Nomogram for predicting oral feeding intolerance in patients with acute pancreatitis

Clinical Predictors and Prevalence of Enteral Nutrition Intolerance in Acute Pancreatitis: An Updated Systematic Review and Meta-Analysis

Background: Acute pancreatitis (AP) leads to severe inflammation and nutritional deficits, with 80% of severe cases experiencing critical protein loss. Timely enteral nutrition is essential for recovery. This study systematically reviews and analyzes the incidence and predictors of enteral nutrition intolerance (ENI) in AP patients. Methods: Web of Science, Embase, Cochrane Library, and PubMed were searched up to May 2024. Studies reporting on ENI incidence and predictors in AP patients were included based on predefined criteria. Bias was assessed using standardized tools, and meta-analyses provided summary estimates with confidence intervals. Results: From the 2697 screened studies, 28 involving 4853 patients met the inclusion criteria. The pooled incidence of ENI was 26%. Significant predictors included comorbid diabetes, pancreatic necrosis, elevated pre-refeeding serum lipase levels, peri-pancreatic fluid collections, and systemic inflammatory response syndrome at admission. Higher ENI rates were observed in Europe, among patients with severe acute pancreatitis (SAP), those receiving nasoenteric feeding, and in prospective study cohorts. Conclusions: ENI affects approximately one-quarter of AP patients and is not significantly associated with age, sex, or the cause of AP. Its incidence varies by region, disease severity, feeding method and study design. Identifying predictors, such as comorbid diabetes and pancreatic necrosis, may help clinicians reduce the risk of ENI. The limitations of this study include the heterogeneity of the included studies and inconsistent ENI diagnostic criteria.

Clinical Characteristics and Influencing Factors of Feeding Intolerance After Surgery for Neonatal Necrotizing Enterocolitis

BACKGROUND

Feeding intolerance (FI) following surgery for neonatal necrotizing enterocolitis (NEC) can impact recovery and prognosis, making the early identification of FI risk essential for optimizing management and improving outcomes.

METHODS

We retrospectively collected data from patients who underwent surgery for NEC between January 2013 and December 2023. Multivariate binary logistic regression was performed to identify independent factors influencing postoperative feeding intolerance.

RESULTS

Of the 519 infants enrolled in this retrospective study, 155 (29.9%) were diagnosed with feeding intolerance, while 364 (70.1%) were identified as having feeding tolerance. Compared to infants with feeding tolerance, those with feeding intolerance had lower birth weight, smaller gestational age, and lower Apgar scores (all p < 0.01). A 5 min Apgar < 7 (OR 4.794; 95%CI 1.339-17.156), the interval between diagnosis and surgery (OR 0.973; 95%CI 0.947-1.000), and primary anastomosis resection (OR 0.278, 95%CI 0.139-0.555) were identified as significant factors influencing postoperative feeding intolerance. The results remained consistent after performing propensity score matching analysis. Feeding intolerance may result in prolonged hospital stays, and more complications such as retinopathy of prematurity, intestinal failure-associated liver disease, and intraventricular hemorrhage.

CONCLUSIONS

A lower 5 min Apgar score, shorter interval from diagnosis to surgery and intestine resection with ostomy are associated with a higher incidence of FI after surgery. FI after NEC surgery can prolong recovery and increase family burden.

The mechanism of transcutaneous gastric pacing treatment on gastrointestinal motility recovery and inflammation improvement in early-stage acute pancreatitis patients

PURPOSE

Acute pancreatitis (AP) is often accompanied by gastrointestinal motility disorders. The purpose of this study was to investigate the efficacy and possible mechanism of transcutaneous gastric pacing (TGP) in early-stage AP patients.

MATERIALS AND METHODS

Sixty-five AP patients were randomly divided into conventional treatment group and TGP group. The serum ghrelin and vasoactive intestinal peptide (VIP) were used to assess the possible gastrointestinal hormonal mechanism involved. The parameters of electrogastrogram (EGG) were used to evaluate the gastric motility in AP patients. The first defecation time was used to assess the recovery of intestinal motility. The heart rate variability (HRV) test was performed to assess autonomic nervous function.

