Gastroenterology – Guidelines on Parenteral Nutrition, Chapter 15Gastroenterologie – Leitlinie Parenterale Ernährung, Kapitel 15

GMS German Medical Science — an Interdisciplinary Journal

B. Koletzko¹  S. C. Bischoff²  R. J. Schulz³ 

[1] Dept. Metabolic Diseases & Nutritional Medicine, Dr. von Hauner Children's Hospital, University of Munich, Germany;Dept. Nutritional Medicine and Prevention, University StuttgartHohenheim, Germany;Clinic for Geriatrics, St. MarienHospital, Cologne, Germany

关键词: pancreatitis;    ulcerative colitis;    Crohn's disease;    inflammatory bowel disease;   

Others  :  869125

实施日期：2009-01-14，发布日期：2009-11-18

【 摘 要 】

In patients with Crohn's disease and ulcerative colitis parenteral nutrition (PN) is indicated when enteral nutrition is not possible or should be avoided for medical reasons. In Crohn's patients PN is indicated when there are signs/symptoms of ileus or subileus in the small intestine, scars or intestinal fistulae. PN requires no specific compounding for chronic inflammatory bowel diseases. In both diseases it should be composed of 55–60% carbohydrates, 25–30% lipids and 10–15% amino acids. PN helps in the correction of malnutrition, particularly the intake of energy, minerals, trace elements, deficiency of calcium, vitamin D, folic acid, vitamin B12, and zinc. Enteral nutrition is clearly superior to PN in severe, acute pancreatitis. An intolerance to enteral nutrition results in an indication for total PN in complications such as pseudocysts, intestinal and pancreatic fistulae, and pancreatic abscesses or pancreatic ascites. If enteral nutrition is not possible, PN is recommended, at the earliest, 5 days after admission to the hospital. TPN should not be routinely administered in mild acute pancreatitis or nil by moth status <7 days, due to high costs and an increased risk of infection. The energy requirements are between 25 and 35 kcal/kg body weight/day. A standard solution including lipids (monitoring triglyceride levels!) can be administered in acute pancreatitis. Glucose (max. 4–5 g/kg body weight/day) and amino acids (about 1.2–1.5 g/kg body weight/day) should be administered and the additional enrichment of TPN with glutamine should be considered in severe, progressive forms of pancreatitis.

【 授权许可】

   
© 2009 Schulz et al.This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.

