阶段性营养支持在重症急性胰腺炎治疗中的应用

目的观察肠内和肠外联合阶段性营养对重症急性胰腺炎治疗效果的影响。方法重症急性胰腺炎患者50例分为完全胃肠外营养组（TPN组,n=25）和肠内营养加肠外阶段性营养组（PN＋EN组,n=25）,比较两组治疗效果及临床指标的变化。结果两组患者治疗后血淀粉酶均有下降,但两组间比较无显著性差异（P〉0．05）。营养支持后PN＋EN组在APACHE1I评分和CT评分较TPN组明显降低（P〈0．01）,两组血清白蛋白及血钙水平较治疗前升高（P〈0．01）,血糖明显降低（P〈0．01）,但两组间比较无显著性差异（P〉0．05）。与TPN组相比,PN＋EN组患者住院天数、腹胀缓解时间、体温恢复正常时间均明显缩短,感染发生率显著降低（P〈0．01）。结论肠内和肠外联合阶段性营养对重症急性胰腺炎治疗效果优于完全胃肠外营养。     

肠内营养治疗急性胰腺炎切人时机的临床研究

[目的]探讨急性胰腺炎肠内营养治疗的最佳切人时机。[方法]将诊断为急性胰腺炎的200例患者随机分为3组：ENl组、EN2组和EN3组,分别于入院后2～3d、4～6d和7～9d开始肠内营养,并于人院后第10天测定各组患者的血液淀粉酶、脂肪酶、c-反应蛋白、胰蛋白酶原激活肽、D-fL酸水平及二胺氧化酶活性,并将其与治疗前进行比较。[结果]除EN3组G反应蛋白水平与治疗前无明显差异,其余各组Amy、LPS、CRP及TAP水平均显著降低;ENl组D-fL酸水平及DAO活性均较治疗前显著降低,EN2组D-fL酸水平最著降低。ENl组改善以上指标的程度最著高于EN3组。[结论]入院后2～3d是急性胰腺炎患者肠内营养的最佳切人时机,治疗效果优于后期切入点。     

早期肠内营养在大鼠重症急性胰腺炎肠道免疫屏障中的作用

[目的]探讨早期肠内营养在大鼠重症急性胰腺炎肠道屏障中的作用及机制。[方法]将60只SD大鼠随机分成3组:正常对照组即假手术组(SO组),肠外营养组(TPN组),肠内营养组(EEN组),每组20只。各组于造模后1d检测血清淀粉酶(AMY),第6天统计死亡率后处死大鼠并收集标本,回肠HE染色评估肠黏膜病理损伤,免疫组化法测定末端回肠Peyer结的MAdcAM-1、CD4+、CD8+的含量,检测内毒素含量和细菌移位率。[结果]1死亡率:SO组(0%)明显低于TPN组(50%)和EEN组(25%),EEN组明显低于TPN组,均P<0.05;2AMY含量:TPN组、EEN组与SO组比较,EEN组与TPN组比较,均差异有统计学意义(P<0.01);3回肠黏膜组织评分:TPN组、EEN组与SO组比较,EEN组与TPN组比较,均差异有统计学意义(P<0.05);4末端回肠Peyer结CD4+、CD8+、MAdcAM-1:TPN组、EEN组与SO组比较,EEN组与TPN组比较,均差异有统计学意义(P<0.05);5血内毒素水平:TPN组、EEN组与SO组比较,EEN组与TPN组比较,均差异有统计学意义(P<0.05);6各种细菌易位率:TPN组、EEN组与SO组比较,EEN组与TPN组比较,均差异有统计学意义(P<0.01)。[结论]早期肠内营养在维护大鼠重症急性胰腺炎肠道屏障方面的作用效果显著。     

Abdominal paracentesis drainage improves tolerance of enteral nutrition in acute pancreatitis: a randomized controlled trial

Objective: The objective of this study is to determine whether abdominal paracentesis drainage (APD) could improve the administration of enteral nutrition (EN) in acute pancreatitis.