RESULTS

Compared with the conventional treatment group, the TGP treatment significantly improved symptoms in early AP patients, and shortened the first defecation time (p < 0.05) and the hospital days (p < 0.05). The level of VIP (P < 0.05) was also decreased in TGP group. The percentage of normal gastric slow waves (GSWS) (p < 0.05) was increased. The interleukin (IL)-6 level was decreased (P < 0.05). Concurrently, the vagal activity (HF) was increased (p < 0.01), the sympathetic activity (LF) was decreased (p < 0.01), and the ratio of sympathetic vagal (LF/HF) was decreased (p < 0.01).

CONCLUSIONS

The TGP treatment significantly improves the clinical symptoms in early AP patients. It also increases the percentage of normal GSWS. The therapeutic effect of TGP may be caused by autonomic nervous function mechanisms.

Predicting persistent organ failure on admission in patients with acute pancreatitis: development and validation of a mobile nomogram

BACKGROUND

Early prediction of persistent organ failure (POF) is important for triage and timely treatment of patients with acute pancreatitis (AP).

METHODS

All AP patients were consecutively admitted within 48 h of symptom onset. A nomogram was developed to predict POF on admission using data from a retrospective training cohort, validated by two prospective cohorts. The clinical utility of the nomogram was defined by concordance index (C-index), decision curve analysis (DCA), and clinical impact curve (CIC), while the performance by post-test probability.

RESULTS

There were 816, 398, and 880 patients in the training, internal and external validation cohorts, respectively. Six independent predictors determined by logistic regression analysis were age, respiratory rate, albumin, lactate dehydrogenase, oxygen support, and pleural effusion and were included in the nomogram (web-based calculator: https://shina.shinyapps.io/DynNomapp/). This nomogram had reasonable predictive ability (C-indexes 0.88/0.91/0.81 for each cohort) and promising clinical utility (DCA and CIC). The nomogram had a positive likelihood ratio and post-test probability of developing POF in the training, internal and external validation cohorts of 4.26/31.7%, 7.89/39.1%, and 2.75/41%, respectively, superior or equal to other prognostic scores.

CONCLUSIONS

This nomogram can predict POF of AP patients and should be considered for clinical practice and trial allocation.

Effects of Preoperative Oral Nutritional Supplements on Improving Postoperative Early Enteral Feeding Intolerance and Short-Term Prognosis for Gastric Cancer: A Prospective, Single-Center, Single-Blind, Randomized Controlled Trial

BACKGROUND

Early enteral nutrition (EN) after abdominal surgery can improve the prognosis of patients. However, the high feeding intolerance (FI) rate is the primary factor impeding postoperative EN.

METHODS

Sixty-seven patients who underwent radical subtotal or total gastrectomy for gastric cancer (GC) were randomly allocated to the preoperative oral nutritional supplement group (ONS group) or dietary advice alone (DA group). Both groups were fed via nasojejunal tubes (NJs) from the first day after surgery to the fifth day. The primary endpoint is the FI rate.

RESULTS

Of the patients, 66 completed the trial (31 in the ONS group, 35 in the DA group). The FI rate in the ONS group was lower than that in the DA group (25.8% vs. 31.4%, p = 0.249). The postoperative five-day 50% energy compliance rate in the ONS group was higher than that in the DA group (54.8% vs. 48.6%, p = 0.465). The main gastrointestinal intolerance symptoms were distension (ONS vs. DA: 45.2% vs. 62.9, p = 0.150) and abdominal pain (ONS vs. DA: 29.0% vs. 45.7%, p = 0.226). Postoperative nausea/vomiting rate and heartburn/reflux rate were similar between the two groups. We noted no difference in perioperative serum indices, short-term prognosis or postoperative complication rates between the two groups.

CONCLUSIONS

The study shows that short-term preoperative ONS cannot significantly improve FI and the energy compliance rate in the early stage after radical gastrectomy.

Prevalence of Chronic Metabolic Comorbidities in Acute Pancreatitis and Its Impact on Early Gastrointestinal Symptoms during Hospitalization: A Prospective Cohort Study

Background

The prevalence of chronic comorbidities is increasing worldwide, and this has been paralleled by a growing interest in how these comorbidities affect patients with acute pancreatitis. The aim was to investigate the associations between pre-existing diabetes mellitus, obesity, metabolic syndrome, and gastrointestinal symptoms during the early course of acute pancreatitis.

Methods

This was a prospective cohort study of patients with a primary diagnosis of acute pancreatitis. Study groups were formed based on the presence of metabolic comorbidities (pre-existing diabetes mellitus, obesity, and metabolic syndrome). Patient-reported outcomes (nausea, bloating, and abdominal pain) were collected prospectively every 24 h (including weekends and public holidays) over the first 72 h of hospitalization.

