Diarrhoea is an extremely common symptom present in many gastrointestinal conditions including disorders of gut–brain interaction, coeliac disease, non-coeliac gluten sensitivity, bile acid diarrhoea, pancreatic insufficiency, diverticulitis, radiation enteritis and inflammatory bowel disease (IBD). Diarrhoea related to IBD will not be considered here. However, the manuscript focuses on a range of dietary treatments for the remaining conditions, including interventions that involve restriction of nutrients (eg, low-fat diet) or other food components (eg, gluten-free diet); whole diet interventions (eg, low FODMAP (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) diet); or that involve supplementation (eg, probiotics). The quality of scientific evidence for these interventions across different diarrhoeal conditions varies, and although supplements and whole diet interventions are generally supported by clinical trial evidence, there remain many gaps in evidence which are needed to be filled to strengthen dietary management strategies in clinical guidelines, particularly for conditions such as radiation enteritis. Dietitians with expertise in gastroenterology can add considerable value in the treatment pathway for patients with diarrhoea, enhancing the effectiveness of dietary intervention, monitoring for nutritional adequacy, optimising overall diet quality and empowering patients to self-manage their diet considering the important influence of interindividual psychosocial and cultural factors. Diet is a fundamental treatment in most diarrhoeal conditions, and this manuscript reviews the evidence for the use of specific dietary interventions for these conditions and also provides practical advice for non-dietetic clinicians relating to dietary assessment, identification of dietary triggers and advice on when to refer to the dietitian.

Background and Methods: Pancreatico-duodenectomy (PD) carries significant morbidity and mortality, with very few modifiable risk factors. Radiological evidence of sarcopenia is associated with poor outcomes. This retrospective study aimed to analyse the relationship between easy-to-use bedside nutritional assessment techniques and radiological markers of muscle loss to identify those patients most likely to benefit from prehabilitation. Results: Data were available in 184 consecutive patients undergoing PD. Malnutrition was present in 33–71%, and 48% had a high visceral fat-to-skeletal muscle ratio, suggestive of sarcopenic obesity (SO). Surgical risk was higher in patients with obesity (OR 1.07, 95%CI 1.01–1.14, p = 0.031), and length of stay was 5 days longer in those with SO (p = 0.006). There was no correlation between skeletal muscle and malnutrition using percentage weight loss or the malnutrition universal screening tool (MUST), but a weak correlation between the highest hand grip strength (HGS; 0.468, p < 0.001) and the Global Leadership in Malnutrition (GLIM) criteria (−0.379, p < 0.001). Conclusions: Nutritional assessment tools give widely variable results. Further research is needed to identify patients at significant nutritional risk prior to PD. In the meantime, those with malnutrition (according to the GLIM criteria), obesity or low HGS should be referred to prehabilitation.

Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20% of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS® (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.

IntroductionApproximately 10300 people are diagnosed with pancreatic cancer each year in the UK. The cancer and its treatment inflict a significant physical, functional and emotional burden on patients. Research suggests that patients have many ongoing needs for support and care, but that these needs are not met by existing services. Family members often step in to fill this gap and provide support and care during and after treatment. Research in other cancers shows that this informal caregiving can place a very heavy burden on carers. However, there are few studies in the international literature that have focused on informal carers in pancreatic cancer; none have been conducted in the UK.Methods and analysisTwo complementary research methods will be utilised. First, a longitudinal quantitative study of 300 carers investigating, using validated questionnaires to assess the impact of caregiving (Caregiver Reaction Assessment), the unmet needs of carers (Supportive Care Needs Survey) and the quality-of-life (Short Form 12-item health survey), will be conducted. Second, qualitative interviews will be conducted with up to 30 carers to explore their experiences in more depth. Mixed-effects regression models will be applied to survey results to determine how impact, needs and quality-of-life vary over time, compare outcomes between carers of patients with operable and inoperable disease and identify social factors which affect outcomes. Interview data will undergo reflexive thematic analysis.Ethics and disseminationThe protocol has been approved by the Health Research Authority of the UK (Ethical approval IRAS ID 309503). Findings will be published in peer-reviewed journals and presented at national and international conferences.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy for which the mainstay of treatment is surgical resection, followed by adjuvant chemotherapy. Patients with PDAC are disproportionately affected by malnutrition, which increases the rate of perioperative morbidity and mortality, as well as reducing the chance of completing adjuvant chemotherapy. This review presents the current evidence for pre-, intra-, and post-operative strategies to improve the nutritional status of PDAC patients. Such preoperative strategies include accurate assessment of nutritional status, diagnosis and appropriate treatment of pancreatic exocrine insufficiency, and prehabilitation. Postoperative interventions include accurate monitoring of nutritional intake and proactive use of supplementary feeding methods, as required. There is early evidence to suggest that perioperative supplementation with immunonutrition and probiotics may be beneficial, but further study and understanding of the underlying mechanism of action are required.

