INTRODUCTION:

Pancreatitis, encompassing both acute and chronic forms, presents a significant burden on healthcare systems, with acute pancreatitis being a common cause of hospitalization¹. The etiology of acute pancreatitis often involves gallstones and alcohol consumption in adults, while in children, it can be idiopathic or secondary to trauma². Chronic pancreatitis, on the other hand, is frequently linked to repetitive alcohol use, leading to the loss of acinar cells and collagen deposition³.

Additionally, hereditary factors can contribute to acute, recurrent acute, and chronic pancreatitis⁴. Chronic use of alcoholism is one of the most common cause pancreatitis and there are sociocultural associated stigma still persist in the society.^5,8 Implementing awareness programs about the negative impacts of alcohol for adolescents and providing counselling for alcoholics alongside their families could assist in curbing alcoholism to a degree.^9,14

Nutritional management is crucial in pancreatitis cases, especially in chronic pancreatitis where exocrine insufficiency can lead to malnutrition. Patients with chronic pancreatitis may experience progressive loss of pancreatic function, necessitating careful nutritional assessment and treatment¹⁵. Furthermore, individuals with chronic pancreatitis are at an increased risk of developing pancreatic cancer, particularly those with a family history of the disease, smokers, and individuals with diabetes mellitus.

Pancreatitis is a significant health concern globally, with varying incidence rates across different regions. In the United States, chronic pancreatitis (CP) has an annual incidence of 5 to 8 cases per 100,000 adults.¹⁶ In Europe and Western countries, the estimated incidence of chronic pancreatitis is around six cases per 100,000 people per year.¹⁷ However, in India, the reported incidence of chronic pancreatitis is higher, with a prevalence of 42 to 73 cases per 100,000 adults.¹⁸ In fact, the recent consensus report on the prevalence of chronic pancreatitis in the Asia‐Pacific region highlighted the increase in prevalence of chronic pancreatitis in South India, 114–200/100 000 population.¹⁹

In cases of acute pancreatitis, 75%–80% are classified as mild and edematous, while 20%–25% are considered severe necrotizing pancreatitis. The mortality rate for mild to moderate pancreatitis stands at less than 5%. However, this rate escalates to 19%–30% for severe pancreatitis.²⁰ Mortality rates can soar to 50% when gland necrosis exceeds 50%, and potentially up to 80% in the presence of sepsis. Roughly half of the fatalities associated with acute pancreatitis occur within the initial two weeks of the illness, predominantly due to organ failure. The mortality rates in chronic pancreatitis can be influenced by various factors. For instance, the mortality rate in patients with the PPP syndrome (Pancreatitis, panniculitis, and polyarthritis syndrome²¹ caused by pancreatitis is reported to be 24%, while it rises to 74% when associated with pancreatic cancer.²² Additionally, the mortality rate for ruptured pseudoaneurysms, a complication of chronic pancreatitis, ranges from 12.5% in treated patients to over 90% in untreated cases.²³

Studies have shown that nurses perceive themselves as having an important role in providing nutrition care to patients with chronic diseases, including pancreatitis^24,26. However, further training and education are needed to enhance nurses' self-perceived effectiveness in delivering nutrition care²⁴. Additionally, the implementation of standardized nursing interventions, such as mindfulness stress reduction training, has been shown to have a positive impact on the curative effect, negative emotions, and quality of life in patients with acute pancreatitis²⁷.

Furthermore, nurses are integral in multidisciplinary teams for the management of severe acute pancreatitis, working alongside pancreatologists, pancreatic surgeons, radiologists, dieticians, and specialist nurses to provide comprehensive care to patients²⁸. Their involvement in perioperative and postoperative care is crucial, ensuring that patients receive optimal nutrition support and monitoring to aid in their recovery²⁹.