Results

A total of 183 consecutive patients were enrolled. Of them, 111 (61%) had at least one major metabolic comorbidity. Patients with pre-existing diabetes mellitus and those with metabolic syndrome had worse nausea at 49-72 h of hospitalization (p = 0.017 and p = 0.012, respectively), but not at other time points. Bloating and abdominal pain did not differ between the study groupings throughout the study period. The studied patient-reported outcomes did not differ significantly between acute pancreatitis patients with and without obesity at any point in time.

Conclusion

More than 3 out of 5 patients hospitalized for acute pancreatitis have at least one major chronic metabolic comorbidity. The presence of metabolic comorbidities does not considerably and consistently affect early gastrointestinal symptoms in patients with acute pancreatitis.

Nomogram for predicting diabetes mellitus after the first attack of acute pancreatitis

BACKGROUND

Diabetes mellitus can occur after acute pancreatitis (AP), but there are currently no tools for evaluating the risk of developing diabetes after an attack of AP. The aim of the study was to develop a nomogram for prediction of new-onset diabetes mellitus after the first attack of AP.

PATIENTS AND METHODS

We enrolled 616 patients with first-attack AP. We collected and statistically analyzed demographic data (age, BMI, and duration of hospitalization) and laboratory data (glucose, low-density lipoprotein cholesterol, triglyceride, and cholesterol).

RESULTS

Univariate analysis suggested duration of hospitalization (P=0.0003), BMI (P=0.0059), cholesterol (P=0.0005), triglyceride (P=0.0005), hemoglobin (P=0.0229), and glucose (P<0.001) at admission were significantly associated with newly developed diabetes after the first-attack AP. Multivariate analysis showed that age [odds ratio (OR)=1.01; 95% confidence interval (CI): 1.00-1.03; P=0.045], BMI (OR=1.06; 95% CI: 1.01-1.12; P=0.018), glucose (OR=1.07; 95% CI: 1.02-1.12; P=0.008), triglyceride (OR=1.03; 95% CI: 1.00-1.06; P=0.035), and low-density lipoprotein-cholesterol (OR=1.18; 95% CI: 1.00-1.38; P=0.044) at admission were important predictors.

CONCLUSION

The nomogram is a potentially clinically useful tool for predicting new-onset diabetes, which is currently clinically unprecedented. This finding is not confined to the patients with severe AP but is also for patients who have recovered from mild AP. The nomogram must to be validated externally.

Early Hemoconcentration Is Associated With Increased Opioid Use in Hospitalized Patients With Acute Pancreatitis

OBJECTIVES

Opioids are commonly required for abdominal pain in hospitalized patients with acute pancreatitis (AP). The factors associated with increased opioid requirements are unknown.

METHODS

The medical records of adult inpatients with AP from 2006 to 2016 were reviewed. Patients with chronic pancreatitis, psychiatric comorbidities, intubation, chronic opioid, and illicit drug use were excluded. The total quantity of opioids required during the first 7 days of hospitalization was converted to oral morphine equivalents (OME), divided by the number of days opioids were required to obtain the mean OME per day(s) of treatment (MOME). Multiple regression analysis was performed to identify factors associated with MOME.

RESULTS

A total of 267 patients were included. The mean (standard deviation) age was 46.9 (13.9) years and 56% were males. The most common etiology was alcohol (55.4%). The mean (standard deviation) MOME was 59.1 (54.5) mg. Although age (P = 0.008), black race (P = 0.004), and first episode of AP (P = 0.049) were associated with a lower MOME, early hemoconcentration (hematocrit ≥44%) (P < 0.001) was associated with an increased MOME.

CONCLUSIONS

Early hemoconcentration is associated with an increased opioid requirement in hospitalized patients with AP. The impact of fluid therapy in these patients merits prospective study.

Risk factors for intolerance to enteral nutrition in patients with severe acute pancreatitis

AIM

To identify the risk factors for intolerance to enteral nutrition in patients with severe acute pancreatitis (SAP) and provide clinical data for the early clinical application of enteral nutrition in these patients.

METHODS

The clinical data of 243 patients who underwent enteral nutrition treatment for SAP at Tongde Hospital of Zhejiang Province from January 2012 to January 2018 were retrospectively analyzed. According to the presence of intolerance to enteral nutrition or not, the patients were divided into a tolerance group and an intolerance group. The risk factors for intolerance to enteral nutrition were determined by univariate analysis and multivariate logistic regression analysis.