Aims: Treatment of pancreatic exocrine insufficiency (PEI) following pancreatoduodenectomy (PD) im-proves quality of life, clinical outcomes, and survival. However, diagnosing PEI following PD is chal-lenging owing to the difficulties with current tests and often non-specific symptoms. This work aims toquantify the true rate of long-term PEI in patients following a PD. Methods: Patients underwent a PEI screen approximately one to two years following PD for oncologicindication, including the13C Mixed triglyceride breath test (13CMTGT), faecal elastase 1 (FE-1) and the PEIQuestionnaire (PEI-Q). Four reviewers with expertise in PEI reviewed the results blinded to other de-cisions to classify PEI status; disagreements were resolved on consensus. Results: 26 patients were recruited. Of those with valid test results, these were indicative of PEI based onpre-specified thresholds for 60 % (15/25) for the13CMTGT, 82 % (18/22) for FE-1, and 88 % (22/25) for thePEI-Q. After discussion between reviewers, the consensus PEI prevalence was 81 % (95 % CI: 61e93 %; 21/26), with 50 % (N1/413) classified as having severe, 23 % (N1/46) moderate, and 8 % (N1/42) mild PEI. Discussion: Since no ideal test exists for PEI, this collation of diagnostic modalities and blinded expertreview was designed to ascertain the true rate of long-term PEI following PD. This required our cohort tosurvive a year, travel to hospital, and undergo a period of starvation and PERT hold, and therefore there islikely to be recruitment bias towardsfitter, younger patients with less aggressive pathology. Despite this,over 80 % were deemed to have PEI, with over 90 % of these being considered moderate or severe. (c) 2023 The Authors. Published by Elsevier B.V. on behalf of IAP and EPC. This is an open access articleunder the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Provision of feeds containing hydrolysed, peptide-based proteins and medium-chain triglycerides (MCT), can help mitigate gastrointestinal (GI) intolerance in adults with impaired GI function, maldigestion and/or malabsorption. This study evaluated a high-protein, peptide-based, MCT-containing oral nutritional supplement (PEHP; 1.5kcal/ml and 7.5g protein/100ml). Adults with impaired GI function were recruited by their managing dietitian and took PEHP orally for 28-days, with GI tolerance, compliance, weight, energy and protein intake assessed via non-validated questionnaires and a 24-hour dietary recall at baseline and at intervention end. Fifteen, adults (56 years (16), 67kg (26.0), 24kg/m2 (7.6)) took part in this study. Intensity of nausea (Z= -2.070, p=0.038, n=15) and abdominal pain (Z= -2.236, p=0.025, n=15) improved significantly compared to baseline. Reductions in the intensity of diarrhoea, constipation, vomiting, flatulence, and burping were observed but were not statistically significant (p>0.05 for all). Compliance was higher with PEHP (81% (24)) than baseline feeds (63% (42)) but not significantly. Weight remained stable between baseline (67kg (26)) and at intervention end (67kg (27), p=0.414, n=15). Compared to baseline, total energy intake increased with PEHP albeit not significantly (1661 kcal/day (572) vs 1981 kcal/day (592), p=0.137, n=15). Increases in total protein intake were also observed, this time significantly (61 g/day (23) vs 78 g/day (29), p=0.042, n=15). This study in adults with impaired GI function found that PEHP improved GI tolerance and protein intake compared to feeds taken at baseline (including both polymeric and peptide-based feeds).

Rationale: The use of oral nutritional supplements (ONS) has been shown to be effective for managing disease-related malnutrition (DRM). The aim of this one-arm multi-centre intervention study was to evaluate the effects of a plant-based ONS in community adult patients at risk of DRM.

Colorectal surgery is carried out for both benign and malignant disease. Enhanced recovery programmes have reduced length of stay and improved outcomes. Extensive surgery can result in long-term nutritional compromise and patients with high-output stoma require careful electrolyte, nutrition, and fluid management.

Pancreatico-duodenectomy (PD) includes resection of the duodenum and use of the proximal jejunum in a blind loop, thus reducing the absorptive capacity for vitamins and minerals. Several studies have analysed the frequency of micronutrient deficiencies, but there is a paucity of data on those taking routine supplements. A retrospective review of medical notes was undertaken on 548 patients under long-term follow-up following PD in a tertiary hepato-pancreatico-biliary centre. Data were available on 205 patients from 1–14 years following PD, and deficiencies were identified as follows: vitamin A (3%), vitamin D (46%), vitamin E (2%), iron (42%), iron-deficiency anaemia (21%), selenium (3%), magnesium (6%), copper (1%), and zinc (44%). Elevated parathyroid hormone was present in 11% of cases. There was no significant difference over time (p > 0.05). Routine supplementation with a vitamin and mineral supplement did appear to reduce the incidence of biochemical deficiency in vitamin A, vitamin E, and selenium compared to published data. However, iron, vitamin D, and zinc deficiencies were prevalent despite supplementation and require surveillance.

