Review finds benefit to early feeding for mild to moderate pancreatitis

The results support feeding acute pancreatitis patients sooner than recommended by current guidelines, according to the review authors, but an accompanying editorial urged caution in applying the research to practice.

Early feeding of patients hospitalized with acute pancreatitis does not appear to increase adverse events and may improve outcomes for some patients, according to a recent systematic review.

The review included 11 randomized trials with 948 patients, all hospitalized with acute pancreatitis. The trials all compared early versus delayed feeding (less or more than 48 hours after hospitalization). A variety of feeding routes were employed, including oral (four studies), nasogastric (two studies), nasojejunal (four studies), and oral or nasoenteric (one study). Most of the outcomes studied were heterogeneous, and this prevented researchers from doing a meta-analysis. Their systematic review was published May 16 in Annals of Internal Medicine.

Seven of the reviewed trials (three with low risk of bias) included patients with mild to moderate pancreatitis, and in four of the trials early feeding was associated with reduced length of stay. Three of the trials found lower rates of gastrointestinal symptoms (feeding intolerance, nausea, vomiting, pain) with early feeding. None of the trials showed an increase in adverse events with early feeding. For patients with predicted severe pancreatitis, there were four trials; one had low risk of bias and it showed no difference in length of stay, mortality, symptoms, or necrotizing pancreatitis between early and late feeding.

The question of when to feed acute pancreatitis patients has long been controversial, according to the study authors, who concluded that their review, based on limited data, suggests that early feeding of patients with acute pancreatitis “does not seem to increase adverse events, and, for patients with mild to moderate pancreatitis, may reduce length of hospital stay.” This conclusion supports the consideration of early feeding in such patients, in contrast with 2013 U.S. guidelines which recommend waiting to start feeding until inflammatory markers are improving or abdominal pain has resolved, they noted.

“Despite these encouraging results, questions persist about feeding in patients with pancreatitis,” the authors added. Issues include the lack of data on patients with severe pancreatitis, the variation in the route and timing of early feeding, and uncertainty about treatment of patients who do not tolerate an initial oral diet.

An accompanying editorial urged even more caution when applying the review's results to practice. The editorialists' concerns included that three of the studied trials were abstract-only, that three permitted use of parenteral nutrition, and that patients were insufficiently stratified by disease severity and not stratified by feeding method. The editorialists recommended that clinicians follow 2016 nutrition support guidelines from the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.