)0.755Mortality

5(20.0%)

4(16.0%)1.000Doleyetal,JPancreas2009ENvsPNandsevereacutepancENvsPNinacutepancreatitisOlahetal,LangenbecksArchSurg2010847patients16RCTENvsPNinacutepancreatitisRecommendationIIThereisnoevidencethatneitherENorPNhasaclinicalbeneficialeffectonclinicaloutcomeinpatientswithmildpancreatitis,ifyoucanpredictthatthepatientcanconsumenormalfoodinbetween5days(A)Iforalnutritionisnotpossiblein5daysenteralnutritionshouldbestartedimmetiately(C)IfthisistrueinpatientswithmalnutritionisnotknownRecommendationIIThereisnoeESPEN,Guidelines2006/2009

Treatmentmild

pancreatitisAssessmentofseverityofacutepancreatitismildtomoderatefasting(2-5days)analgesicsi.v.fluid/electrolytesnopain,enzymes↓refeeding(3-7days)dietrichinCHdietmoderateinprotein/fatnormaldiet↓↓↓↓↓ESPEN,Guidelines2006/2009

TrRecommendationIIINutritionalsupportinessentialinpatientswithseverediseaseandnutritionalriskfactors(A)Therouteofnutrientdelivery(parenteral/enteral)shouldbedeterminedbythepatienttoleranceENshouldbeattemptedinallpatientsfirst(C)IntakesshouldbemonitoredcarefullytoensureadequatenutritionalsupportWhenenteralnutritionisnotsufficientcombineitwithPN(C)RecommendationIIINutritionalESPEN,Guidelines2006/2009

Treatmentsevere

pancreatitisAssessmentofseverityofacutepancreatitissevereearlycontinuousenteralnutrition(naso-jejunaltube)elementaldietorpolymericdietorimmune-enhancingdiet?enteralnutritionisnotpossibleaddparenteralnutrition-allinone-orsinglecomponentsolutions

(CH,protein(AS),fat)

TPN

andcontinuoussmallamountofanenteraldiet(10-30ml/h)

perfusedtothejejunumnutritionalgoalnotreached

ESPEN,Guidelines2006/2009

TrRecommendationIVPatientswithseveredisease,complicationsortheneedforsurgeryrequireearlynutritionalsupporttopreventtheadverseeffectsofnutrientdeprivation

Continousearlyenteraljejunalfeedingover24hisrecommended(A) Whensideeffectsoccurorthecaloricgoal

cannotbeachieved,PNshouldbecombined withEN(C)RecommendationIVPatientswithHownutrients

shouldbeapplied?4trialsshowedthatjejunaltubesarewelltoleratedtherewasnoexacerbationofpancreatitis-relatedsymptomsMcClave,JPEN,1997Cravo,ClinNutr,1989Kudsk,NutrClinPract,1990Nakad,Pancreas,1998Hownutrients

shouldbeappliNasogastricornasojejunalfeedinginpatientswithseverepancreatitis?NasogastricornasojejunalfeeNasogastricvsnasojejunalfeedinginpatientswithacutepancreatitisPetrowetal,JOP2008NasogastricvsnasojejunalfeeNutritionalintolerancePainexazerbationNasogastricvsnasojejunalfeedinginpatientswithacutepancreatitisPetrowetal,JOP2008NutritionalintolerancePainexDiarrheaMortalityNasogastricvsnasojejunalfeedinginpatientswithacutepancreatitisPetrowetal,JOP2008;9(4):440-448.DiarrheaMortalityNasogastricvRecommendationVJejunaltubeplacementissafeandwelltolerated(C)Ifnasogastrictubefeedingisausefulandpracticalapproachcannotbeanswereduptonow!RecommendationVJejunaltubepWhichformulashouldbeused?