INTRODUCTION Acute pancreatitis (AP) is a medical emergency that is common, poorly understood and carries a significant risk of death. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) undertook a comprehensive report into the current management of AP in the UK. The study aimed to provide a more detailed analysis of the findings related to nutritional assessment and support. METHODS The data presented here were analysed from the core dataset used in the NCEPOD study. Adult patients admitted between January and June 2014 with a coded diagnosis of AP were included. A clinical and organisational questionnaire was used to collect data and submitted case notes subjected to peer review. Nutritional data, including assessment and provision of support, were analysed. RESULTS One hundred and forty-seven out of 168 (87.5%) hospitals had a nutrition team in place. A screening nutritional assessment was performed in only 67.4% (368/546) of patients. Subsequent referral to a dietitian and nutrition team input occurred in 39% (201/521) and 25% (143/572) of patients, respectively. Supplemental nutrition was considered and used in 240/555 (43.2%) patients. Overall management of the patients' nutrition was considered adequate by the case reviewers in only 281/332 (85%) of cases and by the clinicians in 77% (421/555) of cases. CONCLUSIONS Many patients do not receive adequate nutritional assessment and, in up to 23% of cases, nutritional intervention is not adequate. Pancreatic exocrine insufficiency is likely under recognised and undertreated. Nutritional strategies to support early intervention and to support clinicians outside of tertiary pancreatic centres are warranted.

Patients with localised upper GI cancers of the oesophagus and stomach can undergo oesophagectomy (OG) or total gastrectomy (TG) with curative intent. Following surgery there is an increased risk of developing vitamin and mineral deficiency (1,2,3). Whilst awareness has improved there is very little national guidance on how to manage and reduce the risks long term.

Summary: Background: Concurrent with its evolution as medical and surgical sub-speciality, pancreatic disease is now recognised as a speciality within dietetics. Recent national guidelines have highlighted the importance of nutritional assessment and intervention in both pancreatic cancer and pancreatitis, but there is a lack of timely and appropriate nutritional support for many patients with pancreatic disease. Methods: The Nutrition Interest Group of the Pancreatic Society of Great Britain and Ireland developed a training course for non-specialist dietitians in 2014. Improvement in knowledge was assessed using questionnaires carried out before and after the training course, and results assessed against pre-agreed targets. Comprehensive evaluation of each aspect of the course was collated. Results: Over four years, 1,215 dietitians attended the course in 32 different locations throughout the United Kingdom. Eight three percent completed knowledge questionnaires before and after the course. There was a significant improvement in test scores (22.2 ± 5.3 vs. 35.8 ± 4.0, P<0.0001), with 94% of delegates achieving the target score for non-specialists. The course was well evaluated with 98% of all markers graded as ‘good’ or ‘excellent’. Conclusions: Targeted educational initiatives delivered outside of normal working hours are an effective means of training and educating a large number of health care professionals over a large geographical area within a short timeframe.

