In a systematic review of 11 randomized trials involving 948 patients hospitalized with acute pancreatitis (AP), early feeding did not appear to increase adverse events and may have led to improved outcomes versus delayed feeding. The review was published online May 16 by Annals of Internal Medicine and was summarized in the May 17 ACP Hospitalist Weekly. The following commentary by Dennis Yang, MD, and Christopher E. Forsmark, MD, FACP, appeared in the ACP Journal Club section of the Oct. 17 Annals of Internal Medicine.
AP is a common cause of hospitalization, is increasing in incidence, and accounts for substantial morbidity and costs. Enteral feeding is recommended over total parenteral nutrition because it has lower costs and fewer risks. The timing (early vs delayed) and type (tube-feeding vs oral) of enteral feeding may vary, depending on the severity of AP and on individual patient factors.
The systematic review by Vaughn and colleagues found that early feeding was well tolerated, did not increase adverse events regardless of AP severity, and reduced length of hospital stay in patients with mild AP. Complications (e.g., pancreatic necrosis or organ failure) did not differ between early and delayed feeding in patients with predicted severe AP.
As is the case with most studies of AP, cross-study comparisons were hindered by the use of a range of definitions, protocols, criteria, and outcomes. Nevertheless, the findings reinforce the recommended strategy of attempting early oral feeding in patients with mild AP using a low-fat solid diet as the first meal. In patients with predicted severe AP, data are more limited. Questions remain about the preferred route, type of diet, and precise timing of feeding in patients with severe AP.
Overall, enteral feeding is preferred for all patients with AP and can begin as soon as clinically tolerated. Oral feeding is reasonable, but tube-feeding should be considered if oral intake is not feasible or inadequate after 3 to 5 days. Further studies in severe AP, with comparable protocols and outcomes, are needed to determine the optimal timing, method, and benefit of enteral feeding for these patients.