Tools and methods for nutritional assessment from a nurse's perspective:

Nutritional assessment in pancreatitis is essential for guiding interventions and improving patient outcomes, especially in chronic pancreatitis. Anthropometric Measurements are easy to perform at the bedside, these measurements, such as weight, BMI, mid-upper arm circumference (MAC), triceps skin fold (TSF) and determination of handgrip strength (HGS) are fundamental for assessing nutritional status and monitoring changes over time.

The Patient-Generated Subjective Global Assessment (PG-SGA) tool is commonly used in nutritional assessment for patients undergoing pancreatic cancer surgery.³⁰. It allows for a detailed evaluation of the patient's nutritional status, aiding in identifying malnutrition and developing tailored nutritional interventions. The PG-SGA is also useful in screening for malnutrition in pancreatitis patients³¹. The Prognostic Nutritional Index (PNI) is valuable for predicting postoperative events in patients with gastric cancer³². Along with other tools like the Glasgow Prognostic Score (GPS) and Malnutritional Universal Screening Tool (MUST), the PNI provides insights into the nutritional status of patients with gastrointestinal conditions, including pancreatitis.

The Global Leadership Initiative on Malnutrition (GLIM) criteria, along with tools like SGA, PG-SGA, and PNI, have been compared for diagnosing malnutrition in hepatobiliary-pancreatic surgery patients, highlighting the significance of selecting appropriate tools for nutritional assessment.

Table 1: List of nutritional screening and assessment tools

Sl. No	Screening and Assessment tool for nutrition in Pancreatitis
1.	Nutritional Risk Screening 2002 (NRS-2002)
2.	Malnutritional Universal Screening Tool (MUST)
3.	Mini Nutritional Assessment (MNA)
4.	Subjective Global Assessment (SGA)
5.	Patient-Generated Subjective Global Assessment (PG-SGA)
6.	Prognostic Nutritional Index (PNI)
7.	The Global Leadership Initiative on Malnutrition (GLIM) criteria

A combination of imaging techniques, serum markers, pain assessment tools, and severity scores can aid in the comprehensive assessment of pancreatic conditions, from diagnosis to prognosis and management.

Table 2: List of Pancreatitis screening and assessment tools

Sl. No	Assessment and diagnosis tool in Pancreatitis
1.	Laboratory tests and radiological imaging.
2.	Systemic Inflammatory Response Syndrome (SIRS) Scores
3.	Acute Physiology and Chronic Health Evaluation II (APACHE II)
4.	Ranson’s Criteria
5.	Modified Glasgow Scores
6.	Balthazar score (CT scan based)
7.	Harmless Acute Pancreatitis Score (HAPS)
8.	Bedside Index of Severity in Acute Pancreatitis (BISAP)

Pain assessment tools like COMPAT (Comprehensive Pain Assessment Tool for Chronic Pancreatitis) and the Rosemont Criteria play a significant role in evaluating and managing pain in chronic pancreatitis.^33–35 Various interventions including nerve blocks have shown promise in alleviating pain in patients with pancreatitis.^36–38 Further research and clinical trials are essential to enhance pain assessment and management strategies in both chronic and acute pancreatitis.

Nutritional Management Strategies:

Nutritional management during mild to moderate acute pancreatitis:

All patients with mild to moderate acute pancreatitis (AP) should undergo nutritional risk screening using tools like NRS-2002 and severe AP patients are always considered at nutritional risk.³⁹

Enteral nutrition is deemed unnecessary if patients are able to resume a normal diet within 5–7 days, according to ESPEN Guidelines (Grade B).^40,41The earlier ESPEN-2006 guidelines say EN can be initiated if oral intake is not tolerated for more than 5 days and not supported early enteral nutrition (within 5 days).⁴¹ However the new ESPEN guidelines say, oral feeding is recommended as soon as tolerated for mild AP patients, regardless of serum lipase levels.³⁹For AP patients EN should commence within 24-72 hours of admission if oral feeding is not tolerated in AP. Third day of hospital admission is the best cut-off time for early enteral nutrition. A common approach for these situations is outlined in Figure 1. These guidelines are consistent with the international consensus on nutrition therapy in pancreatitis.⁴²

Figure 1. Sequence of Nutritional management in mild to moderate acute pancreatitis.