【 参考文献 】

• [1]Buchman AL, Scolapio J, Freyer J. AGA technical review on short bowel syndrome and intestinal transplantation. Gastroenterol. 2003;124(4):1111-34.
• [2]Bartels M, Nagel E, Pichlmayr R. Welche Rolle spielt die Ernährung bei der Colitis ulcerosa? Ein Beitrag zum heutigen Stellenwert der diätetischen Therapie in der Behandlung entzündlicher Darmerkrankungen [What is the role of nutrition in ulcerative colitis? A contribution to the current status of diet therapy in treatment of inflammatory bowel diseases]. Langenbecks Arch Chir. 1995;380(1):4-11.
• [3]Diamanti A, Gambarara M, Knafelz D, Marcellini M, Boldrini R, Ferretti F, Papadatou B, Castro M. Prevalence of liver complications in pediatric patients on home parenteral nutrition: indications for intestinal or combined liver-intestinal transplantation. Transplant Proc. 2003;35(8):3047-9. DOI: 10.1016/j.transproceed.2003.10.037 
• [4]Iyer KR, Srinath C, Horslen S, Fox IJ, Shaw BW, Sudan DL, Langnas AN. Late graft loss and long-term outcome after isolated intestinal transplantation in children. J Pediatr Surg. 2002;37(2):151-4. DOI: 10.1053/jpsu.2002.30240 
• [5]Keller KM, Wirth S. Parenteral nutrition in treatment of short stature in adolescents with Crohn disease. Klin Pädiatr. 1992;204:411-6. DOI: 10.1055/s-2007-1025381 
• [6]Kelly DG, Fleming CR. Nutritional considerations in inflammatory bowel diseases. Gastroenterol Clin North Am. 1995;24(3):597-611.
• [7]Kolb S. Parenterale Ernährung zu Hause bei Morbus Crohn. Ernährung. 1990;1:40-4.
• [8]Ruemmele FM, Roy CC, Levy E, Seidman EG. Nutrition as primary therapy in pediatric Crohn's disease: fact or fantasy?. J Pediatr. 2000;136(3):285-91. DOI: 10.1067/mpd.2000.104537 
• [9]Silk DB. Medical management of severe inflammatory disease of the rectum: nutritional aspects. Baillieres Clin Gastroenterol. 1992;6(1):27-41. DOI: 10.1016/0950-3528(92)90016-8 
• [10]Stokes MA. Crohn's disease and nutrition. Br J Surg. 1992;79(5):391-4. DOI: 10.1002/bjs.1800790505 
• [11]Greenberg GR, Fleming CR, Jeejeebhoy KN, Rosenberg IH, Sales D, Tremaine WJ. Controlled trial of bowel rest and nutritional support in the management of Crohn's disease. Gut. 1988;29:1309-15. DOI: 10.1136/gut.29.10.1309 
• [12]Gilroy R, Sudan D. Liver and small bowel transplantation: therapeutic alternatives for the treatment of liver disease and intestinal failure. Semin Liver Dis. 2000;20:437-50. DOI: 10.1055/s-2000-13151 
• [13]Goh J, O'Morain CA. Review article: nutrition and adult inflammatory bowel disease. Aliment Pharmacol Ther. 2003;17(3):307-20. DOI: 10.1046/j.1365-2036.2003.01482.x 
• [14]Tsujikawa T, Andoh A, Fujiyama Y. Enteral and parenteral nutrition therapy for Crohn's disease. Curr Pharm Des. 2003;9(4):323-32.
• [15]Evans JP, Steinhart AH, Cohen Z, McLeod RS. Home total parenteral nutrition: an alternative to early surgery for complicated inflammatory bowel disease. J Gastrointest Surg. 2003;7(4):562-6. DOI: 10.1016/S1091-255X(02)00132-4 
• [16]Abu-Elmagd K, Bond G. Gut failure and abdominal visceral transplantation. Proc Nutr Soc. 2003;62:727-37. DOI: 10.1079/PNS2003288 
• [17]American Gastroenterological Association. American Gastroenterological Association medical position statement: parenteral nutrition. Gastroenterology. 2001;121(4):966-9. DOI: 10.1016/S0016-5085(01)91000-5 
• [18]Campos FG, Waitzberg DL, Teixeira MG, Mucerino DR, Habr-Gama A, Kiss DR. Inflammatory bowel diseases: principles of nutritional therapy. Rev Hosp Clin Fac Med Sao Paulo. 2002;57(4):187-98. DOI: 10.1590/S0041-87812002000400009 
• [19]Cucino C, Sonnenberg A. Cause of death in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2001;7(3):250-5. DOI: 10.1097/00054725-200108000-00011 
• [20]Forbes A. Review article: Crohn's disease – the role of nutritional therapy. Aliment Pharmacol Ther. 2002;16 Suppl 4:48-52. DOI: 10.1046/j.1365-2036.16.s4.7.x 
• [21]Higgens CS, Keighley MR, Allan RN. Impact of preoperative weight loss and body composition changes on postoperative outcome in surgery for inflammatory bowel disease. Gut. 1984;25:732-6. DOI: 10.1136/gut.25.7.732 
• [22]Hwang TL, Lue MC, Chen LL. Early use of cyclic TPN prevents further deterioration of liver functions for the TPN patients with impaired liver function. Hepatogastroenterology. 2000;47(35):1347-50.
