Oral refeeding after onset of acute pancreatitis: a review of literature

Immediate Oral Refeeding in Patients With Mild and Moderate Acute Pancreatitis: A Multicenter, Randomized Controlled Trial (PADI trial)

OBJECTIVE

To establish the optimal time to start oral refeeding in mild and moderate acute pancreatitis (AP) to reduce hospital length-of-stay (LOS) and complications.

SUMMARY BACKGROUND DATA

Oral diet is essential in mild and moderate AP. The greatest benefits are obtained if refeeding starts early; however, the definition of "early" remains controversial.

METHODS

This multicenter, randomized, controlled trial (NCT03829085) included patients with a diagnosis of mild or moderate AP admitted consecutively to 4 hospitals from 2017 to 2019. Patients were randomized into 2 treatment groups: immediate oral refeeding (IORF) and conventional oral refeeding (CORF). The IORF group (low-fat-solid diet initiated immediately after hospital admission) was compared to CORF group (progressive oral diet was restarted when clinical and laboratory parameters had improved) in terms of LOS (primary endpoint), pain relapse, diet intolerance, complications, and, hospital costs.

RESULTS

One hundred and thirty one patients were included for randomization. The mean LOS for the IORF and CORF groups was 3.4 (SD ± 1.7) and 8.8 (SD ± 7.9) days, respectively (P < 0.001). In the CORF group alone, pain relapse rate was 16%. There were fewer complications (8% vs 26%) and health costs were twice as low, with a savings of 1325.7€/patient in the IORF than CORF group.

CONCLUSIONS

IORF is safe and feasible in mild and moderate AP, resulting in significantly shorter LOS and cost savings, without causing adverse effects or complications.

Surgical Intervention Strategies of Necrotizing Pancreatitis With Abdominal Compartment Syndrome

OBJECTIVE

Acute pancreatitis can usually recover after conservative treatment. Five to 10 percent of acute pancreatitis may proceed into peripancreatic fluid collection and necrosis development, called necrotizing pancreatitis (NP), which has a high mortality rate. If it is accompanied by the occurrence of abdominal compartment syndrome (ACS) and does not respond to medical therapy, surgical intervention is indicated.

METHODS

We analyzed our experience of surgical intervention strategies for NP patients with medically irreversible ACS from January 1, 2004, to December 31, 2018.

RESULTS

Of the 47 NP patients with ACS, mean Ranson score was 6.5, mean Acute Physiology and Chronic Health Evaluation II score was 22.2, and Modified computed tomography severity index score was all 8 or greater. The mean total postoperative hospital length of stay was 80.2 days, of which the mean intensive care unit length of stay was 16.6 days. The overall complication rate was 31.9%. The mortality rate was 8.5%. Among the 47 patients, only fungemia was significantly associated with mortality incidence.

CONCLUSIONS

The combination of multiple drainage tube placement, feeding jejunostomy, and ileostomy at the same time were effective surgical intervention strategies for NP patients with ACS, which brought a lower mortality rate.

Soluble Dietary Fiber Reduces Feeding Intolerance in Severe Acute Pancreatitis: A Randomized Study

BACKGROUND

Feeding intolerance of enteral nutrition (EN) frequently occurs in patients with severe acute pancreatitis (SAP) because of intestinal motility disorders. Soluble dietary fiber (SDF) modulates the intestinal motility. The present study examined whether SDF can improve intestinal motility and permeability, and thereby reduce feeding intolerance, in patients with SAP.

METHODS

This study was a single-blind, randomized, controlled, single-center trial. Forty-nine patients with SAP were included. The control and SDF groups received the same EN solution via a nasojejunal tube. The SDF group additionally received 20-g/d polydextrose. The primary outcome was the time to reach the energy goal. Follow-up was continued for 28 days after admission or until discharge from the hospital.

RESULTS

Among 49 randomized patients, 46 patients (n = 22, control group; n = 24, SDF group) were included in the intent-to-treat analysis. The time to reach the energy goal was 7.00 (6.00, 8.25) days and 5.00 (4.25, 6.00) days in the control and SDF groups, respectively (P < 0.001). The rates of feeding intolerance were significantly reduced in the SDF group (59.09% vs 25.00%, P < .05). SDF was associated with decreases in the incidence of abdominal distension (72.73% vs 29.17%, P < .01), diarrhea (40.91% vs 8.33%, P < .05), and constipation (72.73% vs 12.50%, P < .001). The time to first flatus and first defecation were significantly shorter in the SDF group (P < .001). The intestinal mucosal barrier function and levels of gastrointestinal hormone were improved by SDF, as evidenced by significantly reduced blood levels of diamine oxidase, D-lactic acid, endotoxin, and vasoactive intestinal peptide (P < .05).

