Factors associated with intolerance after refeeding in mild 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.

Refeeding syndrome in a woman with pancreatitis: a case report

Refeeding syndrome can occur in malnourished patients with acute pancreatitis who have electrolyte imbalances. Refeeding syndrome is characterized by severe electrolyte imbalances (mainly hypophosphatemia, hypomagnesemia, and hypokalemia), vitamin deficiency (mainly thiamine deficiency), fluid overload, and salt retention resulting in organ dysfunction and cardiac arrhythmias. We herein report a case involving a patient with severe pancreatitis and gallbladder stones who developed refeeding syndrome with shock and loss of consciousness. The patient was treated by opportune vitamin and electrolyte supplementation therapy and showed substantial improvement after 2 weeks of hospitalization, gaining the ability to eat small bites of solid food orally. Early diagnosis and treatment of refeeding syndrome may reduce morbidity and mortality in patients with acute pancreatitis. Patients should be fasted only if alimentation is contraindicated, and electrolyte values must be closely monitored.

Incidence and risk factors of oral feeding intolerance in acute pancreatitis: Results from an international, multicenter, prospective cohort study

BACKGROUND

Inability to advance to an oral diet, or oral feeding intolerance, is a common complication in patients with acute pancreatitis associated with worse clinical outcomes. The factors related to oral feeding intolerance are not well studied.

OBJECTIVE

We aimed to determine the incidence and risk factors of oral feeding intolerance in acute pancreatitis.

METHODS

Patients were prospectively enrolled in the Acute Pancreatitis Patient Registry to Examine Novel Therapies in Clinical Experience, an international acute pancreatitis registry, between 2015 and 2018. Oral feeding intolerance was defined as worsening abdominal pain and/or vomiting after resumption of oral diet. The timing of the initial feeding attempt was stratified based on the day of hospitalization. Multivariable logistic regression was performed to assess for independent risk factors/predictors of oral feeding intolerance.

RESULTS

Of 1233 acute pancreatitis patients included in the study, 160 (13%) experienced oral feeding intolerance. The incidence of oral feeding intolerance was similar irrespective of the timing of the initial feeding attempt relative to hospital admission day (p = 0.41). Patients with oral feeding intolerance were more likely to be younger (45 vs. 50 years of age), men (61% vs. 49%), and active alcohol users (44% vs. 36%). They also had higher blood urea nitrogen (20 vs. 15 mg/dl; p < 0.001) and hematocrit levels (41.7% vs. 40.5%; p = 0.017) on admission; were more likely to have a nonbiliary acute pancreatitis etiology (69% vs. 51%), systemic inflammatory response syndrome of 2 or greater on admission (49% vs. 35%) and at 48 h (50% vs. 26%), develop pancreatic necrosis (29% vs. 13%), moderate to severe acute pancreatitis (41% vs. 24%), and have a longer hospital stay (10 vs. 6 days; all p < 0.04). The adjusted analysis showed that systemic inflammatory response syndrome of 2 or greater at 48 h (odds ratio 3.10; 95% confidence interval 1.83-5.25) and a nonbiliary acute pancreatitis etiology (odds ratio 1.65; 95% confidence interval 1.01-2.69) were independent risk factors for oral feeding intolerance.

CONCLUSION

Oral feeding intolerance occurs in 13% of acute pancreatitis patients and is independently associated with systemic inflammatory response syndrome at 48 h and a nonbiliary etiology.

Identification of risk factors for enteral feeding intolerance screening in critically ill patients

Objectives:

To identify risk factors for enteral feeding intolerance screening in critically ill patients, thereby, provide some reference for healthcare staff to assess the risk of feeding intolerance, and lay the foundation for future scale development.

Methods:

This study used a mixed methodology, including a literature review, semi-structured interviews, the Delphi technique, and the analytic hierarchy process. We used the literature review and semi-structured interviews (n=22) to draft a preliminarily item pool for feeding intolerance, Delphi technique (n=30) to screen and determine the items, and the analytic hierarchy process to calculate the weight of each item. The study was conducted between June 2014 and September 2015 in Daping Hospital, Third Military Medical University, Chongqing, China.

Results:

Twenty-three risk factors were selected for the scale, including 5 dimensions. We assigned a weight to each item according to their impact on the feeding intolerance, with a higher score indicating a greater impact. The weight of each dimension was decreasing as follows: patient conditions, weight score equals 42; general conditions, weight score equals 23; gastrointestinal functions, weight score equals 15; biochemical indexes, weight score equals 14; and treatment measures, weight score equals 6.

Conclusion:

Developed list of risk factors based on literature review, survey among health care professionals and expert consensus should provide a basis for future studies assessing the risk of feeding intolerance in critically ill patients.

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.

Ghrelin and gastroparesis as early predictors of clinical outcomes in acute pancreatitis

BACKGROUND

Impaired motor and hormonal gastrointestinal functions have been implicated in the pathogenesis of acute pancreatitis. The aim of the present study was to investigate the predictive value of the Gastroparesis Cardinal Symptom Index and serum ghrelin in the development of clinically meaningful outcomes in patients with acute pancreatitis.