Background and aims: Malnutrition in chronic pancreatitis is complex and multifactorial, with malabsorption, pain, toxic dependencies and co-morbidities, such as diabetes, each playing a role. The aims of this systematic review were to assess the impact of nutritional intervention on markers of nutritional status in this complex patient group. Materials and methods: A systematic review of EMBASE and PubMed was carried out in February 2020, identifying 2620 articles. After screening to exclude those reporting short term changes (less than 3 months), with only one data point, or in the wrong population, eight papers were selected for analysis. Results: Seven studies documented the impact of a nutritional intervention, one was an observational study only. Overall, studies were limited by predominantly retrospective designs, heterogenous populations and poor control of potentially confounding variables. Data could not be combined due to variability in reporting methods. All studies exploring nutritional intervention, whether that consisted of advice by a specialist dietitian, dose escalation of pancreatic enzymes, oral nutritional supplements or enteral feeding, demonstrated improved body weight and pain control, whereas patients who did not receive an intervention deteriorated nutritionally. Conclusion: Patients with chronic pancreatitis benefit from nutritional intervention. Further work is required to explore the impact of nutritional intervention on body composition and functional outcomes. (C) 2022 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Meeting energy and protein requirements in critically ill patients is important for prognosis, yet difficult to achieve as a consequence of disease, management and/or altered nutritional intake[1]. Improvements in achieving energy and protein requirements with a high-energy, high-protein peptide-based tube feed were observed in community patients with impaired gastrointestinal function[2]. To establish whether this remained true in the critical care setting, where feeding intolerance is observed frequently in patients with[3] and without SARS-CoV-2[4], a retrospective multicentre audit was performed. Adults (> 18years) with or without SARS-CoV-2, admitted to critical care across 6 UK hospitals between May 2020 and December 2020, were retrospectively included if they received a peptide-based enteral tube feed (Nutrison Peptisorb Plus HEHP®, Nutricia Ltd), containing 1.5kcal/ml and 7.5g protein/100ml (herein referred to as HEHP). Data were collected from 15 critically ill patients (52±12y; 87% male), with mean length of hospital stay being 26days (range: 7-49days). Of these, 10 were SARS-CoV-2 positive, with the remainder having pancreatitis (n=3), delayed gastric emptying (n=1) or unconfirmed diagnosis (n=1). HEHP was used second line (after whole protein) and indications (multiple were cited for some) for use included tolerance issues (n=10), elevated energy and protein requirements (n=5) or due to primary diagnosis (n=2). Estimated energy and protein intakes (% of requirements achieved) were recorded before and during use of HEHP. In addition, Dietitians were asked whether HEHP allowed patients to better meet their nutrient target Mean intake of HEHP was 2008±461kcal/day and 100±23g protein/day provided over a mean of 12days (range: 3-29days). The percentage of estimated energy and protein targets achieved increased albeit non significantly with the use of HEHP (from 76% before vs 87% during use of HEHP for both) and the direction of effect remained true regardless of SARS-CoV-2 status. Two thirds (67%, n=10 of 15) of Dietitians reported HEHP helped patients better meet their nutrient targets and 87% (n=13 of 15) of Dietitians perceived the high protein content of HEHP as beneficial for this patient group. Gastrointestinal tolerance (anecdotal reports) remained largely unchanged in approximately half of SARS-CoV-2 positive patients when using HEHP yet improved for others including non-SARS-CoV-2 patients. Enteral tube feeding in critically ill patients poses numerous difficulties, especially in SARS-CoV-2 positive patients. This audit in critically ill patients demonstrates that a high-energy, high-protein, peptide-based enteral tube feed can help complex patients better achieve energy and protein targets in patients with and without SARS-CoV-2. References 1.Pullen K, Colins R, Stone T et al. Are energy and protein requirements met in hospital? Clin Nutr 2017; 31(2): 178-187. 2.Green B, Sorensen K, Phillips M et al. Complex Enterally Tube-Fed Community Patients Display Stable Tolerance, Improved Compliance and Better Achieve Energy and Protein Targets with a High-Energy, High-Protein Peptide-Based Enteral Tube Feed: Results from a Multi-Centre Pilot Study. Nutrients. 2020, 12, 3538. 3.Liu R, Paz M, Siraj L et al. Feeding intolerance in critically ill patients with COVID-19. Clin Nutr 2021. 4.Gungabissoon U, Hacquoil K, Bains C et al. Prevalence, Risk Factors, Clinical Consequences, and Treatment of Enteral Feed Intolerance During Critical Illness. J. Parenter. Enteral. Nutr. 2015, 39, 441–448.

Objective There is emerging evidence that the pancreas may be a target organ of SARS-CoV-2 infection. This aim of this study was to investigate the outcome of patients with acute pancreatitis (AP) and coexistent SARS-CoV-2 infection. Design A prospective international multicentre cohort study including consecutive patients admitted with AP during the current pandemic was undertaken. Primary outcome measure was severity of AP. Secondary outcome measures were aetiology of AP, intensive care unit (ICU) admission, length of hospital stay, local complications, acute respiratory distress syndrome (ARDS), persistent organ failure and 30-day mortality. Multilevel logistic regression was used to compare the two groups. Results 1777 patients with AP were included during the study period from 1 March to 23 July 2020. 149 patients (8.3%) had concomitant SARS-CoV-2 infection. Overall, SARS-CoV-2-positive patients were older male patients and more likely to develop severe AP and ARDS (p<0.001). Unadjusted analysis showed that SARS-CoV-2-positive patients with AP were more likely to require ICU admission (OR 5.21, p<0.001), local complications (OR 2.91, p<0.001), persistent organ failure (OR 7.32, p<0.001), prolonged hospital stay (OR 1.89, p<0.001) and a higher 30-day mortality (OR 6.56, p<0.001). Adjusted analysis showed length of stay (OR 1.32, p<0.001), persistent organ failure (OR 2.77, p<0.003) and 30-day mortality (OR 2.41, p<0.04) were significantly higher in SARS-CoV-2 co-infection. Conclusion Patients with AP and coexistent SARS-CoV-2 infection are at increased risk of severe AP, worse clinical outcomes, prolonged length of hospital stay and high 30-day mortality.