CONCLUSIONS

SDF shortens the time to reach the energy goal during EN and improves intestinal permeability and motility disorders, thus reducing the incidence of feeding intolerance in SAP patients.

EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis

BACKGROUND

Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has increased, it is now 3.6-13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population.

METHODS

Pediatric Pancreatitis was divided into three main clinical categories: acute pancreatitis, acute recurrent pancreatitis and chronic pancreatitis. Fifteen relevant topics (acute pancreatitis: diagnosis; etiology; prognosis; imaging; complications; therapy; biliary tract management; acute recurrent pancreatitis: diagnosis; chronic pancreatitis: diagnosis, etiology, treatment, imaging, intervention, pain, complications; enzyme replacement) were defined. Ten experts from the USA and Europe reviewed and summarized the available literature. Evidence was classified according to the GRADE classification system.

RESULTS

Within fifteen topics, forty-seven relevant clinical questions were defined. The draft of the updated guideline was presented and discussed at the consensus meeting held during the 49th Meeting of European Pancreatic Club, in Budapest, on July 1, 2017.

CONCLUSIONS

These evidence-based guidelines provides the current state of the art of the diagnosis and management of pediatric pancreatitis.

Which Patients with Mild Acute Pancreatitis Require Prolonged Hospitalization?

Objectives:

In our experience, a subset of mild acute pancreatitis (AP) patients, as defined by the Revised Atlanta Classification, has longer than expected hospitalization. Our aims are to report the prevalence of patients with mild AP who have a prolonged length of stay (LOS), evaluate the etiology, thoroughly phenotype, and finally compare this subset to those with expected LOS.

Methods:

Patients admitted with AP from 2003 to 2015 were prospectively enrolled into this cohort study. LOS ≥8 days was considered as prolonged LOS. Data on demographics, clinical and laboratory variables, management, and outcomes was both prospectively and retrospectively collected. Continuous variables were compared using the nonparametric t-test (Wilcoxon's test) and categorical variables using the Pearson’s χ² test.

Results:

Among 231 enrolled mild AP patients, 46 (20%) had a prolonged LOS (≥8 days). The main determinants of prolonged LOS included ongoing pancreatitis-related symptoms (n=31, 67.4%) and performance of cholecystectomy (n=11, 23.9%). When compared to patients with expected LOS (<8 days, n=185), patients with prolonged LOS due to ongoing symptoms (n=31) were more likely to have systemic inflammatory response syndrome at 48 h from admission (37% vs. 13.4%, P<0.001), a prolonged fasting period (6.6 vs. 2.8 days, P<0.001), and need for nutritional support (30% vs. 1.6%, P<0.001).

Conclusions:

About 20% of patients with mild AP have a longer than expected hospital stay, mostly attributed to ongoing pancreatitis-related symptoms. An early decision (at 72 h) for enteral nutrition support in these patients needs to be explored so as to shorten hospitalization and reduce cost of care.

Efficacy of early oral refeeding in patients of mild acute pancreatitis

Objective:

To compare Early Oral Refeeding (EORF) with Routine Oral Refeeding (RORF) on outcome of patients of mild Acute Pancreatitis (AP) in terms of Mean Length of Hospital Stay (LOHS).

Methods:

This randomized controlled trialwas conducted atSurgical Department CMH Rawalpindi, from 1st Feb 2015 to 01st Aug 2016. A total of 60 patients with pain epigastrium were enrolled in the study. Severity of pancreatitis was assessed using Glasgow Scale. Patients were randomly divided in two groups. Group-A was started feeding within 12 hours (EORF group) and Group-B after 12 hours (RORF group). Demographic details and data were recorded on a structured proforma. After discharge, LOHS was measured for both groups and outcome was compared.

Results:

The groups were comparable with respect to age, sex, etiology, Glasgow Scale, time from onset of pain and Serum Amylase levels at admission. Treatment was standardized according to international guidelines for both groups. The mean LOHS was 7.8 ± 2.14 days in the Group-A and 10.03 ± 1.75 days in Group-B. The difference in the mean LOHS between the two groups was statistically significant (p<0.05).

