Artificial nutrition in pancreatic disease: what lessons have we learned from the literature?

Acute pancreatitis is a disease process that begins with an initial injury to the pancreatic acinar cell due to the erroneous premature activation and intracellular release of digestive enzymes. The local injury is amplified through the induction of a systemic inflammatory response, mediated by the generation and release of cytokines and an aggressive inflammatory cell recruitment. Failure to maintain gut integrity may exacerbate the stress response and the systemic inflammatory reaction associated with this process, worsening the overall clinical severity of the pancreatitis and contributing further to complications of organ failure and nosocomial infection. Emphasis in the clinical nutritional management of these patients has shifted from efforts to minimize stimulation of the gland, to attaining enteral access, starting tube feeds low in the gastrointestinal tract, and monitoring tolerance. While clinical guidelines help identify those patients with acute pancreatitis at greatest need for aggressive nutritional support, the proper timing to initiate feeding, the optimal composition of the enteral formula, and whether or not enteral feeding is better than no nutritional therapy is still not clear from the current literature.