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Acute Pancreatitis: How Soon Should We Feed Patients?

Management of nutrition in the setting of acute pancreatitis varies and can include oral, enteral, or parenteral nutrition. Most agree that maintenance of gut barrier function in acute pancreatitis is best achieved through the use of enteral rather than parenteral nutrition in patients requiring specialized nutrition support (14). Characteristics of enteral nutrition that may affect gastrointestinal tolerance in patients with acute pancreatitis include the method of delivery (bolus vs. continuous), the formula (monomeric, oligomeric, polymeric, immune-modulating, fiber, or fiber-free), and the delivery route (gastric vs. jejunal). Current literature supports the use of a polymeric formula (2) delivered through either a gastric tube or a jejunal tube (5) with as-needed adjustment to improve tolerance (2), which in turn influences morbidity and length of hospital stay. Early enteral nutrition, defined as the provision of nutrients within 48 hours of hospitalization, has been associated with reduced mortality and infections compared with delayed enteral nutrition (2). Yet, the heterogeneity of acute pancreatitis and the variability of feeding protocols make it challenging to define the benefits of early enteral nutrition. Vaughn and colleagues report a systematic review of early versus delayed enteral nutrition in adults with acute pancreatitis (6). Enteral nutrition included oral and tube feeding and was considered early if it was started within 48 hours of hospitalization. The researchers identified and evaluated 11 randomized controlled trials that included 948 patients with acute pancreatitis. They concluded that the limited evidence suggests possible shorter hospital stay and no adverse events with early enteral nutrition in patients with mild to moderate pancreatitis. Caution is needed when considering this conclusion. First, 3 of the 11 trials reviewed, which accounted for 18% of included patients, were reported in abstract form only. Inclusion of abstract-only presentations in a systematic review may introduce bias (7). Further, as noted by the authors, the risk of bias varied significantly, with only 4 studies identified as having low risk. Second, 3 of the 11 trials permitted the use of parenteral nutrition. Use of parenteral nutrition in patients with moderate to severe pancreatitis is associated with longer hospital stay (1) and increased mortality (2) and may therefore have interfered with the assessment of the effect of early enteral nutrition on length of stay in patients with severe pancreatitis. Recent guidelines suggest that parenteral nutrition should be considered only when enteral nutrition is not feasible within 7 days from the onset of pancreatitis (2). The time to initial feeding documented in this review seems to be less than 7 days from admission; therefore, use of parenteral nutrition may affect length of stay. The number of patients this might have affected is unclear. Third, classification of patients with mild, moderate, and severe pancreatitis is essential to the interpretation of these findings. The American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM) suggest that the nutritional support clinician assess patients with acute pancreatitis frequently because nutritional status can deteriorate in a patient presenting with mild disease who rapidly progresses to severe disease (2). We would not expect patients with mild pancreatitis to have prolonged hospital stays because more than 80% of these patients advance to an oral diet within 1 week of hospitalization (2). However, tolerance of an oral diet in patients with moderate or severe pancreatitis is less well-described. Stratifying data by disease severity and feeding method (oral vs. feeding tube) instead of grouping classifications of acute pancreatitis and feeding methods would have permitted a better understanding of feeding protocols. Finally, gastrointestinal tolerance of enteral nutrition could play a major role in the morbidity associated with severe pancreatitis. Vaughn and colleagues did not report the enteral nutrition protocols and formulas, probably because the details were not included in the original reports. However, this information is essential to understanding outcomes related to enteral nutrition. Specifically, evidence suggests that immune-enhancing enteral formulas are beneficial for patients with severe pancreatitis (8, 9). Further research on these products is warranted to define the benefit of early versus delayed enteral nutrition. To best address the question of delayed versus early enteral nutrition, additional randomized clinical trials are needed with clear feeding protocols to reflect current guidelines, which should minimize heterogeneity of feeding practices. Recommendations from ASPEN and SCCM set the stage for nutrition support clinicians to improve specialized nutritional support (2). These guidelines suggest the following parameters for supplying this support to patients with acute pancreatitis (2). First, initial assessment should evaluate disease severity to direct nutrition therapy. Second, diet should be advanced as tolerated in patients with mild pancreatitis, and specialized nutritional support should be considered for patients unable to advance diet within 7 days. Third, in patients with moderate to severe pancreatitis, a nasoenteric or oroenteric tube should be placed and enteral nutrition should be started at a trophic rate and advanced to goal as fluid volume resuscitation is completed (within 24 to 48 hours of admission). Fourth, a standard polymeric formula should be used to initiate enteral nutrition in patients with severe pancreatitis, and enteral nutrition can be delivered through the gastric or jejunal route. Finally, in patients with severe pancreatitis, parenteral nutrition should be considered after 1 week from disease onset if enteral nutrition is not feasible. In summary, Vaughn and colleagues' systematic review adds to the body of literature aimed at identifying the optimal nutritional management of patients with acute pancreatitis while highlighting the need for additional clinical trials to more clearly define the benefits of early enteral nutrition.