Methods: Between January 2015 and April 2016, a total of 161 acute pancreatitis patients were enrolled and randomly assigned to either the APD group or the non-APD group. Several indexes associated with the administration of EN, including the gastroparesis cardinal symptom index (GCSI), the incidence of gastrointestinal adverse events, and the clinical outcomes, were recorded.

Results: The mean GCSI scores were 13.6?±?2.1 before randomization and 7.1?±?2.3 after a week in the APD group. These scores were 13.9?±?2.4 and 9.7?±?1.9 in the non-APD group. The incidences of gastrointestinal adverse events in the two groups were similar (p?>?.05), except for diarrhea. However, the patients in the APD group spent less time achieving the nutrition target (25 per kilogram of body weight per day) and fully tolerated the oral diet (p?<?.05). Additionally, the clinical outcomes of the APD group were better compared with those of the non-APD group.

Conclusion: APD can improve the administration of EN in acute pancreatitis. Given the positive effect of EN on clinical outcomes, this phenomenon possibly explains why APD could improve the clinical outcomes of acute pancreatitis patients in some aspects.     

Enteral nutrition and acute pancreatitis

INTRODUCTION Acute pancreatitis (AP) is a common severe illness of the digestive tract with variable involvement of other regional tissues and / or remote organ sysems[1-3],Mild disease is associated with minimal organ dysfunction and rapid recovery ,while severe disease is associated with multiple organ system failure and local complications such as necrosis , abscess , fistulas and pseudocyst formation [4-6].     

早期空肠内营养联合中药肠内滴注对重症急性胰腺炎患者肠麻痹的改善作用

目的:评价早期空肠内营养联合中药加味大承气颗粒肠内滴注治疗对改善重症急性胰腺炎患者肠麻痹的作用,探索重症急性胰腺炎的中西医结合治疗的新途径.方法:39例重症急性胰腺炎患者在常规治疗基础上,随机分成3组分别进行全胃肠外营养(PN组)、早期肠内营养(EN组)、肠内营养+中药大承气颗粒(EN+中药组)肠内滴注,观察患者腹痛腹胀缓解时间、胃肠道功能恢复(肠鸣音出现、肛门排气及排便)时间,并动态监测血淀粉酶、高敏C反应蛋白(CRP)、血浆肿瘤坏死因子-α(TNF-α).结果:EN组、EN+中药组患者经治疗后腹痛腹胀症状均缓解或消失,胃肠道功能恢复正常.PN组12例中,有2例腹胀、肠麻痹持续加重,其中1例出现腹腔隔室综合征并发多脏器功能衰竭.EN组、EN+中药组在腹胀(d)、腹痛缓解时间(d)以及胃肠道功能恢复时间(d)均优于PN组(4.22±0.94,3.02±0.75vs5.72±1.55;4.66±1.14,3.14±0.62vs6.81±1.81;3.42±0.82,3.21±0.88vs6.04±1.67,均P<0.05),其中EN+中药组腹胀(d)、腹痛缓解时间(d)优于EN组(3.02±0.75vs4.22...     

Treatment outcome of selective digestive decontamination and enteral nutrition in patients with severe acute pancreatitis

Background/Purpose

Sepsis due to infected pancreatic necrosis is the most serious complication in the late phase of severe acute pancreatitis (SAP). Bacterial translocation from the gut is thought to be the main cause of pancreatic infection. The possibility has recently been reported that selective digestive decontamination (SDD) and enteral nutrition (EN) may alleviate the complications and reduce the mortality rate in patients with SAP. We analyzed the treatment outcome of SDD and EN in patients with SAP.

Methods

We divided 90 patients with SAP into three groups: SDD(?)EN(?),group A; SDD(+)EN(?), group B; and SDD(+)EN(+), group C. Clinical outcome was analyzed retrospectively. The effect of SDD was compared in groups A and B, and the effect of EN was compared in groups B and C.

Results

The background of patients was not significantly different between the groups. SDD reduced the incidence of organ dysfunction (from 70% to 59%) and the mortality rate (from 40% to 28%), but the differences were not significant. EN reduced the incidence of infected pancreatic necrosis (from 31% to 24%) and the frequency of surgery for pancreas (from 28% to 18%), and further reduced the mortality rate (from 28% for SDD to 16%), but the differences were not significant. The peripheral lymphocyte count was significantly increased in patients with EN.