Nutritional support is essential in the management of acute pancreatitis. Current guidelines and studies recommend enteral nutrition over parenteral nutrition as the preferred route of nutritional therapy for patients with acute pancreatitis.^43–48 Early enteral nutrition is advised for both adults and pediatric patients to enhance recovery and reduce mortality rates.^49,50

Benefits of Early Enteral Feeding:

· Preserves gastrointestinal integrity, mitigating bacterial invasion.

· Establishes systemic immunity baseline, tempering immune reactions.

· Diminishes oxidative stress impacts.

· Mitigates the severity of illnesses.

· Accelerates the resolution of diseases.

· Decreases complications, leading to fewer infections, reduced surgical needs, shorter hospital stays, and potentially less multiorgan dysfunction.

The goal of nutritional support in acute pancreatitis is to correct the negative nitrogen balance, reduce inflammation, and improve patient outcomes.⁵¹ Prolonged fasting is no longer necessary, and early nutritional intervention is recommended to prevent malnutrition and its complications.⁵² Enteral nutrition is more effective than total parenteral nutrition in reducing the risk of multiple organ failure, pancreatic infectious complications, and mortality in acute pancreatitis cases^48,53

Furthermore, in cases of mild acute pancreatitis, optimizing dietary management is essential, as this form represents a majority of cases. Studies have shown that initiating oral nutrition with a soft diet or a low-fat solid diet after mild acute pancreatitis is safe and can provide necessary calories for recovery^39,54–56 Additionally, dietary fat restriction and medications like Bezafibrate have been effective in preventing relapses of hypertriglyceridemia-induced acute pancreatitis in adults.⁵⁷

Moreover, recommendations for acute pancreatitis patients include high-rate intravenous fluids and early enteral nutrition, unless contraindicated or not feasible, as these interventions have been shown to decrease the length of hospital stay and the risk of mortality.⁵⁸ It is also crucial to consider the associations between dietary fiber intake and markers of glucose metabolism in individuals with new-onset prediabetes or diabetes after acute pancreatitis, as dietary fiber intake can impact blood glucose levels.⁵⁹

In nutshell, dietary recommendations in acute pancreatitis should focus on high dietary fiber intake post-acute episode, dietary fat restriction, and specific interventions like Bezafibrate for preventing relapses in hypertriglyceridemia-induced cases. Early enteral nutrition and high-rate intravenous fluids are also essential for improved outcomes in acute pancreatitis management.

Nutritional management during Severe acute pancreatitis.

Table 1. Recommended Dosages of Nutrients in Severe Acute Pancreatitis

Substrate	Quantity
Energy	25–35 kcal/kg BW/day
Carbohydrates	3–6 g/kg BW/day corresponding to blood glucose concentration (aim: <10 mmol/L)*
Lipids	Up to 2 g/kg BW/day corresponding to blood triglyceride concentration (aim: <12 mmol/L)*
Protein	1.2–1.5 g/kg BW/day

*Overfeeding should be avoided, especially in obese patients possibly according to measured REE (indirect calorimetry).

Patients with severe disease, complications, or the need for surgery require early nutrition support to prevent the adverse effects of nutrient deprivation. Following are the interventions to be considered.

· Begin with comprehensive fluid resuscitation to stabilize the patient.

· If oral feeding is not tolerated, start early enteral nutrition (within 24-72 hrs from admission)

· Aim for continuous early enteral jejunal feeding over a 24-hour period, utilizing a polymeric, elemental, or potentially immunoenhancing diet.³⁹

· If encountering side effects or if achieving caloric goals is challenging, consider supplementing total parenteral nutrition (TPN) alongside enteral nutrition.

