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Nutritional immunomodulation of acute pancreatitis

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Abstract

Despite the great advances in our understanding of the pathophysiology of acute pancreatitis, no specific therapy has emerged, and treatment remains supportive. In patients with the severe form of the disease, in which mortality remains high at 20% to 30%, the function of the upper gastrointestinal tract is disturbed due to extrinsic compression by the inflamed and swollen pancreas, and normal eating is impossible. Such patients often develop multiple organ failure, necessitating intensive-care management and artificial ventilation for weeks on end. In this setting, protein catabolism will rapidly result in protein deficiency and further complications unless nutritional support is commenced. Recent studies have shown that, despite the risk of disease exacerbation through pancreatic stimulation, enteral feeding is more effective than parenteral feeding in improving outcome. Experimental studies suggest that this can be attributed to its content of specific immunomodulating nutrients, such as glutamine, arginine, and n-3 fatty acids, and by its stabilizing effect on the gut flora through the provision of prebiotics. Further studies are indicated to examine whether dietary enrichment with these substrates, along with regulation of the gut bacteria with probiotics, can improve outcome further.

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References and Recommended Reading

  1. Abou-Assi S, Craig K, O’Keefe SJ: Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study. Am J Gastroenterol 2002, 97:2255–2262.

    Article  PubMed  Google Scholar 

  2. Buter A, Imrie CW, Carter CR, et al.: Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 2002, 89:298–302.

    Article  CAS  PubMed  Google Scholar 

  3. Kumar A, Singh N, Prakash S, et al.: Early enteral nutrition in severe acute pancreatitis: a prospective randomized controlled trial comparing nasojejunal and nasogastric routes. J Clin Gastroenterol 2006, 40:431–434.

    Article  CAS  PubMed  Google Scholar 

  4. Olah A, Pardavi G, Belagyi T, et al.: Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition 2002, 18:259–262.

    Article  PubMed  Google Scholar 

  5. Windsor AC, Kanwar S, Li AG, et al.: Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut 1998, 42:431–435.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. O’Keefe SJ, Lee RB, Anderson FP, et al.: Physiological effects of enteral and parenteral feeding on pancreaticobiliary secretion in humans. Am J Physiol Gastrointest Liver Physiol 2003, 284:G27–G36.

    PubMed  Google Scholar 

  7. Sax HC, Warner BW, Talamini MA, et al.: Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J Surg 1987, 153:117–124.

    Article  CAS  PubMed  Google Scholar 

  8. Kudsk KA, Minard G, Wojtysiak SL, et al.: Visceral protein response to enteral versus parenteral nutrition and sepsis in patients with trauma. Surgery 1994, 116:516–523.

    CAS  PubMed  Google Scholar 

  9. Fink MP: Gastrointestinal mucosal injury in experimental models of shock, trauma, and sepsis. Crit Care Med 1991, 19:627–641.

    Article  CAS  PubMed  Google Scholar 

  10. Ammori BJ: Role of the gut in the course of severe acute pancreatitis. Pancreas 2003, 26:122–129.

    Article  PubMed  Google Scholar 

  11. O’Keefe SJ, Lee RB, Li J, et al.: Trypsin secretion and turnover in patients with acute pancreatitis. Am J Physiol Gastrointest Liver Physiol 2005, 289:G181–G187.

    Article  PubMed  Google Scholar 

  12. van den Berghe G, Wouters P, Weekers F, et al.: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001, 345:1359–1367.

    Article  PubMed  Google Scholar 

  13. Fukatsu K, Kudsk KA, Zarzaur BL, et al.: TPN decreases IL-4 and IL-10 mRNA expression in lipopolysaccharide stimulated intestinal lamina propria cells but glutamine supplementation preserves the expression. Shock 2001, 15:318–322.

    Article  CAS  PubMed  Google Scholar 

  14. Gupta R, Patel K, Calder PC, et al.: A randomised clinical trial to assess the effect of total enteral and total parenteral nutritional support on metabolic, inflammatory and oxidative markers in patients with predicted severe acute pancreatitis (APACHE II > or =6). Pancreatology 2003, 3:406–413.

    Article  CAS  PubMed  Google Scholar 

  15. Makhija R, Kingsnorth AN: Cytokine storm in acute pancreatitis. J Hepatobiliary Pancreat Surg 2002, 9:401–410.

    Article  PubMed  Google Scholar 

  16. O’Keefe SJ, Foody W, Gill S: Transnasal endoscopic placement of feeding tubes in the intensive care unit. JPEN J Parenter Enteral Nutr 2003, 27:349–354.

    Article  PubMed  Google Scholar 

  17. O’Keefe S J, Lee RB, Li J, et al.: Trypsin and splanchnic protein turnover during feeding and fasting in human subjects. Am J Physiol Gastrointest Liver Physiol 2006, 290:G213–G221.

