胰腺炎的营养治疗课件

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后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用后面内容直接删除就行主要经营：网络软件设计、图文设计制作、发布广告等公司秉着以优质的服务对待每一位客户，做到让客户满意！主要经营：网络软件设计、图文设计制作、发布广告等致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划感谢您的观看和下载Theusercandemonstrateonaprojectororcomputer,orprintthepresentationandmakeitintoafilmtobeusedinawiderfield感谢您的观看和下载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