METHODS

This was a prospective clinical study. The Gastroparesis Cardinal Symptom Index and serum ghrelin were measured for 48 h after hospitalization. Univariate and multivariate logistic regression analyses were conducted.

RESULTS

The Gastroparesis Cardinal Symptom Index total score alone on day 2 was a significant predictor of oral feeding intolerance in both unadjusted (odds ratio 1.21 (1.01-1.46), P = 0.04) and adjusted (odds ratio 1.30 (1.01-1.69), P = 0.05) analyses. Adding ghrelin to Gastroparesis Cardinal Symptom Index further improved prediction in both unadjusted (odds ratio 1.26 (1.02-1.56), P = 0.03) and adjusted (odds ratio 1.53 (1.00-2.35), P = 0.05) analyses.

CONCLUSION

This pilot study demonstrates that the Gastroparesis Cardinal Symptom Index has a potential to be used as a predictor of oral feeding intolerance. Ghrelin, when combined with the Gastroparesis Cardinal Symptom Index, may further improve the predictive accuracy. These findings need to be confirmed in larger studies.

[Recent Advances in Management of Acute Pancreatitis]

Acute pancreatitis is common but remains a condition with significant morbidity and mortality. Despite a better understanding of the pathophysiology of acute pancreatitis achieved during the past few decades, there is no specific pharmacologic entity available. Therefore, supportive care is still the mainstay of treatment. Recently, novel interventions for increasing survival and minimizing morbidity have been investigated, which are highlighted in this review.

Treating acute pancreatitis: what's new?

The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.

Risk factors of refeeding intolerance in mild acute interstitial pancreatitis: a retrospective study of 323 patients

OBJECTIVES

This study was aimed to access the frequency and identify independent risk factors of refeeding intolerance in patients with mild acute interstitial pancreatitis.

MATERIALS AND METHODS

Patients with mild acute pancreatitis (AP) were included in this observational, descriptive, and retrospective study. Clinical variables, therapy-related variables, and biochemical and radiological variables were analyzed by univariate and multivariate analysis.

RESULTS

Of 323 included cases, 40 patients (12.4%) developed refeeding intolerance. In the final regression model, hypertriglyceridemia-induced AP (odds ratio, 7.72; 95% CI: 2.50-23.82, P < 0.001), elevated serum lipase (>2-fold of the upper limit of normal) before refeeding (odds ratio, 2.13; 95% CI: 1.2-3.77, P = 0.009), and immediate feeding (odds ratio, 1.75; 95% CI: 1.31-2.33, P < 0.001) were critical risk factors of refeeding intolerance.

CONCLUSION

Refeeding intolerance occurs in 12.4% patients with mild AP and appears more often in those with hypertriglyceridemia-induced AP, elevated serum lipase (>2-fold of the upper limit of normal) before refeeding, and immediate feeding.

Early and/or immediately full caloric diet versus standard refeeding in mild acute pancreatitis: a randomized open-label trial

Refeeding after acute pancreatitis (AP) is traditionally started in a successively increasing manner when abdominal pain is absent and pancreatic enzymes are decreasing. We aimed to evaluate length of hospital stay (LOHS) and refeeding tolerance for early refeeding and/or immediately full caloric intake in patients recovering from AP.

METHODS

In this randomized, open-label trial, patients with AP were randomized into four different refeeding protocols. Group 1 and 2 received a stepwise increasing diet during three days while 3 and 4 received an immediately full caloric, low fat diet. Group 2 and 4 started refeeding early (once bowel sounds returned) and 1 and 3 started at standard time (bowel sounds present, no abdominal pain, no fever, leucocytes and pancreatic enzymes decreasing). Main outcomes measurements were LOHS and tolerance (ability to ingest >50% of meals without severe pain, nausea or AP relapse).

RESULTS

Eighty patients were evaluated and 72 randomized (median age 60 years, range 24-85, 33 male). LOHS was significantly reduced after early refeeding (median 5 versus 7 days (p = 0.001)) but not in patients receiving immediately full caloric diet, compared to standard management (6 versus 6 days (p = 0.12)). There was no difference in refeeding tolerance comparing immediately full caloric diet versus stepwise increasing diet (31/35 (89%) versus 33/37 (89%) patients tolerating the treatment, p = 1.00) or early versus standard time for refeeding (33/37 (89%) versus 31/35 (89%), (p = 1.00)).

CONCLUSIONS

Refeeding after AP when bowel sounds are present with immediately full caloric diet is safe and well tolerated. Early refeeding shortens LOHS.

Clinical management of patients with acute pancreatitis

Acute pancreatitis is the leading cause of hospitalization for gastrointestinal disorders in the United States. As rates of hospitalization for acute pancreatitis continue to increase, so does demand for effective management. We review approaches to best manage patients with acute pancreatitis, covering diagnosis, risk and prognostic factors, treatment, and complications, considering recommendations from current practice guidelines.