Elemental,semielemental,polymeric,or immunenhancing(Arg,RNA,n-3-FA,Glu)Enteraldietwithpre-orprobioticsTPNandglutamineandorn-3-FAThereisnoclearconsensusaboutthepreferredformulabutmosttrialswereperformedwithsemielementaldietsWhichformulashouldbeused?Tiengouetal,JPEN,2006

SemielementalvspolymericdietinacutepancreatitisTiengouetal,JPEN,2006SemiEN(immunmodulating)

vsEN(standard)

Hospital ICU Mortality N Stay StayEN(Arg/Glu) 27.2d* 8.6d* 22.2% vs1) 16EN(STD) 38.4d 34.8d28.6%EN(n-3-FA) 13.1d* 7.1%vs 2) 28EN(STD) 19.3d 14.2% *p<0.05

1)Hallayetal,Hepatogastroenterol,20012)Lasztityetal,ClinNutr,2005EN(immunmodulating)

vsEN(sAlgorythmforusingenteralformulaSevereacutepancreatitisGI-functionNormalGI-functionImpairedPolymericdietElemental-orsemielementaldietGI-functionImpairedElemental-orsemielementaldiatGI-functionNormalPolymericdietAlgorythmforusingenteralfoSynbiotics*inseverepancreatitis

Incidenceofinfectednecrosisandabscess4.530.4%(p<0.02)LOHS 13.721.4d(ns)Needforre-surgery17(p<0.02)Olahetal,BrJSurg2002Enteralnutritionwith10goatfibre

(β-glucan)

andLactobacillusplantarum299,109Rand,db,controlledtrial(N=45),1week*ProbioProbioticsControlpSynbiotics*inseverepancreatSynbiotics*inseverepancreatitis

ProbioticsControlpMOF15%31%sigSepticcomplicatios27%52%nsLOHS(d) 1520nsNeedforsurgery12%24%nsMortality6%21%nsOlahetal,Hepatogastroenterol2007Enteralnutritionwith10gβ-glucan,inulin,pectin,resistantstarch

andLbplantarum299,pediacoccus,leuconostoc,paracasei,1010

Rand,db,controlledtrial(N=62),1week*Synbiotic2000Synbiotics*inseverepancreatSynbiotics*insevereacutepancreatitis

ProbioticsPlacebo

N=152N=144Infectiouscompl.30%28%Bowelischaemia(N)9*0Mortality24(16%)**9(6%)Multifibredietplusandcornstarch,maltodextrinBesselinketal,Lancet2008and4Lactobacilli,2Bifidobacteria1010,

twicedailyRand,db,placebo-controledtrial,N=298,4weeks*Ecolocgic641(*/**sig)Synbiotics*insevereacutepaComparisonofthe3studiesusingprobioticsinacutepancreatitis

Olah2002Olah2007Besselink2008ProbioControlSynbioticControlEcologicControl(n=22)(n=23)(n=33)(n=29)(n=152)(n=144)

BaselineAPACHEII8.99.411.7ImrieScoresMeanCRP206188216191268270%Alcohol59%70%60%62%18%19%%Necrosis41%48%60%62%30%24%Age44.146.547.546.060.459.9Comparisonofthe3studiesusWhatwentwrong?AggressiveenteralNutrition(30kcal/Tag)PatientswithvasoactivetreatmentMultifibredietplusprebiotics (30gfibre/day)6probioticstrains(2x/day1010) -ForthefirsttimeBifidobacteria)Fermentation↑→distension↑→ischaemia?Whatwentwrong?AggressiveentPN(immunmodulating)

vsPN(standard)GlutamineN-3fattyacidsPN(immunmodulating)

vsPN(McClaveetal,JPEN,2006AcutepancreatitisGlutaminevsstandardPNComplicationsRR0.68CI:0.42-1.09p=0.11McClaveetal,JPEN,2006AcuteAcutepancreatitisGlutaminevsstandardPN3furtherrandomizedcontrolledtrialsSignificantreductionofcomplications(N=40)Significantreductionofmortality

Sahinetal,EurJCinNutr2007

Significantreductionofcomplications(N=44)