• [23]Meadows N. Monitoring and complications of parenteral nutrition. Nutrition. 1998;14(10):806-8. DOI: 10.1016/S0899-9007(98)00089-6 
• [24]Muiesan P, Dhawan A, Novelli M, Mieli-Vergani G, Rela M, Heaton ND. Isolated liver transplant and sequential small bowel transplantation for intestinal failure and related liver disease in children. Transplantation. 2000;69(11):2323-6. DOI: 10.1097/00007890-200006150-00017 
• [25]Müller A, Neuhaus P. Dünndarmtransplantation - klinischer Stand und eigene Ergebnisse. Dtsch Ärztebl. 2004;101(1-2):A38-43. Available from: http://www.aerzteblatt.de/v4/archiv/lit.asp?id=39981 
• [26]Seo M, Okada M, Yao T, Furukawa H, Matake H. The role of total parenteral nutrition in the management of patients with acute attacks of inflammatory bowel disease. J Clin Gastroenterol. 1999;29(3):270-5. DOI: 10.1097/00004836-199910000-00009 
• [27]Stange EF, Schreiber S, Raedler A, Stallmach A, Schölmerich J, Loeschke K, Starlinger M, Fischbach W, Caspary WF. Therapie des Morbus Crohn – Ergebnisse einer Konsensuskonferenz der Deutschen Gesellschaft fur Verdauungs- und Stoffwechselkrankheiten [Therapy of Crohn diseases – results of a Consensus Conference of the German Society of Digestive and Metabolic Diseases]. Z Gastroenterol. 1997;35(7):541-4.
• [28]Lowen CC, Greene LM, McClave SA. Nutritional support in patients with inflammatory bowel disease. Postgrad Med. 1992;91(5):407-14.
• [29]González-Huix F, Fernández-Bañares F, Esteve-Comas M, Abad-Lacruz A, Cabré E, Acero D, Figa M, Guilera M, Humbert P, de León R, et al. Enteral versus parenteral nutrition as adjunct therapy in acute ulcerative colitis. Am J Gastroenterol. 1993;88(2):227-32.
• [30]Bodoky G, Harsanyi L, Pap A, Tihanyi T, Flautner L. Effect of enteral nutrition on exocrine pancreatic function. Am J Surg. 1991;161(1):144-8. DOI: 10.1016/0002-9610(91)90375-N 
• [31]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;97:2255-62. DOI: 10.1111/j.1572-0241.2002.05979.x 
• [32]Gupta R, Patel K, Calder PC, Yaqoob P, Primrose JN, Johnson CD. 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(5):406-13. DOI: 10.1159/000073657 
• [33]Hernández-Aranda JC, Gallo-Chico B, Ramírez-Barba EJ. Apoyo nutricional en pancreatitis aguda grave: Ensayo clinico controlado [Nutritional support in severe acute pancreatitis: Controlled clinical trial]. Nutr Hosp. 1996;11(3):160-6.
• [34]Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg. 1997;84(12):1665-9.
• [35]Louie B, Noseworthy T, Hailey D, Gramlich L, Jacobs P, Warnock G. Enteral or Parenteral Nutrition for Severe Pancreatitis: A Health Technology Assessment. JPEN J Parenter Enteral Nutr. 2002;26(4):S32.
• [36]Mans G. Die Ernährungstherapie der akuten Pankreatitis. Aktuel Ernaehr Med. 1997;22:276-80.
• [37]Nathens AB, Curtis JR, Beale RJ, Cook DJ, Moreno RP, Romand JA, Skerrett SJ, Stapleton RD, Ware LB, Waldmann CS. Management of the critically ill patient with severe acute pancreatitis. Crit Care Med. 2004;32(12):2524-36. DOI: 10.1097/01.CCM.0000148222.09869.92 
• [38]Olah A, Pardavi G, Belagyi T, Nagy A, Issekutz A, Mohamed GE. Early nasojejunal feeding in acute pancreatitis is associated with a lower complication rate. Nutrition. 2002;18(3):259-62. DOI: 10.1016/S0899-9007(01)00755-9 
• [39]Powell JJ, Murchison JT, Fearon KC, Ross JA, Siriwardena AK. Randomized controlled trial of the effect of early enteral nutrition on markers of the inflammatory response in predicted severe acute pancreatitis. Br J Surg. 2000;87(10):1375-81. DOI: 10.1046/j.1365-2168.2000.01558.x 
• [40]Windsor AC, Kanwar S, Li AG, Barnes E, Guthrie JA, Spark JI, Welsh F, Guillou PJ, Reynolds JV. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut. 1998;42(3):431-5.
• [41]Zhao G, Wang CY, Wang F, Xiong JX. Clinical study on nutrition support in patients with severe acute pancreatitis. World J Gastroenterol. 2003;9(9):2105-8.
• [42]Sax HC, Warner BW, Talamini MA, Hamilton FN, Bell RH Jr, Fischer JE, Bower RH. Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J Surg. 1987;153(1):117-24. DOI: 10.1016/0002-9610(87)90211-X 
• [43]Tenner S. Initial management of acute pancreatitis: critical issues during the first 72 hours. Am J Gastroenterol. 2004;99:2489-94. DOI: 10.1111/j.1572-0241.2004.40329.x 