Conclusion:

In patients of mild acute pancreatitis, early oral feeding is feasible and safe and has better outcome then those with routine oral refeeding.

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.

Nutrition in acute pancreatitis: a critical review

Severe acute pancreatitis poses unique nutritional challenges. The optimal nutritional support in patients with severe acute pancreatitis has been a subject of debate for decades. This review provides a critical review of the available literature. According to current literature, enteral nutrition is superior to parenteral nutrition, although several limitations should be taken into account. The optimal route of enteral nutrition remains unclear, but normal or nasogastric tube feeding seems safe when tolerated. In patients with predicted severe acute pancreatitis an on-demand feeding strategy is advised and when patients do not tolerate an oral diet after 72 hours, enteral nutrition can be started. The use of supplements, both parenteral as enteral, are not recommended. Optimal nutritional support in severe cases often requires a tailor-made approach with day-to-day evaluation of its effectiveness.

The oral refeeding trilemma of acute pancreatitis: what, when and who?

Tolerance of oral refeeding is an essential goal of nutritional management of acute pancreatitis. However, oral feeding intolerance remains one of the most common complications in patients with this disease. It often results in longer periods of hospitalization, increased treatment costs, increased risk of readmission, and reduced quality of life. The traditional practice involves keeping patients nil by mouth followed by gradual stepwise reintroduction of food. However, it does not have a solid evidence base and, hence, there is increasing interest in determining alternative strategies that may be beneficial in reducing the occurrence of oral feeding intolerance. This review focuses on the randomized controlled trials that investigated the key questions informing the nutritional management of acute pancreatitis: when to feed, what to feed and who is in charge of the decision-making.

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.

[Pediatric pancreatitis. Evidence based management guidelines of the Hungarian Pancreatic Study Group]

Pediatric pancreatitis is a rare disease with variable etiology. In the past 10-15 years the incidence of pediatric pancreatitis has been increased. The management of pediatric pancreatitis requires up-to-date and evidence based management guidelines. The Hungarian Pancreatic Study Group proposed to prepare an evidence based guideline based on the available international guidelines and evidences. The preparatory and consultation task force appointed by the Hungarian Pancreatic Study Group translated and complemented and/or modified the international guidelines if it was necessary. In 8 clinical topics (diagnosis; etiology; prognosis; imaging; therapy; biliary tract management; complications; chronic pancreatitis) 50 relevant questions were defined. Evidence was classified according to the UpToDate(®) grading system. The draft of the guidelines was presented and discussed at the consensus meeting on September 12, 2014. All clinical statements were accepted with total (more than 95%) agreement. The present Hungarian Pancreatic Study Group guideline is the first evidence based pediatric pancreatitis guideline in Hungary. The present guideline is the first evidence-based pancreatic cancer guideline in Hungary that provides a solid ground for teaching purposes, offers quick reference for daily patient care in pediatric pancreatitis and guides financing options. The authors strongly believe that these guidelines will become a standard reference for pancreatic cancer treatment in Hungary.

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.

Acute pancreatitis in children and adolescents

In this Topic Highlight, the causes, diagnosis, and treatment of acute pancreatitis in children are discussed. Acute pancreatitis should be considered during the differential diagnosis of abdominal pain in children and requires prompt treatment because it may become life-threatening. The etiology, clinical manifestations, and course of acute pancreatitis in children are often different than in adults. Therefore, the specific features of acute pancreatitis in children must be considered. The etiology of acute pancreatitis in children is often drugs, infections, trauma, or anatomic abnormalities. Diagnosis is based on clinical symptoms (such as abdominal pain and vomiting), serum pancreatic enzyme levels, and imaging studies. Several scoring systems have been proposed for the assessment of severity, which is useful for selecting treatments and predicting prognosis. The basic pathogenesis of acute pancreatitis does not greatly differ between adults and children, and the treatments for adults and children are similar. In large part, our understanding of the pathology, optimal treatment, assessment of severity, and outcome of acute pancreatitis in children is taken from the adult literature. However, we often find that the common management of adult pancreatitis is difficult to apply to children. With advances in diagnostic techniques and treatment methods, severe acute pancreatitis in children is becoming better understood and more controllable.