Fuentes-Orozcoetal,JEPN2008

SignificantreductioninthelengthoforganfailureN=76)Reductionofinfection(earlyvslate)8vs23%Reductionofsurgery(earlyvslate)13vs43%Reductionofmortality(earlyvslate)5vs21%

Xueetal,WJGastroenterol2008

Acutepancreatitis3furtherraN-3-FAinTPNinpatientswith

severeacutepancreatitisN=40ControlN-3-FASIRSratio9/204/20ARDSratio5/204/20Infectiouscomplication,n5/203/20Renaldysfunction,n2/201/20CRRT,days26±3.4

18±2.3ICU,days27.5±5.621.4±4.2Lengthofhospitalstay,days70.5±9.165.2±7.3Wangetal,JPEN2008Prospective,randomized,double-blindstudy,PNover5daysN-3-FAinTPNinpatientswithN-3-FAinTPNinpatientswith

severeacutepancreatitisPatientssupplementedwithfishoilhadsignificantlylowerCRPlevelsafter5daysofparenteralnutritionWangetal,JPEN2008N-3-FAinTPNinpatientswithN-3-FAinTPNinpatientswith

severeacutepancreatitisN=60ControlN-3-FAApacheII,7thday13±2.38±1.9*Fluidequilibrium,days8.4±2.35.1±2.2SIRSscore,7thday2.5±0.71.7±0.5*Xiongetal,JPEN2008Prospective,randomized,double-blindstudy*P<0.05Duringtheinitialstageofacutepancreatitisn-3FAefficientlyreducethemagnitudeandpersistencetimeofSIRSandretrievetheunbalanceofthepro/anti-inflammatorycytokinesN-3-FAinTPNinpatientswithRecommendationVIElementalandsemielementalformulascanbeusedsafelyinacutepancreatitis(A)Standardpolymericformulascanbetriediftheyaretolerated(C)ThereisnoevidenceforusingimmunomodulatingformulasorprobioticsIfTPNhastobeused,glutamine couldhaveabeneficialeffect(B),forn-3FAweneedfurthertrialsRecommendationVIElementalandConclusionNutritionalsupportisessentialinsevereacutepancreatitisStartingwithearlyenteralnutritionisrecommendedThecombinationofENandPEmakesenseifenteralnutritionisinadaequateProbioticscannotberecommendedyetMorestudiesinthisfieldarenecessaryInPEglutaminecabehelpfulConclusionNutritionalsupport后面內(nèi)容直接刪除就行資料可以編輯修改使用資料可以編輯修改使用后面內(nèi)容直接刪除就行主要經(jīng)營：網(wǎng)絡(luò)軟件設(shè)計(jì)、圖文設(shè)計(jì)制作、發(fā)布廣告等公司秉著以優(yōu)質(zhì)的服務(wù)對待每一位客戶，做到讓客戶滿意！主要經(jīng)營：網(wǎng)絡(luò)軟件設(shè)計(jì)、圖文設(shè)計(jì)制作、發(fā)布廣告等致力于數(shù)據(jù)挖掘，合同簡歷、論文寫作、PPT設(shè)計(jì)、計(jì)劃書、策劃案、學(xué)習(xí)課件、各類模板等方方面面，打造全網(wǎng)一站式需求致力于數(shù)據(jù)挖掘，合同簡歷、論文寫作、PPT設(shè)計(jì)、計(jì)劃書、策劃感謝您的觀看和下載Theusercandemonstrateonaprojectororcomputer,orprintthepresentationandmakeitintoafilmtobeusedinawiderfield感謝您的觀看和下載Theusercandemonstr

NutritioninAcutePancreatitis“AnEvidenceBasedApproach”

NutritioninAcutePancreatWhichpatientsbenefitsfromnutritionalsupportinacutepancreatitis?Allpatientswithacutepancreatitis?

