Nutrition in Acute Pancreatitis: Have We Come Full Circle?
Preface: This randomized controlled trial demonstrated that early tube feeding is not superior to delayed initiation of oral feeds in patients with severe acute pancreatitis.
Current guidelines recommend early use of a nasoenteric tube with polymeric or semi-elemental formulas as the standard of care in patients with acute pancreatitis that is predicted to be severe (Am J Gastroenterol 2013; 108:1400). The early use of enteral nutrition has been considered important to stabilize the gut mucosal barrier and prevent bacterial translocation, thus reducing the risk for serious infections and death.
In the current randomized, controlled trial, investigators compared the rate of serious infection or death using different nutrition strategies in 208 patients with predicted severe acute pancreatitis at 19 Dutch hospitals. Patients were randomized to receive early placement of a nasoenteric tube and initiation of tube feedings within 24 hours of randomization or introduction of a regular oral diet at 72 hours.
Rates of serious infection (infected pancreatic necrosis, bacteremia, or pneumonia) or death were similar in the early tube feeding group and the oral diet group (30% and 27%). The overall mortality in these groups was also similar (11% and 7%, respectively), as were secondary outcomes of pancreatic necrosis, ICU admission, need for mechanical ventilation, and new-onset organ failure. Two thirds of patients in the oral diet group tolerated the introduction of an oral diet, and the time to tolerating a full oral diet was shorter in the oral diet group.
This small randomized controlled trial supported findings from other previous trials that suggested that gastric feeds carry no higher morbidity compared with post-gastric feeding in patients with severe acute pancreatitis (SAP). The theory behind post-gastric feeding in SAP is that gastric feeds would increase pancreatic stimulation and therefore pancreatic inflammation worsening the overall morbidity and mortality.
Therefore, these data suggest that patients with SAP can be fed either via nasogastric tubes, nasojejunal tubes or orally with equal outcomes. The rates of serious infection or death (30%) in this study is also consistent with prior trials that these patients are very sick and need aggressive supportive therapy to optimize their outcomes.
Bakker OJ et al. Early versus on-demand nasoenteric tube feeding in acute pancreatitis. N Engl J Med 2014 Nov 20; 371:1983.