Quality of life after acute pancreatitis: a systematic review and meta-analysis

Patient-centered outcomes, including quality of life (QoL), after acute pancreatitis (AP) remain largely unknown. Our aim was to systematically review the best available evidence on QoL after AP. English-language articles on the effect of AP on QoL were identified in MEDLINE, EMBASE, and Scopus. Results were statistically aggregated to obtain a pooled mean difference (MD) and corresponding 95% confidence interval (CI) for individual QoL domains and component summaries, where appropriate. A total of 16 prospective observational studies encompassing 687 AP patients were included. Four studies comprising 267 AP patients, as measured by SF-36 and SF-12 questionnaires, were suitable for meta-analysis. The general health and vitality domains were significantly worse in the patients compared with healthy controls (MD, -10.90; 95% CI, -15.63 to -6.17; P < 0.00001 and MD, -4.64; 95% CI, -7.32 to -1.95; P = 0.0007, respectively). The remaining individual domains and physical and mental component summary scores did not differ between patients and controls. The QoL seems to be significantly impaired in patients after AP with a need to standardize reporting on QoL. Future studies should investigate the effect of different interventions on patients' QoL.

Early oral refeeding based on hunger in moderate and severe acute pancreatitis: a prospective controlled, randomized clinical trial

OBJECTIVE

Early enteral nutrition is beneficial for acute pancreatitis (AP), but the optimal timing and criteria remain unclear. The aim of this study was to explore the feasibility and safety of early oral refeeding (EORF) based on hunger in patients with moderate or severe AP.

METHODS

In a prospective, single-center, controlled, randomized clinical trial (ChiCTR-TRC-12002994), eligible patients with moderate or severe AP were randomized to either EORF or conventional oral refeeding (CORF). Patients in the EORF group restarted an oral diet when they felt hungry, regardless of laboratory parameters. Those in the CORF group restarted an oral diet only when clinical and laboratory symptoms had resolved. Clinical outcomes were compared between the two groups.

RESULTS

In all, 146 eligible patients with moderate or severe AP were included and randomized to the EORF (n = 70) or CORF (n = 76) group. There were eight dropouts after randomization (three in EORF group; five in CORF group). The groups had similar baseline characteristics. The total length of hospitalization (13.7 ± 5.4 d versus 15.7 ± 6.2 d; P = 0.0398) and duration of fasting (8.3 ± 3.9 d versus 10.5 ± 5.1 d; P = 0.0047) were shorter in the EORF group than in the CORF group. There was no difference in the number of adverse events or complications between the two groups. The mean blood glucose level after oral refeeding was higher in the EORF group than in the CORF group (P = 0.0030).

CONCLUSIONS

This controlled, randomized clinical trial confirmed the effectiveness and feasibility of EORF based on hunger in patients with moderate or severe AP. EORF could shorten the length of hospitalization in patients with moderate or severe AP.

Timing of enteral nutrition in acute pancreatitis: meta-analysis of individuals using a single-arm of randomised trials

INTRODUCTION

In acute pancreatitis, enteral nutrition (EN) reduces the rate of complications, such as infected pancreatic necrosis, organ failure, and mortality, as compared to parenteral nutrition (PN). Starting EN within 24 h of admission might further reduce complications.

METHODS

A literature search for trials of EN in acute pancreatitis was performed. Authors of eligible trials were requested to provide the data of all patients in the EN-arm of their trials. A meta-analysis of individual patient data was performed. The cohort of patients with EN was divided into patients receiving EN within 24 h or after 24 h of admission. Multivariable logistic regression, adjusting for predicted disease severity and trial, was used to study the effect of timing of EN on a composite endpoint of infected pancreatic necrosis, organ failure, or mortality.

RESULTS

Observational data from 165 individuals from 8 randomised trials were obtained; 100 patients with EN within 24 h and 65 patients with EN after 24 h of admission. In the multivariable model, EN started within 24 h of admission compared to EN started after 24 h of admission, reduced the composite endpoint from 45% to 19% (adjusted odds ratio [OR] of 0.44; 95% confidence interval [CI] 0.20-0.96). Within the composite endpoint, organ failure was reduced from 42% to 16% (adjusted OR 0.42; 95% CI 0.19-0.94).