    Article  PubMed  Google Scholar 

  18. Nishimoto N, Kishimoto T: Interleukin 6: from bench to bedside. Nat Clin Pract Rheumatol 2006, 2:619–626.

    Article  CAS  PubMed  Google Scholar 

  19. Stimac D, Fisic E, Milic S, et al.: Prognostic values of IL-6, IL-8, and IL-10 in acute pancreatitis. J Clin Gastroenterol 2006, 40:209–212.

    Article  CAS  PubMed  Google Scholar 

  20. Papachristou GI, Whitcomb DC: Inflammatory markers of disease severity in acute pancreatitis. Clin Lab Med 2005, 25(1):17–37. Good review.

    Article  PubMed  Google Scholar 

  21. Genton L, Kudsk KA, Reese SR, et al.: Enteral feeding preserves gut Th-2 cytokines despite mucosal cellular adhesion molecule-1 blockade. JPEN J Parenter Enteral Nutr 2005, 29:44–47.

    Article  PubMed  Google Scholar 

  22. Burrin DG, Stoll B: Key nutrients and growth factors for the neonatal gastrointestinal tract. Clin Perinatol 2002, 29:65–96.

    Article  CAS  PubMed  Google Scholar 

  23. Nathan C: Nitric oxide as a secretory product of mammalian cells. Faseb J 1992, 6:3051–3064.

    CAS  PubMed  Google Scholar 

  24. Hyvonen MT, Herzig KH, Sinervirta R, et al.: activated polyamine catabolism in acute pancreatitis: alpha-methylated polyamine analogues prevent trypsinogen activation and pancreatitis-associated mortality. Am J Pathol 2006, 168:115–122.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  25. Windmueller HG, Spaeth AE: Uptake and metabolism of plasma glutamine by the small intestine. Nutr Rev 1990, 48:310–312.

    Article  CAS  PubMed  Google Scholar 

  26. Wischmeyer PE: Clinical applications of L-glutamine: past, present, and future. Nutr Clin Pract 2003, 18:377–385.

    Article  PubMed  Google Scholar 

  27. Briassoulis G, Filippou O, Kanariou M, et al.: Comparative effects of early randomized immune or non-immune-enhancing enteral nutrition on cytokine production in children with septic shock. Intensive Care Med 2005, 31:851–858.

    Article  PubMed  Google Scholar 

  28. de Luis DA, Arranz M, Aller R, et al.: Immunoenhanced enteral nutrition, effect on inflammatory markers in head and neck cancer patients. Eur J Clin Nutr 2005, 59:145–147. This study showed that both immunoenhanced and isonitrogenous enteral feeding formulas inhibit the secretion of IL-6 and CRP in patients with head and neck cancer, suggesting that enteral feeding possesses inherent immunomodulatory effects independent of nutritional supplements.

    Article  PubMed  Google Scholar 

  29. Marin VB, Rodriguez-Osiac L, Schlessinger L, et al.: Controlled study of enteral arginine supplementation in burned children: impact on immunologic and metabolic status. Nutrition 2006, 22:705–712.

    Article  CAS  PubMed  Google Scholar 

  30. Coeffier M, Marion R, Leplingard A, et al.: Glutamine decreases interleukin-8 and interleukin-6 but not nitric oxide and prostaglandins e(2) production by human gut in-vitro. Cytokine 2002, 18:92–97.

    Article  CAS  PubMed  Google Scholar 

  31. de Beaux AC, O’Riordain MG, Ross JA, et al.: Glutamine-supplemented total parenteral nutrition reduces blood mononuclear cell interleukin-8 release in severe acute pancreatitis. Nutrition 1998, 14:261–265.

    Article  PubMed  Google Scholar 

  32. Pearce CB, Sadek SA, Walters AM, et al.: A double-blind, randomised, controlled trial to study the effects of an enteral feed supplemented with glutamine, arginine, and omega-3 fatty acid in predicted acute severe pancreatitis. JOP 2006, 7:361–371.

    PubMed  Google Scholar 

  33. Coeffier M, Le Pessot F, Leplingard A, et al.: Acute enteral glutamine infusion enhances heme oxygenase-1 expression in human duodenal mucosa. J Nutr 2002, 132:2570–2573.

