Exocrine pancreas disfunction in severely traumatised patients and early enteral nutrition

BACKGROUND: We investigated exocrine pancreatic insufficiency in severely traumatised patients with enteral nutrition using the fecal elastase-1 concentration. METHODS: The fecal elastase-1 levels of critically ill patients after major trauma (n=18) were determined in a prospective study. Early enteral nutrition was started with a high molecular diet via a naso-duodenal tube, starting 24-36 hours after admission to the intensive care unit. Enteral feeding was administered continuously starting with 20 mL/h (1 kcal/mL) and advanced gradually to 80 mL/h in the next days. Stool samples from the first and second stool after beginning of the enteral nutrition were taken for determination of the fecal elastase-1. For elastase-1 analysis in a sandwich-type enzyme immunoassay (ELISA), a sample of approximately 1 g stool was taken from the first and second stool after beginning of the enteral nutrition. Elastase-1 concentration of >200 mg/g was considered as normal, whereas <100 mg/g elastase-1 was significantly low indicating a severe exocrine pancreas dysfunction. RESULTS: All patients were fed enterally without relevant feeding-associated complications and no diarrhoea occurred in any patient. In the initial stool passage, 55.6% of the patients had moderately or severely decreased elastase-1 concentrations. In the second stool passage, only 38.9% of the patients showed a decrease in the elastase-1 concentration (p<0.01). The average elastase-concentration in the first stool sample was 268.4 mg/g (median: 162.1 mg/g) and in the second sample 333.8 mg/g (median: 520.2 mg/g). CONCLUSION: The data of this study suggests that initial exocrine pancreas insufficiency may occur in severely traumatised and critically ill patients, which improves under early enteral nutrition with polymeric enteral diets. The clinical consequences of exocrine pancreatic dysfunction in the early posttraumatic situation have to be defined.

Majör travma sonrasý görülen pankreas salgý bozukluðu ve erken enteral beslenme

AMAÇ: Majör travma sonrasýnda yoðun bakým servisinde yatan ve enteral yoldan beslenen hastalarda, pankreas ekzokrin salgýlarýnda görülen deðiþiklikleri saptamaktýr.
GEREÇ-YÖNTEM: Hastalar (n=18) yoðun bakým ünitesinde travma sonrasý 24-36. saatlerde enteral yoldan beslenmeye baþlanarak, sonuçlar ileriye dönük olarak deðerlendirildi. Baþlangýçta yüksek molekül aðýrlýklý diyetler 20 ml/sa’den (1 kcal/mL) verildi ve bu miktar aþamalý olarak 80 ml/sa’ye kadar yükseltildi. Sonrasýnda bu hastalardaki enteral beslenme sonrasý birinci ve ikinci fekal elastaz-1 seviyelerine bakýldý. Ýlk defekasyondan bir gram gaita örneði alýnarak ELISA yöntemiyle fekal elastaz-1 seviyesi belirlendi. Fekal elastaz-1 normal deðeri >200 mg/g olarak kabul edilirken, <100 mg/g olan deðerler ciddi pankreas ekzokrin salgý bozukluðu olarak deðerlendirildi.
BULGULAR: Tüm hastalar sadece enteral yoldan beslendi ve beslenmeye baðlý gastrointestinal komplikasyonlara rastlanmadý. Ýlk labotaruvar deðerlerinde hastalarýn %55,6’sýnda fekal elastaz-1 seviyelerinde orta ve yüksek oranda düþüþ gözlendi. Ýkinci incelemelerde ise bu oranýn %38,9 seviyelerine düþtüðü görüldü (p<0,01). Ýlk incelemede ortalama fekal elastaz-1 seviyesi 268,4 mg/g (median 162,1 mg/g) iken, ikinci incelemede 333,8 mg/g (median 520,2 mg/g) olarak saptandý.
SONUÇ: Bu araþtýrmada, travma sonrasý hastalarda ciddi oranda pankreas iþlev bozukluðu olduðu, yüksek molekül aðýrlýklý diyetle enteral yoldan beslemenin ise kayda deðer bir iyileþme saðladýðý görüldü. Travma sonrasý, hastalarda pankreas ekzokrin enzim seviyelerinin düþüklüðünün nedene yönelik araþtýrmalarla ve bunun olumlu ya da olumsuz etkilerinin yapýlacak diðer çalýþmalarla desteklenmesi gerektiði kanýsýna varýldý.