CONCLUSIONS

In this meta-analysis of observational data from individuals with acute pancreatitis, starting EN within 24 h after hospital admission, compared with after 24 h, was associated with a reduction in complications.

Nutrition and acute pancreatitis: review of the literature and pediatric perspectives

Acute pancreatitis is being diagnosed more frequently in pediatrics and there is limited published research to guide management. In contrast, multiple prospective studies in the adult population have resulted in significant changes in the way the disease is managed, especially with regard to severe disease. The nutritional management of pediatric acute pancreatitis appears to lag behind current adult recommendations, likely resulting from a lack of awareness of the adult data, inherent differences between pediatric and adult pancreatitis, and the paucity of research performed in children. The purpose of this review is to examine the adult literature regarding the nutritional management of acute pancreatitis and discuss the possible relevance of this data in the pediatric population.

Early nasogastric tube feeding versus nil per os in mild to moderate acute pancreatitis: a randomized controlled trial

BACKGROUND & AIMS

Nasojejunal tube feeding is a standard of care in patients with predicted severe acute pancreatitis (AP) and several recent trials suggested that nasogastric tube feeding (NGT) is as safe and efficient as nasojejunal tube feeding in these patients. The aim was to investigate whether NGT presents any benefit to patients with mild to moderate AP.

METHODS

The study design was a randomized controlled trial. The patients in the intervention group received NGT within 24 h of hospital admission. The patients in the control group were on nil per os (NPO). The severity of acute pancreatitis was determined according to the new international multidisciplinary classification.

RESULTS

There were 17 patients randomly allocated to the NGT group and 18 to the NPO group. The visual analogue pain score decreased to a significantly greater extent in the NGT group (from median 9 (range 7-9) at baseline to 1 (0-3) at 72 h after randomization) compared with the NPO group (from 7 (5-9) to 3 (1-4) (p = 0.036). The number of patients not requiring opiates at 48 h after randomization was significantly different (p = 0.024) between NGT (9/17) and NPO (3/18). Oral food intolerance was observed in 1/17 patient in the NGT group and 9/18 patients in the NPO group (p = 0.004). The overall hospital stay in the NGT group was 9 (5-12) days as compared with 8.5 (6-13) days in the NPO group (p = 0.91).

CONCLUSIONS

NGT commenced within 24 h of hospital admission is well tolerated in patients with mild to moderate acute pancreatitis. Further, when compared with NPO, it significantly reduces the intensity and duration of abdominal pain, need for opiates, and risk of oral food intolerance, but not overall hospital stay.

Factors associated with intolerance after refeeding in mild acute pancreatitis

OBJECTIVES

This study aimed to describe the mode of refeeding, frequency of intolerance, and related factors in mild acute pancreatitis (AP).

METHODS

We included all cases of mild AP between January 2007 and December 2009 in an observational, descriptive, and retrospective study. We analyzed demographic and etiological data, admission variables, treatment, refeeding mode, intolerance frequency, and treatment. Intolerance-related variables were determined using a Cox regression.

RESULTS

Two-hundred thirty-two patients were included (median age, 74.3 years, bedside index for severity in AP score, 1). Oral diet was reintroduced at 3 days (range, 0-11 days) in 90.9% of cases with a liquid diet. Intolerance to refeeding appeared in 28 patients (12.1%) at a median time of 1 day (range, 0-14 days). Oral diet was reduced or suspended in 71.4%; analgesic and antiemetic drugs were required in 64% and 35.7% of patients, respectively. The variables independently associated with intolerance to refeeding were choledocholithiasis (hazard ratio [HR], 12.35; 95% confidence interval [CI], 2.98-51.19; P = 0.001), fasting time (HR, 1.33; 95% CI, 1.09-1.63; P = 0.005), refeeding with complete diet (HR, 4.93; 95% CI, 1.66-14.66; P = 0.04), length of symptoms before admission (HR, 1.004; 95% CI, 1.001-1.006; P = 0.012), and metamizole dose (HR, 1.11; 95% CI, 1.02-1.21; P = 0.014).

CONCLUSIONS

Intolerance to refeeding is an infrequent event. We have identified several factors independently associated with intolerance.

Systematic review of diet in the pathogenesis of acute pancreatitis: a tale of too much or too little?

BACKGROUND/AIM

The role of diet as the cause of acute pancreatitis (AP) has been suggested. The aim of the current review was to determine if there exists sufficient evidence linking nutrition, or the lack of it, to the pathogenesis of AP.

