Wiedeck H, Geldner G
Klinik für Anästhesiologie, Universitätsklinikum Ulm.
Zentralbl Chir. 2001 Jan;126(1):10-4. doi: 10.1055/s-2001-11715.
The metabolism of acute pancreatitis is characterized by hypermetabolism and catabolism. Evidence for glucose intolerance occurs in anywhere from 40 to 90% of cases and urine urea nitrogen may increase up to 40 g/day. The most important aspect when considering nutritional therapy is determining the severity of the pancreatitis. The APACHE-II-scoring-system and the time honored Ranson criteria are useful for differentiating severe from mild pancreatitis. Despite some limitations in sensitivity and specificity, studies have suggested that patients with 2 or less Ranson criteria and an APACHE-II-score of 9 or less have mild pancreatitis, while patients with 3 or more Ranson criteria and an APACHE-II-score of 10 or more have severe pancreatitis. Evidence of organ failure on clinical presentation and pancreatic necrosis on dynamic CT scan are also important factors in determining severity of pancreatitis and are probably the two major indicators of patient outcome. Only 3 prospective randomized controlled trials have compared enteral to parenteral nutrition for pancreatitis. All studies described successful use of enteral feeding without exacerbating the disease process although a mild stimulation of exocrine pancreatic secretion could not be prevented, even when the tube was placed below the ligament of Treitz. Kalfarentzos [11] and McClave [14] could show that hyperglycemia was worse in the parenteral feeding patients compared to the enteral feeding group and Windsor [24] concluded with respect to the results of his study, that enteral feeding modulates the inflammatory response in acute pancreatitis. Conclusions regarding the use of enteral or parenteral nutrition in acute pancreatitis are difficult to form, as there is a need of more prospective studies. As ileus may be a problem in patients with greater severity of pancreatitis, limiting the application of early enteral feeding, the route of nutritional support should be determined by the clinical course and the severity of the disease.
急性胰腺炎的代谢特点是高代谢和分解代谢。40%至90%的病例存在葡萄糖不耐受的证据，尿尿素氮可能增加至每日40克。在考虑营养治疗时，最重要的方面是确定胰腺炎的严重程度。APACHE-II评分系统和久负盛名的兰森标准有助于区分重症胰腺炎和轻症胰腺炎。尽管在敏感性和特异性方面存在一些局限性，但研究表明，兰森标准为2项或更少且APACHE-II评分为9分或更低的患者为轻症胰腺炎，而兰森标准为3项或更多且APACHE-II评分为10分或更高的患者为重症胰腺炎。临床表现出现器官功能衰竭以及动态CT扫描显示胰腺坏死也是确定胰腺炎严重程度的重要因素，可能是患者预后的两个主要指标。仅有3项前瞻性随机对照试验比较了胰腺炎患者肠内营养和肠外营养的效果。所有研究均描述了成功使用肠内喂养且未加重疾病进程的情况，尽管即使将喂养管置于屈氏韧带以下，也无法防止胰腺外分泌轻度受刺激。卡尔法伦佐斯[11]和麦克拉夫[14]发现，与肠内喂养组相比，肠外喂养患者的高血糖情况更严重，温莎[24]根据其研究结果得出结论，肠内喂养可调节急性胰腺炎的炎症反应。由于需要更多的前瞻性研究，因此难以就急性胰腺炎中肠内或肠外营养的使用形成结论。由于肠梗阻可能是重症胰腺炎患者的一个问题，限制了早期肠内喂养的应用，营养支持途径应根据临床病程和疾病严重程度来确定。