Conclusions

SDD and EN did not significantly affect the treatment outcome in SAP. However, the results in this study raise the possibility that SDD and EN may decrease the complications and reduce the mortality rate in SAP. The efficacy of SDD and EN for SAP should be evaluated in a randomized controlled trial.     

早期低脂肠内营养对急性重症胰腺炎血清甘油三酯的影响

目的观察早期低脂肠内营养（EEN）治疗对急性胰腺炎（SAP）血清甘油三酯水平的影响。方法将34例SAP并发高脂血症患者随机分为实验组和对照组,给予内镜下置管早期肠内营养治疗,16例实验组患者给予低脂要素肠内营养,18例对照组患者给予标准营养液肠内营养治疗,观察治疗前后甘油三酯（TG）、白细胞（WBC）、C反应蛋白（CRP）、谷草转氨酶（AST）、血钙及血糖的变化。结果两组患者治疗前后甘油三酯水平均明显下降,但实验组甘油三酯水平下降更加显著,且白细胞（WBC）、C反应蛋白（CRP）、谷草转氨酶（AST）、血钙与对照组比较下降更加明显,治疗前后血糖下降显著,治疗后两组比较差异不显著,考虑与均采用胰岛素降糖治疗有关。结论低脂EEN能够有效降低SAP甘油三酯水平并降低炎症反应、改善病情。     

急性胰腺炎全胃肠外营养和肠内营养的荟萃分析

目的 为明确全胃肠外营养（TPN）和肠内营养（EN）对急性胰腺炎（AP）患者的作用，对有关比较TPN和EN在AP中作用的文献进行荟萃分析。方法 检索1966年到2004年6月问发表的有关TPN和EN治疗AP的随机对照临床试验。按人选标准，有8项临床试验纳入本研究，由2名评价者对入选研究中有关试验设计、研究对象的特征、研究结果等内容独立进行摘录，并用RevMan4．2软件进行分析。结果 EN与TPN比较，能显著降低感染发生率（RR=0．45，95％CI为0．29～0．68，P=0．0002）及感染以外并发症发生率（RR=0．67，95％CI为0．47～0．96，P=0．03），减少手术干预（RR=0．47，95％CI为0．24～0．94，P=0．03），并有缩短住院时间的趋势，但不能降低死亡率（RR=0．61，95％CI为0．32～1．18，P=0．14）。结论 AP患者应首先考虑选用EN作为常规治疗，而不支持TPN。     

早期肠内营养对重症胰腺炎患者的影响

目的通过对44例重症胰腺炎不同方法的治疗，观察腑内营养（C-N）和静脉营养（PN）在住院时间、并发症及住院费用的区别。方法病人入院后给予禁饮食、胃肠减压，止痛抑制胃酸、胰液分泌及抗感染等治疗，第2天给予静脉营养。一组在病情稳定后（一般入院3-5天）开始给予肠内营养（EN）；另一组给静脉营养（PN）至进食，其中8例次半月后行肠内营养。结果EN组未出现腹痛腹泻及腹腔感染病，假性囊肿3例，平均住院时间18天，住院费用19996．70元。PN组腹痛腹泻病例12例次，腹腔感染2例次，多器官功能损害1例，静脉导管感染1例，假性囊肿6例，平均住院时间21．7天，住院费用36781．00元。两组住院时间无统计学意义（t检验P〉0．05），住院费用有统计学意义（t检验P〈0．05）。结论重症胰腺炎早期行肠内营养可减少住院费用、腹腔感染和腹痛腹泻等并发症。     