PATIENTS AND METHODS

A systematic search of the scientific literature was carried out using Embase, PubMed, MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965 - 2011 to obtain access to studies involving dietary factors and the pathogenesis of AP.

RESULTS

A total of 17 studies were identified describing diet and AP. These included 12 human and 5 animal studies. 8 reports were found to link malnutrition and/or refeeding to the pathogenesis of AP. Two studies found an increased consumption of fats and proteins in patients with alcohol-related AP while 1 study noted a lesser intake of carbohydrate in patients. However, none of these differences attained statistical significance. A recent prospective case-control study found a significantly higher risk for AP amongst patients eating par-boiled rice and fresh water fish.

CONCLUSIONS

Evidence from literature does not appear to support the role of diet as a single bolus meal as a cause for AP. Prolonged consumption of diets rich in proteins and fats may work synergistically with gallstones / alcohol to trigger an attack of AP indicating a possible role of diet as a cofactor in the development of AP possibly by lowering the threshold needed by these other agents to lead to the attack of AP.

Oral refeeding in mild acute pancreatitis: An old challenge

Although the idea that pancreas rest has long been considered as a very relevant topic in acute pancreatitis (AP) therapy, the right time and type of diet to be offered to patients recovering from an acute attack are a great challenge to clinicians who treat this condition. Fortunately, the last decade was noted for several trials looking for the best answer to the question: “when and how to start oral refeeding in AP?” It is well known that 80% of patients present with mild disease characterized by usually uncomplicated clinical course are managed with pancreatic rest through nil per oral; while the use of specific nutritional intervention is an exception. Therefore, mild AP has been the most investigated form of AP and researchers have tried different kind of meals to offer calories and reduce costs by shortening hospitalization time. Usually in mild AP, the oral refeeding is introduced between the first 3 d and 7 d after hospitalization but, the type of diet and patients’ tolerance have been scrutinized in detail with mixed results. Although 20% to 25% have pain recurrence requiring nutritional support and greater time of hospitalization, most patients seem to tolerate oral refeeding well. We propose analyzing the most recent investigations of this matter and their conclusions to develop a better understanding of the management of AP.

Three initial diets for management of mild acute pancreatitis: A meta-analysis

AIM: To compare non-liquid and clear-liquid diets, and to assess whether the latter is the optimal treatment for mild acute pancreatitis.

METHODS: The Cochrane Library, PUBMED, EMBASE, EBM review databases, Science Citation Index Expanded, and several Chinese databases were searched up to March 2011. Randomized controlled trials (RCTs) that compared non-liquid with clear-liquid diets in patients with mild acute pancreatitis were included. A meta-analysis was performed using available evidence from RCTs.

RESULTS: Three RCTs of adequate quality involving a total of 362 participants were included in the final analysis. Compared to liquid diet, non-liquid diet significantly decreased the length of hospitalization [mean difference (MD): 1.18, 95% CI: 0.82-1.55; P﹤0.00001] and total length of hospitalization (MD: 1.31, 95% CI: 0.45-2.17; P = 0.003). The subgroup analysis showed solid diet was more favorable than clear liquid diet in the length of hospitalization, with a pooled MD being -1.05 (95% CI: -1.43 to -0.66; P﹤0.00001). However, compared with clear liquid diet, both soft and solid diets did not show any significant differences for recurrence of pain after re-feeding, either alone [relative risk (RR): 0.95; 95% CI: 0.51-1.87; P = 0.88] and (RR: 1.22; 95% CI: 0.69-2.16; P = 0.49), respectively, or analyzed together as non-liquid diet (RR: 0.80; 95% CI: 0.47-1.36; P = 0.41).

CONCLUSION: The non-liquid soft or solid diet did not increase pain recurrence after re-feeding, compared with the clear-liquid diet. The non-liquid diet reduced hospitalization.