· In cases where enteral nutrition is impractical, such as during prolonged paralytic ileus, administer TPN while introducing a minimal amount of an elemental diet directly into the jejunum, adjusting the volume to tolerance levels (ranging from 10 to 30 mL/h).

· Employing intravenous lipids is deemed safe provided that precautions are taken to prevent hypertriglyceridemia.

Evidence-based facts

· Oral feeding post-minimally invasive necrosectomy is encouraged within 24 hours if the patient's condition permits. For patients unable to eat orally after minimally invasive necrosectomy, EN via nasojejunal tube is indicated.PN is for those post-necrosectomy who cannot tolerate EN or meet nutritional needs, or when EN is contraindicated.³⁹

· In severe AP with intraabdominal pressure (IAP) < 15mmHg, initiate EN early via nasojejunal or nasogastric tube, monitoring IAP and patient condition.For severe AP with IAP > 15mmHg, start EN via nasojejunal route at 20mL/h, adjusting based on tolerance. Consider reducing or stopping EN if IAP increases.In severe AP with IAP > 20mmHg or acute compartment syndrome, halt EN and begin PN.³⁹

· For severe AP with open abdomen, administer EN minimally; if needed, supplement or replace with PN.When EN is infeasible or contraindicated, and PN is required, supplement with parenteral glutamie at 0.20g/kg per day.³⁹

· Immunonutrition is not advised for severe AP.⁶⁰ Probiotics are not recommended for severe AP.⁶¹ Pancreatic enzyme supplementation is generally not recommended except for evident pancreatic exocrine insufficiency (PEI).³⁹

· Generally prophylactic antibiotics are not recommended in acute pancreatitis.^62–64

Fluid Resuscitation in Acute Pancreatitis.

For individuals with acute pancreatitis (AP), Lactated Ringer's solution (RL) is favored over Normal Saline (NS), and Hydroxyethyl Starch (HES) is not advised. Moderate fluid infusion rates are recommended over high rates, according to low-certainty evidence.⁶⁵ Current evidence suggests that fluid resuscitation exceeding 10–15mL/kg is not advisable. Ringer’s lactate is potentially beneficial and preferred over NS.^65–68 The efficacy of early goal-directed therapy (Goal-directed resuscitation protocol includes an initial 20 mL/kg intravenous fluid administration for 30 minutes, followed by a continuous infusion of 3mL/kg/hour. If the BUN level remains unchanged after 8–12 hours, a second fluid challenge of 20mL/kg for 30 minutes is recommended. Should the BUN level decrease after 8–12hours, the infusion rate should be adjusted to 1.5 mL/kg/hour continuously.) for acute pancreatitis patients is still uncertain.⁶⁸

Nutritional management in chronic pancreatitis (CP).

CP patients should be screened for nutrient deficiencies annually or more frequently in severe cases. Patients with CP and normal nutritional status should maintain a balanced diet. In CP, dietary fat does not need to be restricted unless there are uncontrollable symptoms of steatorrhea.⁶⁹ Malnourished CP patients should be advised to consume high-protein, high-energy foods across five to six small meals daily. High-fibre diets should be avoided⁷⁰ in CP especially those who take PERT (Recommendation 23, ESPEN guideline on clinical nutrition, 2020).⁶⁹ However in the general population high fibre diet is found to be a protective factor against pancreatic cancer.⁷¹Patient with AP who is not on PERT may get benefited from high fiber diet.^72,73

Prescribe oral nutritional supplements (ONS) to undernourished patients if oral intake does not meet caloric and protein goals. If malabsorption persists despite enzyme supplementation and bacterial overgrowth exclusion, consider ONS with MCT. Monitor and supplement fat-soluble (in a water-miscible form) and water-soluble vitamins and minerals like magnesium, iron, selenium, and zinc in patients with known malabsorption.