(Mildpancreatitisisdifferentfromseverepancreatitis)Enteralorparenteral?Whereistheevidence?WhichpatientsbenefitsfromnSeverity(Clinical,laboratoryandradiologicalsigns)

NutritionalstatusOutcomepredictors-Mildform(~80%)

-Severeform(~20%)

Outcomepredictors-MildformSeverityassesmentMildform (~80%)

-Ransonsigns3

-CRP<120mg/l

-APACHEIIscore8

-Balthazar‘s-CT-score3

Severeform (~20%)

-Ransoncirteria>3

-CRP>120mg/l

-APACHEIIscore>8

-Balthazar‘s-CT-score>3Severityassesment1068patients,meanage52.8yrs,589edematousAP,479severeAPMORTALITY:total7.8%,mild

aP1%,severeaP16.1%SeverityandoutcomeMortalitycanincreasetoupto40%ifsepsisandMOFoccur1068patients,meanage52.8yESPENGuidelines

EnteralNutrition: ClinicalNutritionVol25(2),April2006ParenteralNutrition: ClinicalNutritionVol28,July2009

/education/

guidelines.htmESPENGuidelines

EnteralNutriSeverityofacutepancreatitiscanbeassessedadequately

Forartificialnutritionalinterventionsmildpancreatitishastobeseparatedfromseverepancreatitis

Nutritionalstatushastobeassessedonadmissionandduringthecourseofthedisease

RecommentationIRecommentationIMaingoalsfornutritioninacutepancreatitisToprovidecalorieswithENorPNtoreverseproteincatabolismwithoutstimulationoftheexocrinepancreaticsecretionToimproveortoavoidnutritionaldepletionToreducemorbidityandmortalityMaingoalsfornutritioninacHowshouldnutritionalsupportbedone?Parenteralorenteral?Gastralorjejunal?HowshouldnutritionalsupportENvsPNandacutepancreatitisMildtomoderatepancreatitisEarlyEN(ED,NJ)vsPNPRCTN=32

EN PN

n=16 n=16Caloricgoal(day4) 72% 86%Daystonormalamylase1.5Daystodietbymouth 1.1LOH(days) 9.71.311.92.6LenghofICUstay(days)1.3%Nosocomialinfection12.58.512.58.5Mortality(%) 0.00.0Cost(US$) 76150.33294551.9*McClaveetal,JPEN,1997

*p<0.05ENvsPNandacutepancreatitiIsthesituationdifferent

inmildtomoderateorseverepancreatitis?Isthesituationdifferent

inENvsPNandacutepancreatitis

Severepancreatitis

EN(SED,NJ)vsPN

PRCT

N=38

EN PN

n=18 n=20LOH(d) 40(25-83) 39(22-73)LOICU(d) 10(5-21) 12(5-24)Complication-septic(Tot.nb) 5(6) 10(15)*-Hyperglycaemia 49-Pancr.necrosis 1 4Pneumonia 24Costs 3timeshigherKalfarentzosetal,BJSurg,1997ENvsPNandacutepancreatitiENvsPNandacutepancreatitis

Severepancreatitis

EN(NJ[Hypocaloric])vsPN

PRCT

N=156

Enroledpatients87%mild10%moderate3%severe75%improvedon48hbowelrestandiv.fluidsdischargedwithin4daysRestrandomizedtojejunalENorPNAbou-Assi,etal,AmJGastroenterology,2002ENvsPNandacutepancreatitiResultsoftherandomizedpatients

n=27n=26Ranson‘sCriteria2.5(0.5)3.1(0.6)Nutr.Goal88%*54%Hyperglycemia(MOF)14pt.*(8)4pt.(7)CatheterSepsis9pt.*1pt.Death6pt.8pt.Durationoffeeding(d)10.8*6.7Hosp.Days18.4(2.9)*15.2(2.6)Hosp.Costs(USdollar)lowerinEN(saving2360.-)*p<0.03Abou-Assi,etal,AmJGastroenterology,2002PNENResultsoftherandomizedpatiMcClaveetal,JPEN,2006EarlyENvsPNinacutepancreatitisInfectiouscompliations

