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Glutamine supported early enteral therapy for severe acute pancreatitis: A systematic review and meta-analysis.
Jiang, X, Pei, LY, Guo, WX, Qi, X, Lu, XG
Asia Pacific journal of clinical nutrition. 2020;(2):253-261
Abstract
BACKGROUND AND OBJECTIVES Several studies have shown that glutamine (Gln) may play an important role in energy metabolism, inflammatory reactions, and immune processes in patients with severe acute pancreatitis (SAP). Nevertheless, the results of individual randomized controlled trials (RCTs) on Gln nutrition support for SAP are contradictory. This systematic review and meta-analysis evaluated the clinical benefit of Gln-supported early enteral nutrition (G+EEN) in patients with SAP. METHODS AND STUDY DESIGN Cochrane Library, PubMed, Embase, CNKI, Wan Fang, and Chinese Biomedical Literature Database were searched for relevant studies published before December 2018. RCTs of G+EEN versus standard early enteral nutrition (EEN) for SAP were selected, with both started within 48 h of admission. RESULTS Seven clinical RCTs including a total of 433 patients (EEN group: 218 patients; G+EEN group: 215 patients) were included. Compared with EEN, G+EEN increased serum albumin (standard mean difference [SMD]=0.74; 95% confidence interval [CI], 0.33-1.15; p<0.01), reduced serum hypersensitive C-reactive protein (SMD=-1.62; 95% CI, -1.98 to -1.26; p<0.01) and risks of mortality risk (risk ratio= 0.38; 95% CI, 0.16-0.90; p=0.03) and multiple organ dysfunction syndrome (MODS)(risk ratio=0.37; 95% CI, 0.15-0.94; p<0.01), and shortened length of hospital stay (SMD=-1.19; 95% CI, -1.88 to 0.49; p<0.01); moreover, it did not significantly increase the incidence of infection-related complications, operative interventions, or APACHE II scores. CONCLUSIONS G+EEN is beneficial in SAP management.
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Analysis of GPRC6A variants in different pancreatitis etiologies.
Kaune, T, Ruffert, C, Hesselbarth, N, Damm, M, Krug, S, Cardinal von Widdern, J, Masson, E, Chen, JM, Rebours, V, Buscail, L, et al
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]. 2020;(7):1262-1267
Abstract
BACKGROUND The G-protein-coupled receptor Class C Group 6 Member A (GPRC6A) is activated by multiple ligands and is important for the regulation of calcium homeostasis. Extracellular calcium is capable to increase NLRP3 inflammasome activity of the innate immune system and deletion of this proinflammatory pathway mitigated pancreatitis severity in vivo. As such this pathway and the GPRC6A receptor is a reasonable candidate gene for pancreatitis. Here we investigated the prevalence of sequence variants in the GPRC6A locus in different pancreatitis aetiologies. METHODS We selected 6 tagging SNPs with the SNPinfo LD TAG SNP Selection tool and the functional relevant SNP rs6907580 for genotyping. Cohorts from Germany, further European countries and China with up to 1,124 patients and 1,999 controls were screened for single SNPs with melting curve analysis. RESULTS We identified an association of rs1606365(G) with alcoholic chronic pancreatitis in a German (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.65-0.89, p = 8 × 10-5) and a Chinese cohort (OR 0.78, 95% CI 0.64-0.96, p = 0.02). However, this association was not replicated in a combined cohort of European patients (OR 1.18, 95% CI 0.99-1.41, p = 0.07). Finally, no association was found with acute and non-alcoholic chronic pancreatitis. CONCLUSIONS Our results support a potential role of calcium sensing receptors and inflammasome activation in alcoholic chronic pancreatitis development. As the functional consequence of the associated variant is unclear, further investigations might elucidate the relevant mechanisms.
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3.
Hepatobiliary Adverse Events.
Abu-Sbeih, H, Wang, Y
Advances in experimental medicine and biology. 2020;:271-276
Abstract
Immune checkpoint inhibitors (ICIs) are increasingly used for multiple cancer types. Hepatotoxicity is a reported adverse event of ICI treatment. It can present as asymptomatic elevation of aspartate transaminase and alanine transaminase or symptomatic hepatitis with fever, malaise, and even death in rare cases. The diagnosis of ICI-induced hepatitis is made after exclusion of other etiologies based on medical history, laboratory evaluation, and imaging and histological findings. Treatment of ICI-induced hepatitis consists of ICI discontinuation and immunosuppression in severe cases. Pancreatic injury as asymptomatic lipase elevation or acute pancreatitis-like disease with abdominal pain and evidence on imaging has been documented as a toxicity of ICI therapy. Appropriate treatment of pancreatitis still needs further investigation. Few cases, reports, and series documented cholecystitis and cholangitis as possible adverse events related to ICI therapy as well.
