早期肠内营养对重症急性胰腺炎患者肠道菌群与感染的影响
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摘要
目的探讨早期肠内营养(enteral nutrition,EN)对重症急性胰腺炎(severe acute pancreatitis,SAP)患者肠道菌群及后期感染的影响。方法连续性纳入自2015年2月-2017年12月医院收治的SAP患者85例,随机分为研究组(n=42)及对照组(n=43)。研究组给予早期EN支持治疗,对照组给予全肠外营养(total parenteral nutrition,TPN)支持治疗,比较两组患者的营养状态、肠道黏膜损伤程度,肠道菌群以及预后的差异。结果入院第14天,研究组血清白蛋白(34.87±5.32)g/L高于对照组(32.18±5.09)g/L,入院第7天及第14天,研究组血清前白蛋白高于对照组(P<0.05);入院第7天起,研究组血清内毒素、D-乳酸以及DAO均低于对照组(P<0.05);入院第7天起,研究组双歧杆菌及乳酸杆菌高于对照组(P<0.05);至第14天,研究组产气荚膜梭菌、肠杆菌及肠球菌低于对照组,拟杆菌高于对照组(P<0.05);研究组IPN、ARDS及脓毒症发生情况低于对照组,研究组ICU天数及住院天数均低于对照组(P<0.05)。结论早期EN可以有效改善SAP患者营养状态,降低肠道黏膜损伤程度,调节肠道菌群失衡,减少IPN发生率,改善预后。
OBJECTIVE To investigate the effect of early enteral nutrition(EN)on intestinal flora and late phase infection in patients with severe acute pancreatitis(SAP).METHODS 85 SAP patients were continuously collected from Feb.2015 to Dec.2017,and were randomly divided into the study group(42 cases)and the control group(43 cases).The study group were treated with early EN,and the control group received total parenteral nutrition(TPN).The nutritional status,intestinal mucosal damage degree,intestinal flora and prognosis were compared between the two groups.RESULTS Serum albumin in the study group was significantly higher than that in the control group on the 14 th day after hospital admission,and the study group showed significantly higher serum prealbumin than the control group on the 7 th day and 14 th day(P<0.05).From the 7 th day on,the study group showed significantly lower serum endotoxin,D-lactic acid and DAO than the control group(all P<0.05).The study group showed significantly higher amounts of Bifidobacterium and Lactobacillus from the 7 th day(P<0.05).The study group had significantly lower amounts of Clostridium difficile and Enterobacter and Enterococcus,whereas significantly higher amount of Bacteroidetes(P<0.05)than the control group on the 14 th day.In terms of clinical prognosis,the study group showed significantly lower incidence of IPN,ARDS and sepsis,in addition,with shorter length of ICU stay and hospital stay than the control group(P<0.05).CONCLUSIONEarly EN can effectively improve the nutritional status,reduce the degree of intestinal mucosal damage,regulate the imbalance of intestinal flora,reduce the incidence of IPN,and improve the prognosis in SAP patients.
OBJECTIVE To investigate the effect of early enteral nutrition(EN)on intestinal flora and late phase infection in patients with severe acute pancreatitis(SAP).METHODS 85 SAP patients were continuously collected from Feb.2015 to Dec.2017,and were randomly divided into the study group(42 cases)and the control group(43 cases).The study group were treated with early EN,and the control group received total parenteral nutrition(TPN).The nutritional status,intestinal mucosal damage degree,intestinal flora and prognosis were compared between the two groups.RESULTS Serum albumin in the study group was significantly higher than that in the control group on the 14 th day after hospital admission,and the study group showed significantly higher serum prealbumin than the control group on the 7 th day and 14 th day(P<0.05).From the 7 th day on,the study group showed significantly lower serum endotoxin,D-lactic acid and DAO than the control group(all P<0.05).The study group showed significantly higher amounts of Bifidobacterium and Lactobacillus from the 7 th day(P<0.05).The study group had significantly lower amounts of Clostridium difficile and Enterobacter and Enterococcus,whereas significantly higher amount of Bacteroidetes(P<0.05)than the control group on the 14 th day.In terms of clinical prognosis,the study group showed significantly lower incidence of IPN,ARDS and sepsis,in addition,with shorter length of ICU stay and hospital stay than the control group(P<0.05).CONCLUSIONEarly EN can effectively improve the nutritional status,reduce the degree of intestinal mucosal damage,regulate the imbalance of intestinal flora,reduce the incidence of IPN,and improve the prognosis in SAP patients.
