Hepatic Failure/GI/Endocrine Emergencies

Nutrition

Historically, patients were kept NPO in order to rest the pancreas and prevent the further release of

pancreatic enzymes. Patients were given TPN until complete resolution of AP.

This practice has largely fallen out of favor because several studies have shown that early

(within 24–48 hours) enteral nutrition is safe and effective for patients with AP. In addition,

a recent meta-analysis of 11 randomized trials concluded that early (within 24–48 hours)

feedings were not associated with increased adverse effects and may reduce hospital length of

stay, particularly for mild to moderate AP. Enteral feeding maintains the gut mucosal barrier

and helps prevent infectious complications such as infected necrosis, which may result from

bacterial translocation from the gut.

ii.

A meta-analysis of eight trials comparing enteral nutrition with TPN in patients with AP showed

decreased mortality (relative risk [RR] 0.5; 95% CI, 0.28–0.91), infectious complications

(RR 0.39; 95% CI, 0.23–0.65), multiorgan failure (RR 0.55; 95% CI, 0.37–0.81), and surgical

interventions (RR 0.44; 95% CI, 0.29–0.67) with the use of enteral nutrition. Enteral nutrition

in these trials was given by the NJ route.

iii.

TPN is mainly reserved for patients unable to meet caloric demands with enteral feeding.

Although the NJ route for enteral feeding has been preferred because it avoids the gastric area

where pancreatic enzyme stimulation may occur, the NG route appears to be safe.

A recent meta-analysis of three randomized controlled trials showed no significant differences

in mortality, tracheal aspiration, or proportion meeting energy balance between the two routes;

however, the results were limited by small sample sizes.

ii.

NG feeding is easier than NJ feeding because NJ tubes can be difficult to place, expensive, and

inconvenient. However, there is concern that NG feeding may increase the risk of aspiration

pneumonitis, particularly in patients with a history of aspiration.

Surgery

Cholecystectomy should be performed in patients with gallstones retained in the gallbladder to

prevent the recurrence of AP. For necrotizing biliary AP, cholecystectomy should be delayed until

inflammation is resolved and fluid collections are cleared in order to avoid infection.

Surgery is generally unnecessary for asymptomatic patients with pseudocysts and pancreatic or

extrapancreatic necrosis.

Surgical debridement of sterile necrosis is only necessary if gastric outlet obstruction or bile duct

obstruction is present.

For stable patients with infected necrotizing pancreatitis, surgical debridement should be

delayed for at least 4 weeks to allow appropriate delineation of necrotic versus non-necrotic

tissue, and antibiotics should be tried before surgical intervention.

ii.

Unstable patients with infected necrosis should undergo immediate debridement, and

necrosectomy may be required in patients who do not respond to a combination of antibiotics

and debridement.