Elsevier

Clinical Nutrition

Volume 26, Issue 6, December 2007, Pages 758-763
Clinical Nutrition

ORIGINAL ARTICLE
Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery—A randomized clinical study

https://doi.org/10.1016/j.clnu.2007.04.007Get rights and content

Summary

Background & aims

In acute pancreatitis, traditional treatment has been initial fasting on purpose to avoid activation of proteolytic enzymes and pancreatic enzyme secretion. 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.

Methods

Sixty patients were randomized to the two treatment groups, fasting or immediate oral feeding. The inclusion criteria were pancreas amylase ⩾3 times above normal, onset of abdominal pain within 48 h, acute physiological and chronic health evaluation (APACHE) score<8 and C-reactive protein (CRP) <150 mg/L. Outcome measures were pancreas-specific amylase, systemic inflammatory response, feasibility and length of hospital stay (LOHS).

Results

The groups were comparable with respect to age, sex, etiology, APACHE, time from onset of pain and amylase at admission. No significant differences were seen between the groups concerning levels of amylase, CRP, leukocytes, abdominal pain or number of gastrointestinal symptoms. The LOHS was significantly shorter in the oral feeding group (4 vs. 6 days; p<0.05).

Conclusions

No signs of exacerbation of the disease process were seen in terms of significant differences between treatment groups for amylase or systemic inflammatory response. In mild acute pancreatitis, immediate oral feeding was feasible and safe and may accelerate recovery without adverse gastrointestinal events.

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

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      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).

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