Acute Pancreatitis: Feed Now or Wait?

David A. Johnson, MD

Disclosures

March 05, 2015

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Nutritional Status in Acute Pancreatitis

I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School. Welcome back to another installment of GI Common Concerns – Computer Consult.

Today I want to talk about refeeding patients with acute pancreatitis. When I was a resident, the standard was that when somebody came in with acute pancreatitis, the patient was placed NPO and IV hydration was administered. We would switch the patient, ultimately, to parenteral feedings. This was the way that we practiced, and during the past two decades, that was pretty much the standard of care.

In 2013, the American College of Gastroenterology (ACG) issued new guidelines[1] on when to refeed and the nutritional status in acute pancreatitis. They said that in mild acute pancreatitis, oral feedings could be begun immediately, if there was no nausea or vomiting, upon resolution of abdominal pain. They also said that in mild acute pancreatitis, a low-fat solid diet was as safe as a clear liquid diet.

In severe acute pancreatitis, however, enteral nutrition is recommended primarily to prevent infectious complications. Parenteral nutrition should be avoided because of the associated risks: gut atrophic changes, IV or central line access difficulties, and IV site infection or central-line associated bloodstream infection.

Enteral nutrition is considered more favorable for many reasons, particularly in patients who have undergone prolonged fasting. Enteral nutrition has positive trophic effects on the gut and enhances gut motility. Many of the infectious complications that occur in patients on prolonged parenteral nutrition are believed to be a consequence of atrophic changes in the gut and bacterial translocation. Furthermore, as you stimulate the gut with distention and motility, there is an increase in splanchnic blood flow. The trophic effects on the gut were believed to be favorable during enteral feeding, so the push was to get away from parenteral nutrition and move toward enteral feeding.

The most recent ACG guidelines also said that the nasojejunal route was equivalent to the nasogastric (NG) route for feeding, so we could feed patients by either route. Many such patients have an ileus, and an NG tube is inserted for that reason. Sometimes they have nausea and vomiting and an NG tube is necessary, and some patients undergo urgent endoscopic placement of a jejunal feeding tube.

Early vs Delayed Feeding

The most recent data were very provocative, coming from a study[2] done in The Netherlands involving 19 hospitals. They looked at patients with severe pancreatitis, because we are concerned about the 20% of such patients who experience the most infectious complications. What should we do with these patients with respect to feeding them?

Most clinicians are concerned about parenteral feedings because of the infectious risks, and we have often gone to postpyloric feedings with placement of a jejunal tube. Do we really need to do that?

This recent study says no, we don't. They included more than 200 patients who met the criteria of being at high risk for complications. These patients came in with high Apache scores, high Glasgow scores, or high C-reactive protein levels and were randomly assigned to receive either nasogastric (or nasojejunal) feedings within 24 hours (early feeding) or to a delayed feeding group, with 72 hours of nothing by mouth before oral feedings were started. Oral feedings were given at a rate intended to meet caloric needs. If oral feeding was not tolerated, it was reintroduced 24 hours later, and if still not tolerated by 96 hours, patients received a nasoenteral feeding tube.

In approximately 70% of the patients, they were able to reintroduce feedings by 72-96 hours, so it was easy to get the oral feedings reinstituted within a short period of time.

The study was powered to look at the infectious complications and mortality associated with parenteral feedings: the lack of gut trophic effects, and infection from bacterial translocation from the gut. The study showed that there was no difference in infectious complications between early and delayed feeding. There were no differences in long-term complications, including infected necrosis or mortality.

We've Come Full Circle

What does this tell us now? We have gone full circle, and this study says that we can begin oral feedings in these patients, even with the high-risk predictors for more severe pancreatitis. We can after fasting them for 72-96 hours to try fairly urgently to reintroduce oral feedings. Why would this make sense?

First, you keep a nasoenteral tube out, and the patients love that. Second, preventing the bacterial ascent through the esophageal sphincter may reduce the risk for bacterial infections in the lungs, and you reduce the risk for esophagitis from bacterial translocation of the lower esophageal sphincter. There are other reasons—such as cost—and accelerating discharge from the hospital.

We looked at making these people strictly NPO. Then we realized that was not good, so we fed them, but we were rushing to try and get postpyloric feeds. We realize now that gastric feeds are equally safe and effective, and we have come back to oral feedings. Have a low threshold to reinstitute oral feedings fairly early in the course.

The evidence is striking, and previous studies were not well-conducted randomized controlled studies. The Cochrane analysis[3] in 2010 suggested that enteral feeding was much better than parenteral nutrition.

So think of the oral route the next time you have a patient with acute pancreatitis. Many people will find it more helpful for their outcomes, they will be thankful that they didn't have a nasoenteral feeding tube, and they might have an accelerated discharge.

I'm Dr David Johnson. I look forward to chatting with you again on another computer consult.

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