肠内营养与肠外营养对重症急性胰腺炎患者肠屏障功能影响的比较

目的 研究肠内与肠外营养对重症急性胰腺炎(SAP)患者肠屏障功能的影响.方法 苏州大学附属第一医院、上海交通大学附属第一医院、无锡市第二人民医院及泰州市人民医院4家单位符合SAP入选标准的63例患者随机分为肠内营养(EN)组及全肠外营养(TPN)组.其中,29例接受EN,经鼻空肠管给予高能肠内营养液;34例接受TPN,通过静脉补充营养液.观察两组患者的血清内毒素、二胺氧化酶(DAO)水平及尿乳果糖/甘露醇(L/M)比值的变化.结果 在第7、14、21天,EN组血清内毒素水平均明显低于TPN组[(39.30±15.82)EU/L比(73.05±21.16)EU/L、(22.64±14.31)EU/L比(49.34±24.54)EU/L、(14.81±10.93)EU/L比(30.08±14.10)EU/L,P值均＜0.05];在第7、14天,EN组的血浆DAO水平均明显低于TPN组[(9.97±3.84)U/L比(19.89±9.89)U/L、(5.42±1.84)U/L比(8.79±4.08)U/L,P值均＜0.05];在第7、14、21天,EN组的尿L/M比值明显低于TPN组(0.28±0.25比0.65±0.45、0.21±0.18比0.54±0.41、0.08±0.04比0.29±0.06,P值均＜0.05).结论 EN在改善肠屏障功能方面优于TPN.

Abstract：

Objective To evaluate the effect of enteral nutrition (EN) versus total parenteral nutrition(TPN) on gut barrier function in patients with severe acute pancreatitis (SAP). Methods Sixtythree patients with SAP enrolled from 4 hospitals were randomly assigned into EN group(29 cases) and TPN group(34 cases). EN group patients were fed via a spiral nasojejunal feeding tube placed routinely by endoscopy or fluoroscopy, and TPN group patients were nourished intravenously with TPN during the same period. The changes of serum endotoxin, diamine oxidase, and urinary excretion of lactulose and mannitol ratio (L/M) were observed. Results Plasma concentration of endotoxin were markedly decreased in EN group as compared with that in TPN group at the 7th,14th ,21th day of entry trial [(39. 30 ± 15. 82) EU/L vs (73.05 ±21.16) EU/L,(22.64 ±14.31) EU/L vs (49.34 ±24.54) EU/L,(14.81 ± 10.93)EU/L vs ( 30. 08 ± 14. 10 ) EU/L, P ＜ 0. 05]. Plasma concentration of diamine oxidase were markedly decreased in EN group as compared with that in TPN group at the 7th, 14th day of entry trial [(9. 97 ± 3. 84)U/Lvs (19.89±9.89)U/L,(5.42±1. 84) U/Lvs (8.79 ±4.08) U/L, both P ＜ 0. 05]. The urinary L/M decreased significantly in EN group than those in TPN group at the 7th, 14th,21th day of entry trial (0.28 ±0.25 vs 0. 65 ±0.45,0.21 ±0. 18 vs 0.54 ±0.41,0.08 ±0.04 vs 0.29 ±0.06, all P＜0.05).Conclusion EN has better effect on improving intestinal barrier function than TPN in treatment of patients with SAP.     

奥曲肽联合肠内营养对小儿急性胰腺炎的干预治疗及对IL-2和IL-6的影响分析

[目的]探讨奥曲肽联合肠内营养治疗小儿急性胰腺炎的临床疗效和对IL-2、IL-6的影响。[方法]将2011年8月-2013年8月间我院收治的59例急性胰腺炎患儿使用分层随机分组法分为对照组28例和治疗组31例,对照组患儿给予肠内营养,治疗组患儿给予肠内营养联合奥曲肽2．5μg／kg静脉滴注,治疗结束后比较临床疗效及患儿的腹部压痛消失时间、腹痛缓解时间、血液淀粉酶和尿液淀粉酶恢复时间,测定血清中IL-2和IL-6的水平。[结果]治疗组总有效率为90．3％,与对照组（75．O％）比较差异有统计学意义（z=2．14,P〈O．05）;治疗组腹痛缓解时间、腹部压痛消失时间和血、尿液淀粉酶恢复时间均明显少于对照组,差异有统计学意义（P〈o．05）;治疗后两组患儿IL-6明显下降（P〈O．05）,IL-2水平升高（P〈0．05）;且治疗组IL-6水平的变化更明显,与对照组相比差异有统计学意义（P〈0．05）。[结论]奥曲肽联合肠内营养进行治疗能明显改善急性胰腺炎患儿的临床症状和体征,降低炎性因子水平,是临床上治疗急性胰腺炎较为有效的方法。     

