Nutrition support in acute pancreatitis Rakesh Tandon Department of Gastroenterology & Human Nutrition, All India Institute of Medical Sciences, New Delhi, India. Acute pancreatitis (AP) is a hypercatabolic state resulting in rapid loss of body weight, fat and protein. Patients with mild to moderate disease (80% of patients) do not require jejunal or parenteral nutrition as they begin oral feeding within 3-4 days of presentation. Patients with severe acute pancreatitis (SAP) however, require nutrition support as the course of disease in them is often protracted. This support has traditionally been given to them through total parenteral nutrition (TPN) because of the presence of ileus and the fear that pancreatic stimulation by oral feeding may aggravate the disease. Indeed, a French study in 1997 pointed to 20% of patients experiencing pain relapse on refeeding (Gut 1997;40:262-6). Recent studies however, have shown that most patients with SAP are able to tolerate early enteral feeding and in fact the enteral feeding may result in a reduction in acute phase response and prevent translocation of bacteria from the gut to the pancreas. There are at least three randomized clinical trials comparing enteral feeding with TPN (JPEN 1997;21:14-20; Br J Surg 1997;84:1665-9; Gut 1998;42:431-5). Although the clinical outcome including mortality was similar in both the groups, there was a tendency to have a lower systemic inflammatory response syndrome (SIRS) scoring as well as a lower IgM anticore endotoxin antibody level in the group fed enterally as compared with that fed parenterally. One common feature in all these studies was that the cost of enteral feeding was much lower than that of parenteral alimentation. A naso-enteral tube is inserted under endoscopic or fluoroscopic guidance on day 3 or 4 and a semi-elemental diet begun. This should have a concentration of 1 calorie/ml. If tolerated, the feeding is advanced to a polymeric formula. Most groups have used naso-jejunal feeding, which has difficulties in maintenance of the tube position and patency. Hence of late, studies have been done to see if intragastric rather than intrajejunal feeding may be tolerated as well. Indeed, a recent randomised study of nasogastric versus nasojejunal feeding in SAP has shown little difference in terms of pain, analgesic intake, C-reactive protein reponse of clinical outcome from these two approaches to early naso-enteric feeding (Int J Pancreatol 2000;28:23-9). If enteral nutrition is however, not tolerated, parenteral nutrition is required. The preferred solution contains carbohydrate, protein and lipid. The exception to this is hypertriglyceridemia, in which case lipid should be excluded. A patient's individual caloric requirement is calculated using indirect calorimetry or the Harris-Benedict equation with appropriate modifications for stress factors. In general, patients with SAP require 2000-2500 calories/day: 50% - 60% from glucose, 15-20 % from protein and 20-30 % from lipid. Best results are obtained when the decision regarding the route of administration and the amount and duration of nutrition is made collectively by a team comprised of at least one physician, a dietitian and a nurse. From "The 8th Congress of the PENSA Programme & Abstract" Kochi, Japan, November 5-7, 2002 Page : 26