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Supplements Perspectives in Exocrine Pancreatic Insufficiency
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A Primer on Exocrine Pancreatic Insufficiency, Fat Malabsorption, and Fatty Acid Abnormalities
Samer Alkaade, MD and Ashley A. Vareedayah, MD
Options for Addressing Exocrine Pancreatic Insufficiency in Patients Receiving Enteral Nutrition Supplementation
Steven D. Freedman, MD, PhD

Guidance for Supplemental Enteral Nutrition Across Patient Populations

Douglas L. Nguyen, MD
Enteral nutrition is preferred over parenteral nutrition as a result of the greater safety of enteral nutrition therapy and comparative convenience. A wide variety of enteral nutrition products have been developed, including disease-specific products to help manage the nutritional needs of patients with kidney failure, liver failure, lung disease, diabetes, and other conditions. An assessment of each patient’s nutritional needs and digestive function should be conducted prior to initiation of enteral nutrition therapy. Other considerations in determining the appropriate route and method of enteral nutrition administration include the time and nursing involvement required for administration, potential complications of medication administration, and concerns related to pancreatic dysfunction in certain groups. Tailored guidelines and treatment considerations are reviewed in this manuscript the application of enteral nutrition in various  patient populations.
Am J Manag Care. 2017;23:-S0
Enteral Nutrition
Enteral nutrition is administration of a specialized liquid food mixture that contains proteins, carbohydrates, lipids, vitamins, and minerals into the stomach or small bowel through tube-feeding.1 Although enteral nutrition may be administered orally, enteral nutrition in hospitalized patients generally refers to products administered through a nasoenteric tube that delivers the enteral nutrition product directly to the stomach, duodenum or jejunum. Alternatively, enteral nutrition may be delivered via a surgically implanted tube, such as a gastrostomy tube or a jejunostomy tube, with the rate of administration controlled using an infusion pump, gravity drip system, or as boluses via a syringe.2-4 For short-term enteral nutrition, a nasogastric or orogastric tube may be used to administer formula. However, long-term enteral nutrition is generally administered through a surgically placed gastrostomy or jejunostomy tube.4

Enteral nutrition is preferred over parenteral nutrition, as use of total parenteral nutrition (TPN) therapy is complex and has been associated with increased complications and higher costs.5,6 Complications associated with TPN include line-associated infections, vascular thrombosis, cholestastic liver disease, metabolic bone disease, and cholelithiasis.5,7 Additionally, close and frequent monitoring of patients on TPN is required due to the possibility of electrolyte imbalances and fluid overload.5,8,9 Depsite these risks for certain patient groups, including patients with intestinal failure, short bowel syndrome, severe fixed intestinal obstructions, or fistulas not amenable to enteral nutrition, parenteral nutrition may be necessary to achieve adequate nutritional status.2,8-12 Finally, TPN does not promote restoration of normal gastrointestinal digestive functions.5,6

Enteral nutrition products have become a preferred alternative to parenteral nutrition as a result of the comparative convenience, greater safety, and efficacy of enteral nutrition therapy.2 Use of enteral feeding carries a low risk of serious complications, reduces bacterial translocation from the gut to the systemic circulation, reduces levels of circulating inflammatory cytokines, helps restore normal gut function, and reduces infectious complications and overall costs of care.3,6,11,13,14 There is some evidence showing improved outcomes of infection in critically ill, hospitalized patients receiving enteral nutrition compared  with parenteral nutrition.9 However, enteral nutrition therapy must be tailored to patient-specific needs; each patient’s baseline nutritional status must be carefully assessed in the context of their anatomy, comorbid diseases, and present medical condition.2,9

Available Forms of Enteral Nutrition Products
The carbohydrate and protein content of enteral nutrition formulas may be elemental, semielemental, or polymeric. Elemental formulas are composed of simple carbohydrates and amino acids, semielemental formulas contain short peptides and more complex carbohydrate, and polymeric formulas contain intact proteins and complex carbohydrates (Table 12,4,12,15-17).15 Products vary in terms of caloric density; protein, fat, fiber, and carbohydrate content; and osmolality.3,4

A wide variety of enteral nutrition products have been developed, including disease-specific formulas for the purpose of managing the nutritional needs of patients with kidney failure, liver failure, lung disease, diabetes, and other conditions (Table 2).2,4,9,12,15,16,18 However, even with a wide variety of formulas available, specialized formulations may be tailored on a case-by-case basis using modular enteral nutrition recipes containing separate protein, carbohydrate, and fat sources to enable more flexibility. This greater flexibility carries the potential drawback of complexity of preparation and handling, which may increase the risk of contamination with bacteria.3,4

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