RESULTS

Eight-four (34.57%) of the 243 SAP patients had intolerance to enteral nutrition. Univariate analysis and multivariate logistic regression analysis showed that age > 60 years (OR = 5.212, 95%CI: 1.462-18.587, P = 0.011), fasting time > 72 h (OR = 3.683, 95%CI: 1.322-11.612, P = 0.012), intra-abdominal pressure (IAP) > 20 cmH₂O (OR = 6.034, 95%CI: 2.431-20.114, P = 0.001), acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ) score > 20 (OR = 6.411, 95%CI: 2.512-22.239, P = 0.001), and serum albumin < 25 g/L (OR = 5.961, 95%CI: 2.318-20.001, P = 0.001) were risk factors for intolerance to enteral nutrition in SAP patients. Adding soluble fiber (OR = 0.221, P = 0.002, 95%CI: 0.067-0.693) was identified to be a protective factor for intolerance to enteral nutrition in SAP patients.

CONCLUSION

The main risk factors for intolerance to enteral nutrition in SAP patients are age > 60 years, fasting time > 72 h, IAP > 20 cmH₂O, APACHE Ⅱ score > 20, and serum albumin < 25 g/L. Soluble fiber diet is able to prevent the development of intolerance to enteral nutrition in SAP patients.

Effect of Intravenous Fluids and Analgesia on Dysmotility in Patients With Acute Pancreatitis: A Prospective Cohort Study

OBJECTIVES

Analgesia and intravenous fluid resuscitation are cornerstones of initial patient management in acute pancreatitis (AP). The aim was to investigate the effect of intravenous fluids and analgesia on gastrointestinal motility in the early course of AP.

METHODS

Gastrointestinal dysmotility was assessed using the Gastroparesis Cardinal Symptom Index (GCSI). One-way analysis of variance and analysis of covariance were conducted, adjusting for age, sex, body mass index, severity of AP, preexisting diabetes mellitus, and time from first symptom onset to hospital admission.

RESULTS

A total of 108 patients with AP were prospectively enrolled. Opioid analgesia, when compared with nonopioid analgesia, was significantly associated with increase in total GCSI score in both unadjusted and adjusted analyses. There was no significant difference between aggressive and nonaggressive fluid resuscitation in both unadjusted and adjusted analyses. A combination of opioids and any intravenous fluids was associated with a significantly increased total GCSI score compared with opioids and no intravenous fluids in both unadjusted and adjusted analyses. Duration of symptoms was the confounder that significantly affected 6 of 9 studied associations.

CONCLUSIONS

Intravenous fluids and analgesia significantly affect motility independent of severity and other covariates. Guidelines on prudent use of opioids and fluids in AP need to be developed, particularly taking into account duration of symptoms from onset to hospitalization.

Glucose Variability Measures as Predictors of Oral Feeding Intolerance in Acute Pancreatitis: A Prospective Pilot Study

BACKGROUND

Oral feeding intolerance (OFI) is a common complication in patients with acute pancreatitis (AP). Variations in blood glucose are associated with impaired gastrointestinal function but, to date, measures of glucose variability have not been investigated to predict OFI in patients with AP.

AIM

To investigate the usefulness of several glucose variability measures in predicting the occurrence of OFI early in the course of AP.

METHODS

In this prospective cohort study, six measures of glucose variability were calculated prior to the occurrence of OFI. Multivariate binary logistic regression analyses were conducted, and the diagnostic performance and accuracy of glucose variability measures were assessed.

RESULTS

Of the 95 prospectively enrolled patients, 21 (22%) developed OFI. After adjusting for confounders, admission blood glucose concentration and mean blood glucose concentration were significantly associated with OFI [odds ratio 1.49 (95% confidence interval 1.01-2.20) and odds ratio 1.67 (95% confidence interval 1.07-2.61), respectively]. Both admission blood glucose and mean blood glucose had an area under the curve of 0.83 and positive likelihood ratios of 6.45 and 10.19, respectively. Blood glucose concentration before refeeding, standard deviation of blood glucose concentration, coefficient of variation, and mean amplitude of glycemic excursions were not significantly associated with OFI.

CONCLUSION

In-hospital blood glucose concentrations are associated with subsequent development of OFI in patients with AP. In particular, admission blood glucose and mean blood glucose could be useful predictors of OFI in this setting.