RR0.46CI:0.29-0.74p=0.001McClaveetal,JPEN,2006EarlyMcClaveetal,JPEN,2006EarlyENvsPNinacutepancreatitisLengthofhospitalstay-3.9dCI:-5.9--2.0p=0.0001McClaveetal,JPEN,2006EarlyMcClaveetal,JPEN,2006EarlyENvsPNinacutepancreatitisMortalityRR0.88CI:0.43-1.79p=0.72McClaveetal,JPEN,2006EarlyEarlyENvsPNinsevereacutepancreatitis(Meta-Analysis) OutcomeMortality RR 0.40(CI:0.2-0.8)Infectednecrosis RR 0.43(CI:0.2-0.9)TotalinfectionsRR 0.48(CI:0.3-0.8)MOF RR0.44(CI:0.3-0.7)NeedforsurgeryRR0.37(CI:0.2-0.6)Jafrietal,Gastroenterology2008,A1417trials,146patientsEN,167PNEarlyENvsPNinsevereacuteENvsPNandsevereacutepancreatitis

EN(SED,NJ)vsPN

PRCT

ScreenedpatientsN=466,severepacreatitisN=70

EN PN

n=35 n=35Pancreaticinfections 7 160.02Extrapancreaticinfections4 110.04Singleorganfailure4 100.08Multipleorganfailure 7120.02Death 2 120.01Petrovetal,DigSurg,2006PvalueComplicationsENvsPNandsevereacutepancENvsPNandsevereacutepancreatitis149patientsFirst48h:CTNecrosis

CRP>195mg/L107Patients

54TPN

~115kJ/KG/d

1,2gN

250ml20%Intralipid

53TEN

~115kJ/KG/d

1,5gN

SurvimedjejunalAPACHEII16±4

CRP218±8APACHEII14±2

CRP211±9Wuetal,Pancreas2010ENvsPNandsevereacutepancENvsPNandsevereacutepancreatitisWuetal,Pancreas2010ENvsPNandsevereacutepancENvsPNandsevereacutepancreatitis

Enteralnutrition(N=25)TPN(N=25)PvalueInfection

16(64.0%)

15(60.0%)1.000ICUstay(days;medianandrange)

10(0-44)

15(0-60)0.625Hospitalstay(days;medianandrange)

42(15-108)

36(20-77)0.755Mortality

5(20.0%)

4(16.0%)1.000Doleyetal,JPancreas2009ENvsPNandsevereacutepancENvsPNinacutepancreatitisOlahetal,LangenbecksArchSurg2010847patients16RCTENvsPNinacutepancreatitisRecommendationIIThereisnoevidencethatneitherENorPNhasaclinicalbeneficialeffectonclinicaloutcomeinpatientswithmildpancreatitis,ifyoucanpredictthatthepatientcanconsumenormalfoodinbetween5days(A)Iforalnutritionisnotpossiblein5daysenteralnutritionshouldbestartedimmetiately(C)IfthisistrueinpatientswithmalnutritionisnotknownRecommendationIIThereisnoeESPEN,Guidelines2006/2009

Treatmentmild

pancreatitisAssessmentofseverityofacutepancreatitismildtomoderatefasting(2-5days)analgesicsi.v.fluid/electrolytesnopain,enzymes↓refeeding(3-7days)dietrichinCHdietmoderateinprotein/fatnormaldiet↓↓↓↓↓ESPEN,Guidelines2006/2009

TrRecommendationIIINutritionalsupportinessentialinpatientswithseverediseaseandnutritionalriskfactors(A)Therouteofnutrientdelivery(parenteral/enteral)shouldbedeterminedbythepatienttoleranceENshouldbeattemptedinallpatientsfirst(C)IntakesshouldbemonitoredcarefullytoensureadequatenutritionalsupportWhenenteralnutritionisnotsufficientcombineitwithPN(C)RecommendationIIINutritionalESPEN,Guidelines2006/2009

Treatmentsevere

pancreatitisAssessmentofseverityofacutepancreatitissevereearlycontinuousenteralnutrition(naso-jejunaltube)elementaldietorpolymericdietorimmune-enhancingdiet?enteralnutritionisnotpossibleaddparent