Benefits of early versus delayed feeding in patients with acute pancreatitis

1. Early feeding may reduce hospital stay in patients with mild pancreatitis.

2. Early feeding was not associated with adverse events and may help reduce gastrointestinal symptoms.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Acute pancreatitis is a common disease of the gastrointestinal tract with increasing costs and incidence worldwide. Recent studies have suggested a protective role of enteral feeding in stimulating the gut, preventing bacterial overgrowth and sepsis, and resulting in reduced infections and lower mortality, and shorter hospital stays if given early. However, the evidence remains controversial and there is no clear consensus on whether early feeding is beneficial compared to delayed feeding. The present study is a systematic review that was conducted using 11 randomized controlled trials to evaluate if early feeding affected mortality, hospital stay, symptoms and other clinical outcomes in patients hospitalized with acute pancreatitis. Overall, 948 patients across 8 peer-reviewed publications and 3 abstract-only presentations were included. Seven trials investigated mild to moderate acute pancreatitis while 4 trials included patients with severe pancreatitis. Early feeding was associated with a shorter hospital stay in patients with mild to moderate pancreatitis. Adverse events were not found to be increased with early feeding. Further, gastrointestinal symptoms were found to be less frequent in those assigned to early feeding.

Overall, the study suggests that early feeding in patients with mild pancreatitis is not associated with adverse events and may help reduce hospital stay. Strengths of this study include a published protocol, a comprehensive literature search including gray literature that helped offset publication bias, and exclusion of trials with total parenteral nutrition which is no longer considered a standard of care. Limitations include inability to conduct a meta-analysis due to clinical heterogeneity across studies, highly variable reported outcomes across studies, and limited power to detect rare outcomes. Future studies may explore the optimal timing and route of feeding in patients with acute pancreatitis.

Click to read the study in the Annals of Internal Medicine

Relevant Reading: Management of Acute Pancreatitis

In-Depth [systematic review]: This is a systematic review utilizing the previously published PROSPERO protocol and the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) recommendations. Between 25 March 2016 and 6 January 2017, the following databases were searched for randomized controlled trials (RCT): MEDLINE, EMBASE, the Cochrane Library, and Web of Science. Studies that compared early (defined as within 48 hours of hospitalization) with delayed (more than 48 hours of hospitalization) enteral nutrition in adults hospitalized with acute pancreatitis were utilized. Data extraction and quality assessment was performed independently and in duplicate by 2 authors. Main outcomes included length of hospital stay, mortality, and readmission, while secondary outcomes included feeding intolerance, nausea, vomiting, recurrent abdominal pain, and necrotizing pancreatitis.

Of the total 1319 citations obtained, 8 peer-reviewed RCTs and 3 conference abstracts that included 948 patients in total met eligibility criteria. Route of feeding in patients with mild to moderate acute pancreatitis differed for the early group. For patients with severe pancreatitis, early group was provided nasojejunal feeding and delayed group either oral or nasojejunal feeding. There were differences in the criteria of feeding for the early and delayed groups. In the early group, these were based on a time window such as within 24 hours of admission, or in others on clinical criteria such as stopping of opiate therapy. For the delayed groups, time to feeding were based on improvement in enzymatic levels or a “period of fasting.” With regard to main outcomes, 4 of 7 studies of patients with mild pancreatitis showed early feeding was associated with a reduced length of stay compared with delayed feeding. Only 1 study (of total 3) of patients with severe pancreatitis found early feeding to be associated with reduced length of stay, but this study was small and did not report mortality. No deaths were reported in studies that included patients with mild pancreatitis, while two studies of patients with severe pancreatitis reported 8.8% and 12.6% reported incidence of death. However, overall no mortality differences were found between early and delayed feeding groups. Readmission rates were only obtained in two studies investigating mild pancreatitis, and found no differences between early and delayed feeding groups. Amongst the secondary outcomes, gastrointestinal symptoms such as nausea and vomiting, and abdominal pain were found to be less frequent among patients randomly assigned to early feeding.

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