Administer EN in malnourished patients not responding to oral nutritional support. Use the nasojejunal route for EN in CP patients with pain, delayed gastric emptying, persistent nausea or vomiting, and gastric outlet syndrome. Long-term jejunostomy access is suitable for those requiring EN beyond 30 days. Use semi-elemental formulas with MCT if standard formulas are intolerable. Supplement pancreatic enzymes in patients on EN showing signs of exocrine failure. PN is indicated for gastric outlet obstruction, complex fistulating disease, or EN intolerance. Prefer central venous access for PN.

Begin pancreatic enzyme replacement therapy (PERT) for diagnosed PEI, with a thorough nutritional assessment to identify malabsorption signs. Utilize pH-sensitive, enteric-coated microspheres for PEI treatment. Distribute oral pancreatic enzymes with meals and snacks, tailoring the dose to individual needs and meal composition. The dosage of pancreatic enzymes is tailored to each patient's unique requirements, considering the severity of their condition and their diet. Typically, a lipase dosage ranging from 20,000 to 50,000 PhU is recommended for main meals, with half of this dosage for snacks. Assess PERT efficacy by gastrointestinal symptom relief and nutritional parameter improvement. Extend evaluation to pancreatic function tests if no response. Increase PERT dosage or add a protein pump inhibitor if the response is unsatisfactory. Exclude other malabsorption causes like SIBO (Small Intestinal Bacterial Overgrowth) if these fail.

Employ dual-energy X-ray absorptiometry (DXA) for CP patients to identify osteopathy. Advise basic preventive measures for all CP patients, including sufficient calcium/vitamin D intake, pancreatic enzyme supplementation if indicated, regular weight-bearing exercise, and avoiding smoking and alcohol. Reserve additional pharmacologic treatment for osteopathy, particularly osteoporosis.

In conclusion, the long-term nutritional management of chronic pancreatitis requires a multidisciplinary approach that includes PERT, a balanced diet, early identification of malnutrition, and medical nutritional therapy.

Enteral Feeding techniques:

The nasogastrojejunal (NGJ) feeding tube system (16F/9F Kendall Dobhoff) is the method of choice for enabling gastric decompression and jejunal feeding concurrently, especially in cases of nausea and vomiting. It's common to place jejunal tubes via a transnasal endoscopic procedure deep into the intestine, typically extending 40cm beyond the ligament of Treitz. Other options include the placement of a jejunostomy tube or PEG tube.

For those without gastric outlet obstruction symptoms, a soft nasoenteric tube facilitates efficient jejunum feeding. After insertion, the tube's placement is verified either through endoscopy or imaging techniques. A significant innovation in this field is the adoption of a nasal bridle, which significantly reduces the risk of the tube's accidental removal.^74,75

Enteral Feeding:

1. Employ a high-protein, low-fat, semi-elemental or polymeric formula for tube feeding.

2. Initiate tube feeding at a slow pace, beginning with 20 to 25mL/hour for the first 24hours. If tolerated, increase by 25mL until reaching the target of 25 kcal/kg ideal body weight per day.

3. An ileus should not deter enteral nutrition (EN); instead, EN serves as a treatment for ileus, albeit with gradual advancement.

4. Start EN promptly after admission to reduce gut permeability and lessen the activation of inflammatory cytokines, offering benefits over delaying feeding beyond 72hours.

5. Given the frequent transfers of critically ill patients to and from the ICU for various procedures and imaging, achieving 100% of the caloric goal via enteral feeding can be challenging. Maximizing EN delivery is crucial as reaching nearer to the caloric and protein goals is linked to better outcomes.

6. Monitor patients for feeding intolerance signs, such as gastric residual volumes over 400mL, vomiting, or diarrhoea (defined as 5 watery stools or over 500 mL within 24hours).

7. Patients with hemodynamic instability, those on pressor medications to maintain blood pressure, and those with low blood pressures should be closely observed for intolerance indicators like abdominal distension and reduced bowel sounds, as they are at heightened risk for gut dysfunction and bowel ischemia.