早期肠内营养在重症急性胰腺炎治疗中的作用

目的探讨重症急性胰腺炎早期肠内营养的可行性、安全性及有效性。方法将我院40例重症急性胰腺炎病人，随机分成肠内营养组（EN）（20例）和对照组（20例），EN组在入院72h后在胃镜辅助下置空肠营养管，由肠外营养逐渐过渡到肠内营养，其余治疗与对照组相同。分别比较两组治疗后7天时的血浆白蛋白和血红蛋白水平，以及治疗前后血尿淀粉酶水平。结果所有病人对早期肠内营养都能耐。无胰腺炎复发，肠内营养对血尿淀粉酶无明显影响，EN组血浆白蛋白和血红蛋白水平较治疗前及对照组有显著提高，EN组有1例出现肺感染，2例并发胰腺假性囊肿。对照组有3例出现肺感染，2例并发胰腺假性囊肿。结论对重症急性胰腺炎进行早期肠内营养支持是可行、安全及有效的，能降低胰周及全身感染率，改善重症急性胰腺炎病人的营养状况。     

培菲康联合柴芍承气汤对早期肠内营养支持重症急性胰腺炎疗效的影响

目的 评价培菲康联合柴芍承气汤对早期肠内营养支持治疗重症急性胰腺炎(SAP)疗效的影响.方法 将47例SAP患者随机分为早期肠内营养支持(EEN)+传统治疗组(PN组,15例),PN组+柴芍承气汤组(中药组,17例),中药组+培菲康组(观察组,15例).测定3组患者治疗前和治疗后第1天、5天、9天和14天血清中内毒素、C反应蛋白(CRP)、肿瘤坏死因子(TNF)-α浓度,比较住院时间、住院总费用及并发症、病死率.结果 与治疗前比较,患者经治疗后第5天起血清CRP、内毒素、TNF-α均改善.治疗后第1天3组患者间血清指标比较差异无统计学意义(P＞0.05);与PN组比较,中药组和观察组第5天和第9天血清指标降低显著(P＜0.05);与中药组比较,观察组从第9天开始对指标改善作用更显著(P＜0.05).与中药组、PN组比较,观察组患者住院时间缩短,并发症发生率和病死率降低,差异有统计学意义(P＜0.05),观察组和中药组患者住院费用较PN组均减少(P＜0.05).治愈出院42例.结论 培菲康联合柴芍承气汤在早期肠内营养支持SAP治疗中血清指标改善显著,减少并发症,降低死亡率,减少住院时间.     

早期肠内营养联合肠屏障保护剂治疗急性重症胰腺炎64例

目的:探讨早期肠内营养联合肠屏障保护剂在急性重症胰腺炎治疗中的应用价值.方法:将64例SAP患者随机分三组,A组予常规治疗,B组在常规治疗基础上通过鼻空肠管给予早期肠内营养,C组通过鼻空肠管给予早期肠内营养并加用肠屏障保护剂.观察患者症状、体征、WBC、CRP、血淀粉酶恢复正常时间,其体质量及血清白蛋白变化情况以及对比其总住院费用、平均每天的住院费用及住院时间.结果:B组在症状、体症、WBC、CRP、血淀粉酶恢复时间以及住院时间、住院费用均明显优于A组(P<0.05).C组在CRP及白细胞数恢复时间上更是优于B组,但平均每天住院费用三组没有明显差异性(P>0.05).结论:在SAP治疗中应用鼻空肠管进行早期肠内营养联合肠屏障保护剂,可以改善SAP患者的营养状况,加快症状恢复,缩短病程,减少医疗费用.     

