Tag Archives: enteral feeds

Acute Pancreatitis Review

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A succinct review (CE Forsmark et al. NEJM 2016; 375: 1972-81) provides some useful pointers regarding acute pancreatitis.

The review covers the causes, epidemiology, diagnosis, prediction of severity and management.  With regard to management:

  • The authors advocate for aggressive fluid resuscitation during the initial 24 hrs -though care to avoid fluid overload.  “One trial suggested the superiority of Ringer’s lactate as compared with normal saline in reducing inflammatory markers.”
  • “Total parenteral nutrition is…more expensive, riskier, and no more effective than enteral nutrition.”
  • “In patients with mild acute pancreatitis who do not have organ failure or necrosis, there is no need for complete resolution of pain or normalization of pancreatic enzyme levels before oral feeding is started.”
  • “A low-fat soft or solid diet is safe and associated with shorter hospital stays than is a clear-liquid diet with slow advancement to solid foods.”  Thus, most patients with mild acute pancreatitis can start a low-fat diet soon after admission, “in the absence of severe pain, nausea, vomiting and ileus.”
  • By day 5, one can predict the need for enteral feeding.  Early initiation of nasoenteric feeding “is not superior to a strategy of attempting an oral diet at 72 hours, with tube feeding only if oral feeding is not tolerated” by day 5.
  • “Whether an elemental or semielemental formula is superior to a polymeric formula is not known”
  • “Prophylaxis with antibiotic therapy is not recommended for any type of acute pancreatitis unless infection is suspected or has been confirmed.”  Infection in necrotic fluid collection “is the main indication for therapy” but is rare in the first 2 weeks of illness.
  • For pancreatitis triggered by gallstones, after removal of any residual stones in the ducts, “cholecystectomy performed during the initial hospitalization…reduces the rate of subsequent gallstone-related complications by almost 75%” compared to waiting for 25-30 days.

Related blog posts:

  • Changing Practice Patterns with Pediatric Pancreatitis | gutsandgrowth
  • Why an ERCP Study Matters to Pediatric Care | gutsandgrowth This post explains why LR may be best.
  • Nutrition University / gutsandgrowth What are the nutritional management recommendations for acute pancreatitis? Justine Turner indicated that too many centers continue to rely on parenteral nutrition.  Yet, guidelines recommend the use of enteral nutrition due to lower risk of poor outcomes (eg. infections when NPO and on parenteral nutrition). ‘Resting pancreas is not helpful.’ With acute pancreatitis, enzyme secretion is reduced.  Her approach is to start nasogastric (NG) feedings at about 24 hours after presentation, as long as hemodynamically stable.  She indicated that nasojejunal (NJ) feedings can be done if NG is not well-tolerated.  NJ feedings are effective at reducing enzyme secretion.  However, Praveen Goday stated that his practice was often starting with NJ feeds.  “Sometimes there is only one shot” before the ICU team starts HAL.  Both physicians indicated that polymeric formulas were probably acceptable; however, starting with semi-elemental or elemental feedings are often done, again as a practical matter to minimize the likelihood of reverting to parenteral nutrition.
Glacier National Park

Glacier National Park

Changing Practice Patterns with Pediatric Pancreatitis

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A recent study (FK Szabo et al. J Pediatr 2015; 167: 397-402) supports the practice of early enteral nutrition and aggressive fluid administration with acute pancreatitis. Starting in January 2014, Cincinnati Children’s began using high rates of intravenous fluid and resuming enteral nutrition within 48 hours for children presenting with acute pancreatitis.  This retrospective study assessed this practice in 201 patients and compared with prior experience dating back to 2009. To be included, patients had to have mild acute pancreatitis based on the Atlanta criteria (Gut 2013; 62: 102-11). Exclusion criteria:

  • Severe acute pancreatitis: multiorgan failure, systemic inflammatory response, local pancreatic complications (eg. necrosis, hemorrhage, pseudocyst), or respiratory complications
  • Pancreatitis due to trauma, gallstones or postsurgical

With regard to enteral nutrition (EN), nasoenteric tubes were not placed during the first 48 hours, but preexisting enteral tubes were used. So, most patients were orally fed. With regard to IV fluids, 62% received 1.5-2 times the maintenance IVF during the first 24 hours of admission.  More than 90% of cases received dextrose 5% normal saline. Key Findings:

  • Length of stay was 2.9 days in the early EN group compared with 4.4 days in the NPO group (P <.0001).  It is noted that the NPO group did include 24% with severe acute pancreatitis compared with 6% in the early EN group.
  • The authors did not identify any change in measured outcomes based on high or low volume IVF.

From the discussion:

  • “EN remains an integral part of management which has been associated with a lower incidence of infection, multiorgan failure, lower mortality rates, and a shorter hospital stay in adult patients with AP [acute pancreatitis]”
  • “Our study shows that oral feeds represent a safe and a feasible strategy in mild AP.” There was not an increase in readmission rates within 72 hours of discharge, either.

Because this is a retrospective study, this limits the interpretation of these findings; there could be an element of reverse causation with regard to the outcomes.

My take: Increasing evidence supports the practice of early enteral feedings in mild acute pancreatitis.  The exact IV fluids to use remain unclear, though my preference is lactated ringer’s based on ERCP-induced pancreatitis studies.

Related blog posts:

  • Why an ERCP Study Matters to Pediatric Care | gutsandgrowth This post explains why LR may be best.
  • Nutrition University / gutsandgrowth What are the nutritional management recommendations for acute pancreatitis? Justine Turner indicated that too many centers continue to rely on parenteral nutrition.  Yet, guidelines recommend the use of enteral nutrition due to lower risk of poor outcomes (eg. infections when NPO and on parenteral nutrition). ‘Resting pancreas is not helpful.’ With acute pancreatitis, enzyme secretion is reduced.  Her approach is to start nasogastric (NG) feedings at about 24 hours after presentation, as long as hemodynamically stable.  She indicated that nasojejunal (NJ) feedings can be done if NG is not well-tolerated.  NJ feedings are effective at reducing enzyme secretion.  However, Praveen Goday stated that his practice was often starting with NJ feeds.  “Sometimes there is only one shot” before the ICU team starts HAL.  Both physicians indicated that polymeric formulas were probably acceptable; however, starting with semi-elemental or elemental feedings are often done, again as a practical matter to minimize the likelihood of reverting to parenteral nutrition.
Artist Point, Yellowstone

Artist Point, Yellowstone