ORIGINAL ARTICLEImmediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery—A randomized clinical study
Introduction
The initiation of acute pancreatitis is due to premature activation of digestive enzymes followed by a systemic inflammatory response-mediated by cytokines.1 In acute pancreatitis, the traditional way of initial treatment has included fasting and administration of parenteral fluids that is practicing “putting the pancreas at rest”. The rational for fasting the patients has been that the presence of food in the duodenum induces a cholecystokinin release that stimulates pancreatic enzyme secretion. In the initiation of acute pancreatitis, premature activation of proteolytic enzymes, such as trypsinogen, within acinar cells might lead to autodigestion and therefore is thought to cause and exaggerate potential tissue injury.2, 3 It has been shown, both experimentally and in humans, that the secretion of pancreatic juice and trypsin is reduced during acute pancreatitis.4, 5
In mild acute pancreatitis, current practice has been initial fasting until abdominal pain has resolved and levels of pancreatic and inflammatory markers have decreased. Oral refeeding has been initiated with small amounts of a diet, rich in carbohydrates and proteins and low in fat, then gradually increasing the intake during 3–7 days in order to avoid pain and pancreatitis relapse.6, 7 However, fasting has been reported to cause atrophy of the enteric mucosa, bacterial overgrowth and decreased secretion of immunoglobulin A.8, 9 Oral feeding stimulate normal bowel function and is the natural way to provide nutrients to the intestinal lumen and should thus be the first logical route of nutritional administration whenever possible.
Immediate oral feeding in patients with acute pancreatitis has not previously been investigated in a clinical randomized study, although early, enteral feeding (nasojejunal and nasogastric) has been investigated in several randomized trials in acute pancreatitis and has been shown to be both feasible and safe.10, 11, 12, 13 However, the concept from these studies have certain limitations, such as that “early” initiation of nutrition has not been defined and the time from onset of pain to initiation of nutrition has not been stated. The feeding has in general been a low fat semielemental formula that has been initiated at a slow rate and thus not comparable with intake of solid normal food.
The aim of the present study was to evaluate the efficacy and feasibility of immediate oral feeding as compared to traditional fasting in patients with mild acute pancreatitis.
Section snippets
Patients and methods
This prospective randomized study was conducted at the Department of Surgery, Lund University Hospital, between March 2003 and August 2005. The inclusion criteria were clinical signs of mild acute pancreatitis, pancreas amylase ⩾3 times above normal, onset of abdominal pain within 48 h, acute physiological and chronic health evaluation score (APACHE) II<8 and C-reactive protein (CRP) <150 mg/L. Patients were excluded if acute pancreatitis was caused by surgery, trauma or cancer and if
Results
Thirty patients in the fasting group and 29 patients in the oral feeding group completed the study protocol. The determination of eligibility for inclusion was made too quickly in one patient in the oral feeding group. In this patient, organ failure developed during the screening and randomization procedure and the patient never managed to start immediate oral feeding and was therefore excluded from analysis. Three patients, one in the fasting group and two in the oral feeding group, developed
Discussion
The goals of fasting, as a traditional therapy in acute pancreatitis, has been to “put the pancreas at rest” by reducing pancreatic secretion of enzymes and minimize the stress on the pancreatic gland and thereby theoretically decrease autodigestion of the pancreas and exacerbation of tissue injury. Although initial fasting is standard and in general accepted in patients with mild acute pancreatitis, the concept has not truly been evaluated and challenged previously in a clinical randomized
Acknowledgments
The authors would like to thank the staff at the Surgical Emergency Ward and Surgical Ward 13, Lund University Hospital, for their excellent help in the collection of samples and clinical data. The study was supported by grants from Swedish Nutrition Foundation, Swedish Research Council (Grant no. 11246) and Foundation for Gut and Intestinal Research.
All authors have been involved in the design of the study. Gunilla E. Eckerwall has coordinated the study activities, evaluated the data and
References (24)
- et al.
Early events in acute pancreatitis
Clin Lab Med
(2005) - et al.
Pancreatic exocrine secretion in acute experimental pancreatitis
Gastroenterology
(1990) - et al.
ESPEN guidelines on enteral nutrition: pancreas
Clin Nutr
(2006) - et al.
The role of the intestine in the pathophysiology and management of severe acute pancreatitis
HPB
(2003) - et al.
Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study
Am J Gastroenterol
(2002) - et al.
The impact of oral feeding on the severity of acute pancreatitis
Am J Surg
(1999) - et al.
Fluid resuscitation and nutritional support during severe acute pancreatitis in the past: what have we learned and how can we do better?
Clin Nutr
(2006) - et al.
Intracellular activation of digestive zymogens in rat pancreatic acini. Stimulation by high doses of cholecystokinin
J Clin Invest
(1991) - et al.
Exocrine insufficiency in acute pancreatitis
Scand J Gastroenterol
(2004) - et al.
Trypsin secretion and turnover in patients with acute pancreatitis
Am J Physiol Gastrointest Liver Physiol
(2005)
Frequency and risk factors of recurrent pain during refeeding in patients with acute pancreatitis: a multivariate multicentre prospective study of 116 patients
Gut
Parenteral nutrition is associated with intestinal morphologic and functional changes in humans
J Parent Enteral Nutr
Cited by (173)
ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis
2024, Clinical NutritionImmediate enteral nutrition can accelerate recovery and be safe in mild acute pancreatitis: A meta-analysis of randomized controlled trials
2022, HeliyonCitation Excerpt :The meta analysis of three studies revealed that immediate EN could significantly decrease the intolerance of feeding, compared with early refeeding (RR = 0.78; 95%CI, 0.63–0.95; P = 0.02; I2 = 0%; presented as Figure 6). Only two studies involving 143 patients displayed the number of complications [15, 23]. The pooled result showed that there was no significant difference between the two groups (RR = 1.12; 95%CI, 0.50–2.49; P = 0.78; I2 = 0%; presented as Figure 7).
ESPEN guideline on hospital nutrition
2021, Clinical Nutrition