    CAS  PubMed  Google Scholar 

  34. Hegazi RA, Rao KN, Mayle A, et al.: Carbon monoxide ameliorates chronic murine colitis through a heme oxygenase 1-dependent pathway. J Exp Med 2005, 202:1703–1713.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  35. Nakamichi I, Habtezion A, Zhong B, et al.: Hemin-activated macrophages home to the pancreas and protect from acute pancreatitis via heme oxygenase-1 induction. J Clin Invest 2005, 115:3007–3014. This study illustrates the significant anti-inflammatory role of HO-1 in animal models of acute pancreatitis.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  36. Peng ZY, Hamiel CR, Banerjee A, et al.: Glutamine attenuation of cell death and inducible nitric oxide synthase expression following inflammatory cytokine-induced injury is dependent on heat shock factor-1 expression. JPEN J Parenter Enteral Nutr 2006, 30:400–406.

    Article  CAS  PubMed  Google Scholar 

  37. Peng ZY, Serkova NJ, Kominsky DJ, et al.: Glutamine-mediated attenuation of cellular metabolic dysfunction and cell death after injury is dependent on heat shock factor-1 expression. JPEN J Parenter Enteral Nutr 2006, 30:373–378.

    Article  CAS  PubMed  Google Scholar 

  38. Ziegler TR, Ogden LG, Singleton KD, et al.: Parenteral glutamine increases serum heat shock protein 70 in critically ill patients. Intensive Care Med 2005, 31:1079–1086.

    Article  PubMed  Google Scholar 

  39. Kolios G, Valatas V, Ward SG: Nitric oxide in inflammatory bowel disease: a universal messenger in an unsolved puzzle. Immunology 2004, 113:427–437.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Ochoa JB, Makarenkova V, Bansal V: A rational use of immune enhancing diets: when should we use dietary arginine supplementation? Nutr Clin Pract 2004, 19:216–225.

    Article  PubMed  Google Scholar 

  41. Backhed F, Ley RE, Sonnenburg JL, et al.: Host-bacterial mutualism in the human intestine. Science 2005, 307:1915–1920.

    Article  PubMed  Google Scholar 

  42. Sonnenburg JL, Xu J, Leip DD, et al.: Glycan foraging in vivo by an intestine-adapted bacterial symbiont. Science 2005, 307:1955–1959.

    Article  CAS  PubMed  Google Scholar 

  43. Kecskes G, Belagyi T, Olah A: Early jejunal nutrition with combined pre- and probiotics in acute pancreatitis-prospective, randomized, double-blind investigations. Magy Seb 2003, 56:3–8.

    PubMed  Google Scholar 

  44. Olah A, Belagyi T, Issekutz A, et al.: [Combination of early nasojejunal feeding with modern synbiotic therapy in the treatment of severe acute pancreatitis (prospective, randomized, double-blind study)]. Magy Seb 2005, 58:173–178.

    PubMed  Google Scholar 

  45. Targarona Modena J, Barreda Cevasco L, Arroyo Basto C, et al.: Total enteral nutrition as prophylactic therapy for pancreatic necrosis infection in severe acute pancreatitis. Pancreatology 2006, 6(:58–64.

    Article  PubMed  Google Scholar 

  46. Tiengou LE, Gloro R, Pouzoulet J, et al.: Semi-elemental formula or polymeric formula: is there a better choice for enteral nutrition in acute pancreatitis? Randomized comparative study. JPEN J Parenter Enteral Nutr 2006, 30:1–5.

    Article  CAS  PubMed  Google Scholar 

  47. Kaushik N, Pietraszewski M, Holst JJ, et al.: Enteral feeding without pancreatic stimulation. Pancreas 2005, 31:353–359.

    Article  PubMed  Google Scholar 

  48. Makola D, Krenitsky J, Parrish C, et al.: Efficacy of enteral nutrition for the treatment of pancreatitis using standard enteral formula. Am J Gastroenterol 2006, 101:2347–2355.

    Article  CAS  PubMed  Google Scholar 

  49. Calder PC: n-3 polyunsaturated fatty acids, inflammation, and inflammatory diseases. Am J Clin Nutr 2006, 83(Suppl):1505S–1519S.

    CAS  PubMed  Google Scholar 

  50. Bansal V, Syres KM, Makarenkova V, et al.: Interactions between fatty acids and arginine metabolism: implications for the design of immune-enhancing diets. JPEN J Parenter Enteral Nutr 2005, 29(Suppl):S75–S80.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Gastroenterology, University of Pittsburgh Medical School, Pittsburgh, PA, 15213, USA

    Refaat A. F. Hegazi MD, PhD, MPH, MS & Stephen J. D. O’Keefe MD, MSc, FRCP

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  1. Refaat A. F. Hegazi MD, PhD, MPH, MS
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  2. Stephen J. D. O’Keefe MD, MSc, FRCP
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Correspondence to Stephen J. D. O’Keefe MD, MSc, FRCP.

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Hegazi, R.A.F., O’Keefe, S.J.D. Nutritional immunomodulation of acute pancreatitis. Curr Gastroenterol Rep 9, 99–106 (2007). https://doi.org/10.1007/s11894-007-0904-4

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