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OPINION Nutritional management of acute pancreatitis
Kumar Krishnan
Purpose of review
Acute pancreatitis is one of the most common causes for hospitalization related to a gastrointestinal disorder.
It carries significant morbidity, and when severe, significant mortality. Multiple interventions have been
studied to treat pancreatitis. Of all these interventions, none is more important or impactful than nutrition.
Recent findings
High-quality evidence along with society guidelines have recommended the use of enteral nutrition over
parenteral nutrition in patients with pancreatitis. Recent systematic reviews and meta-analyses have been
published and will be reviewed here.
Summary
The use of enteral nutrition has been demonstrated to decrease mortality and infectious complications
compared with parenteral nutrition. The ideal timing of initiating enteral nutrition is not clear, however, early
nutrition (within 48 h) appears to be safe and tolerated. Most studies have utilized nasojejunal feeding tubes;
however, some patients may tolerate nasogastric or even oral refeeding. Clinicians who manage patients
with pancreatitis must be aware of the critical role of nutrition in preventing pancreatitis-related complications.
Keywords
enteral nutrition, nasojejunal feeding, pancreatic necrosis, pancreatitis
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all-cause mortality of 0.5 (95% confidence interval included only patients with predicted severe pan-
0.280.91) compared with enteral nutrition. The creatitis. The primary composite end point was
benefit on mortality was even greater in patients with major infection or death. In total, 30 patients in
severe pancreatitis. Length of hospital stay trended to the early group compared with 29 patients in the
favor enteral nutrition group, but this was not sig- delayed/on-demand group reached the composite
nificant. Last, systemic infection rates were also sig- end point. There was no statistically significant
nificantly lower in the enteral nutrition group [7]. difference in major infection or death between
Similar findings were noted in a more recent the two groups. Further, a majority of patients in
meta-analysis of patients with severe pancreatitis. the on-demand group were able to tolerate PO with-
&&
In this meta-analysis, eight studies were used for out the need for nasal/enteral nutrition [14 ].
comparison. Enteral nutrition was associated with These data suggest that although some studies
a decreased risk of mortality, infectious compli- favor early enteral nutrition using a nasal catheter,
cations, and organ failure. No difference in hospital on-demand enteral feeding vs. oral feeding can be
stay was noted [8]. safely performed in a subset of patients after 72 h.
The cumulative evidence from high-quality
studies and the pooled meta-analyses provide strong
clinical evidence that enteral nutrition is superior GASTRIC VS. JEJUNAL FEEDING
to parenteral nutrition in patients with pancrea- It has been suggested that gastric feeding results in
titis, both mild and severe. This has resulted in pancreatic stimulation, that ultimately contributes
strong recommendations by the Americal College to pain and ongoing symptoms of pancreatitis. As
of Gastroenterology, American Gastroenterological such, traditionally, enteral nutrition was delivered
Association (AGA), and International Association of through the placement of a nasal jejunal feeding
Pancreatology/American Pancreas Association to tube. This tube can be placed with fluoroscopic
support the use of enteral nutrition in patients with guidance, or more commonly, endoscopically.
pancreatitis [911]. The primary limitation to nasojejunal feeding is
the need for endoscopy services and a familiarity
of placing nasojejunal catheters. Nasojejunal
TIMING OF ENTERAL NUTRITION catheters are frequently tolerated; however, some
The timing of nutrition in patients with pancreatitis patients complain of discomfort and gagging related
has been debated as well. Most patients with mild to the tube passing in the hypopharynx. Further,
interstitial pancreatitis are clinically well with brief inadvertent removal or displacement of the tube is
bowel rest, with resumption of oral intake within common, and subsequently necessitates additional
4872 h. Others are unable to take per oral (PO) for endoscopy to reposition. It is for this reasons that
prolonged periods of time, and hence require nasogastric feeding is an attractive option.
nutritional support. Three studies have been performed which have
A retrospective study in 1200 patients with severe compared nasogastric with nasojejunal feeding. In
acute pancreatitis compared outcomes of patients 2005, a randomized controlled trials was performed
treated with early (<48 h) vs. late (>48 h) enteral in 50 patients with severe pancreatitis comparing
nutrition. In total, 81% of patients in the late enteral nasojejunal to nasogastric feeding. They noted no
nutrition group developed end-organ damage com- difference in mortality between the groups. Further,
pared with only 21% of those in the early nutrition there were no clinically significant differences in
&
group [12 ]. A recent meta-analysis of eight random- tolerance to tube feeding. Hospital stay was similar
ized controlled trials compared early (<24 h) vs. late in both groups which led to the conclusion that
(>24 h) enteral nutrition. In this study, the odds ratio simple nasogastric feeding was well tolerated and a
of developing organ failure was decreased in patients simpler modality for enteral nutrition [15]. A second,
who received early enteral nutrition. Interestingly, smaller study noted no difference in pain parameters
when comparing patients with predicted severe pan- compared to nasogastric or nasojejunal feeding, indi-
creatitis, there was no statistical benefit to early vs. cating that gastric feeding, and subsequent pancre-
late enteral nutrition. Further, there was no mortality atic stimulation did not exacerbate pain [16]. A more
benefit noted in early vs. late nutrition [13]. recent noninferiority trial also indicated that naso-
A landmark study (the Python study) sought to gastric feeding was not inferior to nasojejunal feeding
determine whether early enteral nutrition was in regards to pain or infectious complications [17]. A
indeed better than delayed nutrition. This was a pooled meta-analysis of all studies assessing nasogas-
prospective randomized control trial comparing tric feeding revealed no difference in mortality,
enteral nutrition within 24 h to oral refeeding vs. length of stay, infectious complications, or tolerabil-
on-demand enteral nutrition after 72 h. The study ity between the two strategies [18].
0267-1379 Copyright 2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-gastroenterology.com 105
17. Singh N, Sharma B, Sharma M, et al. Evaluation of early enteral feeding 19. Poropat G, Giljaca V, Hauser G, Stimac D. Enteral nutrition formula-
through nasogastric and nasojejunal tube in severe acute pancreatitis: a tions for acute pancreatitis. Cochrane Database Syst Rev 2015; 3:
noninferiority randomized controlled trial. Pancreas 2012; 41:153159. CD010605.
18. Zhu Y, Yin H, Zhang R, et al. Nasogastric nutrition versus nasojejunal nutrition 20. Petrov MS, Loveday BP, Pylypchuk RD, et al. Systematic review and meta-
in patients with severe acute pancreatitis: a meta-analysis of randomized analysis of enteral nutrition formulations in acute pancreatitis. Br J Surg 2009;
controlled trials. Gastroenterol Res Pract 2016; 2016:6430632. 96:12431252.