• [44]McClave SA, Greene LM, Snider HL, Makk LJ, Cheadle WG, Owens NA, Dukes LG, Goldsmith LJ. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN J Parenter Enteral Nutr. 1997;21(1):14-20. DOI: 10.1177/014860719702100114 
• [45]Pupelis G, Selga G, Austrums E, Kaminski A. Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis. Nutrition. 2001;17(2):91-4. DOI: 10.1016/S0899-9007(00)00508-6 
• [46]Hallay J, Kovacs G, Szatmari K, Kovács G, Szatmári K, Bakó A, Szentkereszty Z, Lakos G, Sipka S, Sápy P. Early jejunal nutrition and changes in the immunological parameters of patients with acute pancreatitis. Hepatogastroenterology. 2001;48(41):1488-92.
• [47]Harsányi L, Bodoky G, Pap A. The effect of jejunal nutrition on pancreatic exocrine function. Acta Chir Hung. 1992;33(1-2):13-21.
• [48]Pandey SK, Ahuja V, Joshi YK, Sharma MP. A randomized trial of oral refeeding compared with jejunal tube refeeding in acute pancreatitis. Indian J Gastroenterol. 2004;23(2):53-5.
• [49]Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005;100:432-9. DOI: 10.1111/j.1572-0241.2005.40587.x 
• [50]August D. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26:68SA-70SA.
• [51]Heyland DK, MacDonald S, Keefe L, Drover JW. Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA. 1998;280(23):2013-9. DOI: 10.1001/jama.280.23.2013 
• [52]Kaushik N, O'Keefe SJ. Nutritional support in acute pancreatitis. Curr Gastroenterol Rep. 2004;6(4):320-6. DOI: 10.1007/s11894-004-0085-3 
• [53]Mallampalli A, McClave SA, Snider HL. Defining tolerance to enteral feeding in the intensive care unit. Clin Nutr. 2000;19(4):213-5. DOI: 10.1054/clnu.2000.0137 
• [54]Jabbar A, Chang WK, Dryden GW, McClave SA. Gut immunology and the differential response to feeding and starvation. Nutr Clin Pract. 2003;18:461-82. DOI: 10.1177/0115426503018006461 
• [55]Marik PE, Zaloga GP. Meta-analysis of parenteral nutrition versus enteral nutrition in patients with acute pancreatitis. BMJ. 2004;328:1407. DOI: 10.1136/bmj.38118.593900.55 
• [56]Lasztity N, Hamvas J, Biró L, Németh E, Marosvölgyi T, Decsi T, Pap A, Antal M. Effect of enterally administered n-3 polyunsaturated fatty acids in acute pancreatitis--a prospective randomized clinical trial. Clin Nutr. 2005;24:198-205. DOI: 10.1016/j.clnu.2004.12.008 
• [57]Oláh A, Belágyi T, Issekutz A, Gamal ME, Bengmark S. Randomized clinical trial of specific lactobacillus and fibre supplement to early enteral nutrition in patients with acute pancreatitis. Br J Surg. 2002;89(9):1103-7. DOI: 10.1046/j.1365-2168.2002.02189.x 
• [58]Wu H, Wu Z, Wu G. [Effect of intralipid on patients with acute necrotic pancreatitis: a prospective clinical study]. Zhonghua Wai Ke Za Zhi. 1995;33(5):261-4.
• [59]Martinez J, Castilla M, Velasco P, et al. Non-Glucose carbohydrates in the Parenteral Nutrition of Patients with a Systemic Inflammatory Response Syndrome. Nutr Hosp. 1999;14:41.
• [60]de Beaux AC, O'Riordain MG, Ross JA, Jodozi L, Carter DC, Fearon KC. Glutamine-supplemented total parenteral nutrition reduces blood mononuclear cell interleukin-8 release in severe acute pancreatitis. Nutrition. 1998;14(3):261-5. DOI: 10.1016/S0899-9007(97)00477-2 
• [61]Ockenga J, Borchert K, Rifai K, Manns MP, Bischoff SC. Effect of glutamine-enriched total parenteral nutrition in patients with acute pancreatitis. Clin Nutr. 2002;21(5):409-16. DOI: 10.1054/clnu.2002.0569 
• [62]Xian H, Qing-Jiu M, Jian-Guo L, Yan-Kui C, Xi-Lin D. Effect of total parenteral nutrition (TPN) with and without glutamine dipeptide supplementation on outcome in severe acute pancreatitis (SAP). Clin Nutr Suppl. 2004;1(1):43-7. DOI: 10.1016/j.clnu.2004.07.011 
• [63]Al Omran M, Groof A, Wilke D. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev. 2003;CD002837. DOI: 10.1002/14651858.CD002837 
• [64]Meier R, Beglinger C, Layer P, Gullo L, Keim V, Laugier R, Friess H, Schweitzer M, Macfie J; ESPEN Consensus Group. ESPEN guidelines on nutrition in acute pancreatitis. European Society of Parenteral and Enteral Nutrition. Clin Nutr. 2002;21(2):173-83. DOI: 10.1054/clnu.2002.0543 
• [65]Sun B, Gao Y, Xu J, Zhou XL, Zhou ZQ, Liu C, Jiang HC. Role of individually staged nutritional support in the management of severe acute pancreatitis. Hepatobiliary Pancreat Dis Int. 2004;3(3):458-63.