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Nutritional support in patients with acute pancreatitis.
Piccinni, G, Testini, M, Angrisano, A, Lissidini, G, Gurrado, A, Memeo, R, Basile, F, Biondi, A
Frontiers in bioscience (Elite edition). 2012;(6):1999-2006
Abstract
Pancreatitis is a diffuse systemic immuno-inflammatory response to a localized process of auto-digestion within the pancreatic gland, caused by premature activation of proteolytic digestive enzymes. According to the ATLANTA criteria (1992) we recognized a mild and a severe acute pancreatitis (SAP ) . Mortality rate in SAP account up to the 20 percent and most complications and deaths are due to an inflammatory immune response to pancreatic necrosis and/or infection. Patients affected by SAP rapidly incur accelerated catabolism and thus nutritional support is essential, especially in the earliest period of the disease. Recent observations show that the route of nutritional support may also affect disease severity and its course. In this view several important questions about nutritional support need to be addressed : indication , timing, enteral vs parenteral and composition . With this review we analyze the state-of-the-art and we present a decisional flow chart to better manage the nutritional support in SAP.
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What is the best way to feed patients with pancreatitis?
Marik, PE
Current opinion in critical care. 2009;(2):131-8
Abstract
PURPOSE OF REVIEW Patients with acute pancreatitis have traditionally been treated with 'bowel rest'. Recent data, however, suggest that this approach may be associated with increased morbidity and mortality. This paper reviews evolving concepts in the nutritional management of patients with acute pancreatitis. RECENT FINDINGS Both experimental and clinical data strongly support the concept that enteral nutrition started within 24 h of admission to hospital reduces complications, length of hospital stay and mortality in patients with acute pancreatitis. Clinical trials suggest that both gastric and jejunal tube feeding is well tolerated in patients with severe pancreatitis. Although there is limited data for the optimal type of enteral feed, a semielemental formula with omega-3 fatty acids is recommended. On the basis of current evidence, immune modulating formulas with added arginine and probiotics are not recommended. SUMMARY Nutritional support should be viewed as an active therapeutic intervention that improves the outcome of patients with acute pancreatitis. Enteral nutrition should begin within 24 h after admission and following the initial period of volume resuscitation and control of nausea and pain. Patients with mild acute pancreatitis should be started on a low-fat oral diet. In patients with severe acute pancreatitis, enteral nutrition may be provided by the gastric or jejunal route.
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Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A meta-analysis.
Petrov, MS, Atduev, VA, Zagainov, VE
International journal of surgery (London, England). 2008;(2):119-24
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Abstract
BACKGROUND It is believed that certain nutrients such as glutamine, arginine and omega-3 fatty acids may play a significant role in metabolic, inflammatory, and immune processes in acute pancreatitis. The present systematic review aimed to define whether the addition of these substances to enteral nutrition provides any clinical benefit over standard enteral formulas in patients with acute pancreatitis. METHODS A computerized search on electronic databases (Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE) and manual search of the abstracts of major gastroenterological meetings (UEGW, DDW) were undertaken. The studied outcomes were total infectious complication, in-hospital mortality and length of hospital stay. The data were meta-analyzed using a random-effects model. RESULTS A total of three randomized controlled trials satisfied the inclusion criteria. When compared with standard enteral nutrition, immunonutrition was not associated with the significantly reduced risk of total infectious complications (risk ratio 0.82; 95% confidence interval 0.44-1.53; P=0.53) and death (risk ratio 0.64; 95% confidence interval 0.20-2.07; P=0.46). Mean difference in length of hospital stay between two groups was not significant (P=0.80). CONCLUSIONS There is no evidence that enteral nutrition supplemented with glutamine, arginine and/or omega-3 fatty acids, in comparison with standard enteral nutrition, has any beneficial effect on infectious complications, mortality or length of hospital stay in acute pancreatitis. The pursuit of new compositions of enteral formulations in this category of patients may be advocated.
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Review article: Probiotics in gastrointestinal and liver diseases.