Parenteral Nutrition (PN):

PN is recommended only when enteral nutrition (EN) is not feasible, such as in cases of gut failure or when EN administration is hindered by conditions like prolonged ileus, complex pancreatic fistulae, or abdominal compartment syndrome. PN should be administered following sufficient fluid resuscitation and once the patient has achieved full hemodynamic stability, typically within 24–48hours after admission. As a patient's ability to tolerate EN improves, the reliance on PN should be proportionally reduced. EN is generally associated with better outcomes compared to PN. PN has been shown not to significantly stimulate pancreatic secretion, nor does it adversely affect pancreatic function.⁴⁰

Severe acute pancreatitis (AP) leads to significant protein breakdown and heightened energy needs. Infusing amino acids via the parenteral route does not impact pancreatic secretion or its functionality. For patients requiring parenteral nutrition (PN), adding glutamine supplementation (more than 0.30g/kg of Ala–Gln dipeptide) is advisable.⁴⁰

Glucose is recommended as the primary carbohydrate energy source due to its affordability, availability, and ease of monitoring. Its use can help inhibit gluconeogenesis. However, careful monitoring is essential to prevent hyperglycemia. When managing hyperglycemia, the use of exogenous insulin is advised to keep blood glucose levels as normal as possible. Infusing carbohydrates parenterally does not impact pancreatic secretion or functionality.⁴⁰

Lipids serve as an effective calorie source, and their intravenous use in pancreatitis is considered safe, provided that hypertriglyceridemia is managed. It is advised to maintain triglyceride levels below 12mmol/L, with an ideal target being within normal range. Best practice guidelines suggest maintaining fat emulsion infusion rates between 0.8 to 1.5g/kg per day. If hypertriglyceridemia persists for more than 72hours, exceeding 12mmol/L, the infusion should be temporarily halted.⁴⁰

The challenges associated with PN are general and not specific to its application in acute pancreatitis (AP). It's critical to prevent overfeeding. Patients on PN should start with 25non-protein kcal/kg per day, not exceeding a maximum of 30kcal/kg per day. For patients experiencing systemic inflammatory response syndrome (SIRS) or multiple organ dysfunction syndrome (MODS), or those at risk of refeeding syndrome, the caloric limit should be adjusted to 15–20non-protein kcal/kg per day. The weaning from PN is same as that of any other patients (No specific guidelines for pancreatitis patient).⁴⁰

CONCLUSION

In conclusion, pancreatitis, both acute and chronic, presents significant challenges to healthcare systems globally, necessitating a multifaceted approach to management, particularly in the realm of nutritional care. The involvement of nursing professionals is crucial, given their role in assessing, implementing, and monitoring nutritional strategies to support patient recovery and manage long-term complications. Despite the recognition of their pivotal role, there is a pressing need for enhanced training and education to empower nurses in this critical aspect of patient care.

Nutritional management strategies, including the use of specific assessment tools and the timely initiation of enteral nutrition, are key to mitigating the impacts of pancreatitis. The implementation of standardized nursing interventions and the active participation of nurses in multidisciplinary teams underscore the holistic approach required for effective management. Furthermore, addressing the challenges of nutritional management, such as malabsorption, enzyme therapy compliance, and lifestyle modifications, calls for innovative solutions and ongoing research.

Ultimately, the goal is to improve outcomes for patients with pancreatitis through optimized nutritional care, emphasizing the importance of a coordinated, patient-centered approach that leverages the expertise and compassion of nursing professionals. By advancing our understanding and application of nutritional care strategies, we can significantly impact the quality of life and prognosis for individuals affected by this complex condition.

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Received on 07.04.2024 Revised on 19.09.2024

Accepted on 26.12.2024 Published on 24.02.2025

Available online from March 17, 2025

Asian J. Nursing Education and Research. 2025;15(1):1-8.

DOI: 10.52711/2349-2996.2025.00001

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