早期肠内营养联合肠道去污对犬急性坏死性胰腺炎炎症反应的影响

目的观察早期肠内营养(EN)联合肠道去污(SDD)对犬急性坏死性胰腺炎(ANP)内毒素移位及全身炎症反应的影响。方法在麻醉状态下,经腹向胰管内注入5%牛磺胆酸钠混合液(1ml/kg)诱导ANP。造模后,20条杂种犬分为生理盐水(NS)组(n=5)、EN组(n=5)、SDD组(n=5)和早期肠内营养联合肠道去污(ESDD)组(n=5)。在造模后第1、2、3、4、5天测定外周血淀粉酶、乳酸脱氢酶、肿瘤坏死因子(TNF)α、白细胞介素(IL1)β和内毒素的含量。实验第7天处死动物并收集标本。取胰腺组织置于中性甲醛和液氮中保存,行HE染色观察其组织病理学改变并检测中性粒细胞髓过氧化物酶(MPO)活性。结果各组中淀粉酶、乳酸脱氢酶均差异无统计学意义,胰腺病理无明显差异,胰腺组织内的MPO虽然在NS组高于其他各组,但各组之间差异无统计学意义(P>0.05)。内毒素在第2天后NS组明显高于SDD、EN、ESDD组(P<0.05),TNFα、IL1β在前3天各组均无明显差异(P>0.05),在第4、5天时NS组明显高于SDD、EN、ESDD组(P<0.05),ESDD组TNFα、IL1β水平均低于SDD、EN组,但SDD、EN、ESDD组之间无明显差异(P>0.05)。结论SDD、EN或ESDD均不能改善犬ANP胰腺组织自身的炎症,但SDD、EN、ESDD能明显减少犬ANP后期血液中的内毒素、TNFα、IL1β水平,改善全身炎症反应综合征,其中ESDD治疗效果最佳。     

重症急性胰腺炎肠内、外营养研究进展

重症急性胰腺炎有较高的病死率,营养支持是重要的治疗措施。肠内营养和肠外营养各有其优缺点。肠内营养在维护肠道屏障功能、减少细菌移位方面具有独特的作用。     

Treatment strategy against infection: clinical outcome of continuous regional arterial infusion, enteral nutrition, and surgery in severe acute pancreatitis

Background In severe acute pancreatitis (SAP), infectious complications are the main contributors to high mortality. Since 1995, we have performed continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) as prevention therapies against infection. When infected pancreatic necrosis was proven, surgical intervention was adapted. The aim of this study was to investigate the clinical outcome of these treatments. Methods We examined the relationship between the historical change of treatment strategy and clinical outcome. We divided 84 patients with acute necrotizing pancreatitis into two groups, CRAI (−) and CRAI (+), and compared the outcome. We divided 145 patients with SAP into two groups, EN (−) and EN (+), and compared the outcome. We also analyzed the outcome of surgical treatment. Results In the CRAI (+) group, the incidence of infection, the frequency of surgery, and the mortality rate were lower than those in CRAI (−) group: 34% versus 51%, 27% versus 63% (P < 0.05), and 37% versus 54%, respectively. In the EN (+) group, the frequency of surgery and the mortality rate were lower than those in the EN (−) group: 23% versus 32% and 19% versus 35% (P < 0.05), respectively. These improvement effects were manifest in stage 3 (9 ≤ Japanese Severity Score ≤ 14). Treatment outcome of necrosectomy for infected pancreatic necrosis was still poor. Bleeding and abscess–gut fistula were postoperative life-threatening complications. Conclusions CRAI and EN may improve the clinical outcome of SAP, reducing infection and averting pancreatic surgery.     

Nutritional support in acute pancreatitis

Acute pancreatitis can present as a mild or severe disease. Most patients have a mild disease and recover without requiring nutritional support. Patients with severe acute pancreatitis may develop systemic inflammatory response syndrome and progress to multi-organ failure. These ill patients have high metabolism and protein catabolism. Hence, the nutritional management of these patients can be challenging. The aim of nutritional support is to meet the elevated metabolic demands as far as possible without stimulating pancreatic secretion and yet maintaining the gut integrity. The concept of pancreatic rest has evolved over the years. To date, there is a substantial scientific proof that enteral nutrition (EN) in comparison to parenteral nutrition significantly reduces infectious complications, surgical interventions and mortality in predicted severe acute pancreatitis. EN may be able to improve outcome in these patients if given early. In this review, we summarized the current knowledge on nutrition in acute pancreatitis and shared our local experience.