Jonkers, D, Stockbrügger, R
Alimentary pharmacology & therapeutics. 2007;:133-48
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Abstract
BACKGROUND Probiotics, defined as live micro-organisms with beneficial effects for the host, are widely applied in gastrointestinal and liver diseases. AIM AND METHOD To review the available evidence of clinical trials on probiotics in gastrointestinal and liver diseases, with a major focus on irritable bowel syndrome, inflammatory bowel disease, pancreatitis and chronic liver diseases. RESULTS Evidence for the therapeutic or preventive application of particular probiotic strains is available for antibiotic-associated diarrhoea, rota-virus-associated diarrhoea and pouchitis. Results are encouraging for irritable bowel syndrome, ulcerative colitis and for reducing side effects by Helicobacter pylori eradication therapies, but are less clear for Crohn's disease, lactose intolerance and constipation. In general, for most of these patient groups, more placebo-controlled methodologically well-designed studies that pay attention to both clinical outcome and mechanistic aspects are required. The application in liver disease and pancreatitis is promising, but more human trials have to be awaited. Possible mechanisms of probiotics include modulation of the intestinal microbiota and the immune system, but different bacterial may have different effects. CONCLUSION Further insight into disease entities and the functioning of probiotic strains is required to be able to select disease-specific strains, which have to be tested in well-designed placebo-controlled studies.
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Bio-ecological control of acute pancreatitis: the role of enteral nutrition, pro and synbiotics.
Bengmark, S
Current opinion in clinical nutrition and metabolic care. 2005;(5):557-61
Abstract
PURPOSE OF REVIEW Increasing knowledge, both experimental and clinical, supports the fact that early and aggressive enteral nutrition has the capacity to reduce superinflammation and prevent infections in severe acute pancreatitis. Clearly, the main role of enteral nutrition is to boost the immune system, and not, at least initially, to provide calories. Whereas enteral nutrition improves, parenteral nutrition reduces immune functions. RECENT FINDINGS The content of enteral nutrition solutions is more important than the route of administration per se. Antioxidants, plant fibres and live lactic acid bacteria are especially important for boosting the immune system. Recent studies support the fact that enteral nutrition and the supply of fibres and live lactic acid bacteria may significantly reduce the rate of infections. So far none of the treatments has been able to reduce the incidence of the systemic inflammatory response syndrome and multiorgan dysfunction syndrome. A recent unpublished study indicates, however, that the systemic inflammatory response syndrome and multiorgan dysfunction syndrome can also be reduced if much higher doses of lactic acid bacteria and a combination of several bioactive lactic acid bacteria are used (synbiotics). SUMMARY Immunosupporting enteral nutrition with synbiotics is an important tool to control superinflammation and infection, and might also reduce the multiorgan dysfunction syndrome and systemic inflammatory response syndrome. It is essential that it is supplied early, if possible in the emergency room. New autopositioning regurgitation-resistant feeding tubes are available to facilitate such a policy.
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Bacterial translocation and its prevention in acute pancreatitis.
Dervenis, C, Smailis, D, Hatzitheoklitos, E
Journal of hepato-biliary-pancreatic surgery. 2003;(6):415-8
Abstract
In recent years, bacterial translocation from the gut onto pancreatic necrosis has been proposed as the main cause of pancreatic infection and the consequent sepsis. Failure of the intestinal barrier, together with bacterial overgrowth due to motility changes and immunosuppression, constitute the pathways of the continuous pancreatic contamination from bacterial translocation in patients with severe acute pancreatitis. Selective decontamination, by using a combination of oral and intravenous antibiotics, has been reported to decrease the incidence of sepsis and the related mortality. Immunostimulation is another action to be taken to enhance the ability of the immune system to prevent bacterial translocation, by the entrapment and killing, by enterocytes, of the bacteria trying to translocate through the bowel wall. To keep the mucosal barrier function intact is one of the main issues in the prevention of bacterial translocation. This could be achieved by the adequate delivery of oxygen and nutrient supplementation. Enteral nutrition is a key factor, as it has been proven to maintain mucosal integrity, along with preventing deterioration of the immune function of the intestine.
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Enteral and parenteral nutrition in acute pancreatitis.
Imrie, CW, Carter, CR, McKay, CJ
Best practice & research. Clinical gastroenterology. 2002;(3):391-7
Abstract
In the last 5 years naso-enteric feeding has increasingly been used in clinical practice in patients with severe acute pancreatitis. Randomized clinical studies in both mild and severe forms of the disease have demonstrated not only the feasibility but also the safety of this approach. The majority of patients have been fed by variously placed nasojejunal tubes with varied problems in maintaining both location and patency. Most have been surprised to find that it is possible to feed the patients in this way with the potential of improving gut barrier function and immune response, at reduced cost and greater safety than with parenteral nutrition. The current evidence points to nasojejunal feeding being preferable to parenteral feeding, but evidence has yet to be produced to prove beyond reasonable doubt that such feeding is an improvement on conservative management without feeding. Finally, the most recent development has indicated that fine-bore nasogastric feeding may well be a realistic alternative to nasojejunal feeding even in the more severe forms of this disease. A small percentage of patients may still need parenteral nutrition.