Enteral nutrition and acute pancreatitis: a review

Introduction. In patients with acute pancreatitis (AP), nutritional support is required if normal food cannot be tolerated within several days. Enteral nutrition is preferred over parenteral nutrition. We reviewed the literature about enteral nutrition in AP. Methods. A MEDLINE search of the English language literature between 1999-2009. Results. Nasogastric tube feeding appears to be safe and well tolerated in the majority of patients with severe AP, rendering the concept of pancreatic rest less probable. Enteral nutrition has a beneficial influence on the outcome of AP and should probably be initiated as early as possible (within 48 hours). Supplementation of enteral formulas with glutamine or prebiotics and probiotics cannot routinely be recommended. Conclusions. Nutrition therapy in patients with AP emerged from supportive adjunctive therapy to a proactive primary intervention. Large multicentre studies are needed to confirm the safety and effectiveness of nasogastric feeding and to investigate the role of early nutrition support.

ESPEN Guidelines on Parenteral Nutrition: pancreas

Assessment of the severity of acute pancreatitis (AP), together with the patient's nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5-7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided. PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased. When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered. In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.

Nutritional management of patients with acute pancreatitis: a Dutch observational multicentre study

BACKGROUND

Following a nil per os (NPO) regimen, most patients with acute pancreatitis (AP) can resume normal oral intake within 1 week. If not tolerated, it is recommended to initiate artificial feeding, preferably by the enteral route.

AIM

To evaluate the nutritional management of patients with AP in a Dutch cohort (EARL study).

METHODS

Observational study in 18 hospitals. Total days of NPO, tube feeding (TF) with/without oral feeding, total parenteral nutrition (TPN) and total starvation time were analysed.

RESULTS

In mild AP, a majority of cases (80.7%, 117/145) were managed with an NPO regimen only. Twenty-seven patients (18.6%) with mild AP additionally received TF; one received TPN. Of those with severe AP, more than half of the patients (56.2%, nine of 16) were treated with TF besides an NPO regimen; four received TPN. TF was delivered preferably via the jejunal route. The median period of total starvation was 2 days for both mild and severe AP. Only 5.5% (nine of 164) of patients had a prolonged starvation time of more than 5 days.

CONCLUSIONS

The total time of starvation was limited in a majority of patients admitted for AP. According to international guidelines, additional nutritional interventions were quickly undertaken with enteral feeding via the jejunum as the preferred route.

Clinical trial: oral feeding with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis

BACKGROUND

In mild acute pancreatitis, traditional treatment has been initial fasting and oral refeeding with clear liquids to prevent adverse gastrointestinal events such as pain. The diet is gradually progressed to soft solids and hospital discharge is planned based on patients' tolerance to a solid diet.

AIM

To determine the length of hospitalization and tolerance to oral refeeding when initiated on a soft diet as compared to a clear liquid diet.

METHODS

One hundred and one patients with mild acute pancreatitis were randomized to receive either a clear liquid diet or soft diet when oral feeding was initiated. Frequency of pain, total and postrefeeding length of hospitalization, and dietary intake were monitored. Hospital discharge was decided by the medical team without input from the study coordinators.

RESULTS

A statistically significant decrease in the length of hospitalization (total and postrefeeding) of a median of 2 days was seen in patients receiving a soft diet (P < 0.001). No significant difference in the need for cessation of diet because of pain was observed between the two groups. Patients initiated on a soft diet consumed significantly more calories and fats on study day 1 (P < 0.001).

CONCLUSION

Oral refeeding with a soft diet in patients with mild acute pancreatitis can be considered safe and can result in shorter length of hospitalization.

Nutritional support in acute pancreatitis

PURPOSE OF REVIEW

This review explores the role of enteral and parenteral nutrition in severe acute pancreatitis and discusses the potential benefits of glutamine, omega-3 fatty acids, arginine and selenium together with probiotics and prebiotics in these patients. In addition, the method of refeeding during the convalescent period is also examined.

RECENT FINDINGS

A complex picture is emerging in which enteral nutritional support may be important early in the course of the disease with parenteral nutrition being used more as a backup and possibly only after the systemic inflammatory response has peaked. Nasogastric feeding, sometimes supplemented by parenteral nutrition, is as efficacious as nasojejunal feeding. An individualized approach, in which strategies of nutritional support are tailored to patient response, is gaining currency. Data regarding specialized formulae are mixed but the use of prebiotics is showing promise and is worthy of further exploration. In the convalescent period, preliminary data also indicate that the risk of pain developing is no greater if a light diet is instituted rather than clear fluids.

SUMMARY

Nutritional support in acute pancreatitis remains challenging and controversial with a number of different and unexpected approaches, including the use of nasogastric feeding and dual enteral and parenteral nutrition support, being adopted in recent clinical trials.