Ernährung bei akuter Pankreatitis

Zusammenfassung

Die Ernährung bei akuter Pankreatitis erfuhr einen Paradigmenwechsel. Als Therapie „gestern” galt die parenterale Ernährung, um via oraler Nahrungs- und Flüssigkeitskarenz das Pankreas „ruhig zu stellen”. Die frühenterale Ernährung über eine nasojejunale Sonde anstelle der alleinigen parenteralen Ernährung hat sich bei schwerer akuter Pankreatitis weitgehend durchgesetzt. Im Vergleich zur parenteralen Ernährung finden sich aber bei enteraler Ernährung via Sonde signifikant weniger Infektionsprobleme und seltener die Notwendigkeit zu chirurgischen Interventionen. Die Dauer des Krankenhausaufenthalts wird verkürzt und die Behandlungskosten reduziert. Die Letalität scheint durch den gewählten Ernährungsmodus aber nicht gesenkt werden zu können. Möglicherweise kann die enterale Ernährung auch über eine einfacher zu platzierende Magensonde erfolgen. Wichtige Fragen zur quantitativen und qualitativen Zusammensetzung der Sondenernährung, zur Ernährung bei leichter akuter Pankreatitis, zur Reduktion der Schmerzen und Zusammensetzung der Diät beim Kostaufbau sind weitgehend unbeantwortet. In möglichen Therapiestrategien „morgen” wird die Immunonutrition diskutiert. Kleinere, meist unkontrollierte Studien liegen zum Einsatz von MCT/LCT-Fettemulsionen, Glutamin, Arginin, Omega-3-Fettsäuren und Nukleotiden vor. Es fand sich jedoch bislang kein Wirknachweis hinsichtlich klinisch relevanter Endpunkte. In einer aktuell publizierten Studie zum Einsatz von Probiotika fanden sich überraschend viele schwere Komplikationen. In dieser Übersichtsarbeit fassen wir den aktuellen Kenntnisstand zur Ernährungstherapie der akuten Pankreatitis zusammen und diskutieren aktuelle Entwicklungen.

Abstract

Nutritional concepts in acute pancreatitis are undergoing a rapid change. An early start of nutrition via nasojejunal tubes is about to replace parenteral nutrition. Yesterday it was believed that the pancreas had to be put at rest. Thus, stimulation of pancreatic secretion by enteral nutrition was believed to be detrimental. However, on comparing the results of enteral with those of parenteral nutrition, the pancreatic infection rates, rate of surgical interventions, days of hospital stay, and costs are found to be significantly reduced. Whether or not enteral nutrition decreases mortality has not been clearly proven. Pancreatitis is associated with the risk of paralytic ileus. Thus, data suggesting that one does not have to feed via a nasojejunal tube but rather via an easier to place nasogastric tube, are provocative. Numerous questions still have to be answered such as composition of tube diet, nutrition in mild to moderate pancreatitis, ways to reduce pain and composition of diet when oral refeeding is started. The nutrition of tomorrow may implicate immunonutrition. There are only a few small studies suggesting beneficial effects by supplementation of tube feeding with MCT/LCT triglycerides, glutamine, arginin, omega-3-fatty acids, nucleotides. So far, these supplements have failed to show efficacy for clinically relevant endpoints. In an recently published study, prebiotics were associated with a high complication rate. In this review, we summarise the current knowledge on nutrition in acute pancreatitis and discuss future developments.

Schlüsselwörter

Pankreatitis - Ernährung - enteral - parenteral

Key words

pancreatitis - nutrition - enteral - parenteral

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