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Three Part Question

Following the diagnosis of [adults with acute pancreatitis], is the practice of [withholding oral intake] associated with [less complications, namely organ failure and death]?

Clinical Scenario

A 50 year old gentleman has just been admitted to the emergency department with a working diagnosis of severe acute pancreatitis. According to recommended guidelines, it has been advised to withhold oral dietary intake and you wonder why this is so.

Search Strategy

OVID MEDLINE 1946 to June Week 3 2012
EMBASE 1974 to 2012 July 03

[(exp Pancreatitis, Acute Necrotizing/ OR exp Pancreatitis/ OR exp Pancreatitis, Chronic/ OR exp Pancreatitis, Alcoholic/ OR pancreatitis.mp.) AND (exp Fasting/ OR nil by mouth.mp. OR nil per os.mp. OR NPO.mp.)] LIMIT to Human AND English Language AND All Adults (18 years and above)

Search Outcome

168 papers were found of which 2 were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
B. Spanier et al July 2008 Netherlands	Total of 164 patients stratified into mild and severe based of the Atlanta Criteria 148 patients with mild acute pancreatitis 16 patients with severe acute pancreatitis	Observational Cohort Study looking at the total time without caloric intake prior to nutritional interventions with a period of more than 5 days considered prolonged starvation time.	Median % starvation time of total admission days (range)		Unclear objective, unspecified aims. The issues of undernutrition following prolonged starvation were not explored.
			All admissions	MAP: 25% (0-100)
				SAP: 7.9% (1.5-26.7)
			Admissions >7 days	MAP: 17.9% (0-70)
				SAP: 7.1% (1.5-26.7)
G. E. Eckerwell et al. December 2007 Sweden	60	Prospective randomised cohort study comparing the benefits of traditional fasting and immediate oral feeding	Overall complications (pleural effusion, atelectasis, fluid collection)	Fasting - 4; Oral feeding - 3	Blinding was not implemented in both the patients and staff Unclear objectives; intentions of what was investigated were not stated Absence of a standard discharge criteria which may introduce bias
				No mortality or pancreatic complications noted
			Length of hospital stay (p = 0.047)	Fasting - 6 days; Oral feeding - 4 days

Comment(s)

The rational behind withholding oral intake of nutrients is based on the theory that the presence of food in the gastrointestinal tract, namely the duodenum, may exacerbate pancreatic inflammation due to the further release of pancreatic enzymes in response to the meal. It is for this reason that current practise recommends patients with mild pancreatitis be fasted until symptoms subsides and oral intake can be resumed. This often take 5-7 before before enteral nutrition is initiated. Contrarily, patients with severe pancreatitis are also often fasted but this is accompanied by nutritional support. The judgement to assess the need for nutritional support can is often made in 3-4 days. With reported complications of enteric atrophy, sepsis predisposing and decreased nutrient uptake, this then questions the validity of fasting.

Clinical Bottom Line

Nil by mouth should be the initial plan in management but enteral nutrition should be started when possible. Further studies is needed to determined the earliest time at which nutritional support can be given.

References

1. B. Spanier et al. Nutritional management of patients with acute pancreatitis: a Dutch observational multicentre study Aliment Pharmacol Ther July 2008; 28, 1159-1165
2. G. E. Eckerwell et al. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery— A randomized clinical study Clin Nutr Dec 2007; 26(6), 758-763