引文
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[14]Shen QX,Xu GX,Shen MH.Effect of early enteral nutrition(EN)on endotoxin in serum and intestinal permeability in patients with severe acute pancreatitis[J].Eur Rev Med Pharmacol Sci,2017,21(11):2764-2768.
[15]Zou L,Ke L,Li W,et al.Enteral nutrition within 72hafter onset of acute pancreatitis vs delayed initiation[J].Eur J Clin Nutr,2014,68(12):1288-1293.
[16]Vaughn VM,Shuster D,Rogers MAM,et al.Early versus delayed feeding in patients with acute pancreatitis:a systematic review[J].Ann Intern Med,2017,166(12):883-892.
[17]Krezalek MA,Yeh A,Alverdy JC.Influence of nutrition therapy on the intestinal microbiome[J].Curr Opin Clin Nutr Metab Care,2017,20(2):131-137.
[2]Ji L,Sun B,Cheng CD,et al.Clinical experience on the employment of the staged step-up approach in the treatment of local complications secondary to severe acute pancreatitis[J].Zhonghua Wai Ke Za Zhi,2016,54(11):839-843.
[3]Ji L,Lv JC,Song ZF,et al.Risk factors of infected pancreatic necrosis secondary to severe acute pancreatitis[J].Hepatobiliary Pancreat Dis Int,2016,15(4):428-433.
[4]Banks PA,Bollen TL,Dervenis C,et al.Classification of acute pancreatitis-2012:revision of the Atlanta classification and definitions by international consensus[J].Gut,2013,62(1):102-111.
[5]Working Group IAP/APA Acute Pancreatitis Guidelines.IAP/APA evidence-based guidelines for the management of acute pancreatitis[J].Pancreatology,2013,13(4Suppl 2):e1-e15.
[6]Druyan ME,Compher C,Boullata JI,et al.Clinical guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients:applying the GRADE system to development of A.S.P.E.N.clinical guidelines[J].JPEN J Parenter Enteral Nutr,2012,36(1):77-80.
[7]杨卫军,杜吉义,吴正阳,等.重症急性胰腺炎患者继发胰腺感染特点及危险因素分析[J].中华医院感染学杂志,2017,27(19):4453-4456.
[8]Adler DG.Surgery versus endoscopy for patients with infected pancreatic necrosis[J].Lancet,2018,391(10115):6-8.
[9]Windsor JA,Escott A,Brown L,et al.Novel strategies for the treatment of acute pancreatitis based on the determinants of severity[J].J Gastroenterol Hepatol,2017,32(11):1796-1803.
[10]Majidi S,Golembioski A,Wilson SL,et al.Acute pancreatitis:etiology,pathology,diagnosis,and treatment[J].South Med J,2017,110(11):727-732.
[11]Wu LM,Sankaran SJ,Plank LD,et al.Meta-analysis of gut barrier dysfunction in patients with acute pancreatitis[J].Br J Surg,2014,101(13):1644-1656.
[12]黄耿文,申鼎成.意大利重症急性胰腺炎共识指南(2015)解读[J].中国普通外科杂志,2016,25(3):313-317.
[13]Stimac D,Poropat G,Hauser G,et al.Early nasojejunal tube feeding versus nil-by-mouth in acute pancreatitis:a randomized clinical trial[J].Pancreatology,2016,16(4):523-528.
[14]Shen QX,Xu GX,Shen MH.Effect of early enteral nutrition(EN)on endotoxin in serum and intestinal permeability in patients with severe acute pancreatitis[J].Eur Rev Med Pharmacol Sci,2017,21(11):2764-2768.
[15]Zou L,Ke L,Li W,et al.Enteral nutrition within 72hafter onset of acute pancreatitis vs delayed initiation[J].Eur J Clin Nutr,2014,68(12):1288-1293.
[16]Vaughn VM,Shuster D,Rogers MAM,et al.Early versus delayed feeding in patients with acute pancreatitis:a systematic review[J].Ann Intern Med,2017,166(12):883-892.
[17]Krezalek MA,Yeh A,Alverdy JC.Influence of nutrition therapy on the intestinal microbiome[J].Curr Opin Clin Nutr Metab Care,2017,20(2):131-137.