University of Virginia Health System
Nutrition Support E-Journal Club
We had a great March Traineeship - this month our trainees travelled from Arizona, Pennsylvania and British Columbia. The first signs of Spring have reached Charlottesville and our trainees were treated to pleasant weather with daffodils and crocuses in bloom. It won't be long now before our redbuds and dogwoods are in their full glory.
Eckerwall GE, Tingstedt BB, Bergenzaun PE, et al. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery--a randomized clinical study. Clin Nutr 2007;26(6):758-63.
This was a prospective, randomized (unblinded) study of the effects of early introduction of oral intake on the course and outcome of mild acute pancreatitis. Patients (n= 60) with predicted mild pancreatitis were randomized to either remain npo with slow transition to oral intake or immediate start of oral intake as tolerated. The primary outcomes measured were pancreas-specific amylase level, systemic inflammatory response (CRP and leukocytes), length of hospital stay, and what the investigators called "feasibility" (abdominal pain and frequency of GI symptoms).
Inclusion and Exclusion Criteria were:
The inclusion criteria were clinical signs of mild acute pancreatitis, pancreas-specific 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.
Exclusion criteria were age below 18 years, pregnancy, pancreatitis caused by surgery, trauma or cancer, history of chronic pancreatitis, inflammatory bowel disease, stoma, or short bowel.
Major Results reported by authors:
One patient was dropped from the analysis (oral feed) due to development of organ failure prior to starting the protocol. Three patients eventually developed severe pancreatitis, one in the fasting group and two in the oral feeding group.
Not surprisingly, the patients in the oral feeding group were npo for a significantly shorter time (0 days oral vs 3 days fasting, p< 0.001) and started intake of solid food significantly earlier (day 3 +/- 1 oral vs day 5 +/- 2 fasting, p< 0.001) than those treated by fasting. The duration of intravenous fluids was significantly shorter in the oral feeding group than in the fasting group (2 days fasting +/-1 vs 4 days oral +/-2, p< 0.001).
There was no significant difference between groups for pancreas-specific amylase, CRP or leukocytes on any day of the study, nor between groups for nausea, vomiting, abdominal pain and diarrhea, or when these symptoms were analyzed cumulatively. There was no significant difference between the groups in frequency of complications (4 fasting, 3 oral feed), mortality (0), need for cholecystectomy or ERCP, or incidence of hyperglycemia. The length of hospital stay was significantly shorter in the oral feed group compared to the fasting group (4 vs 6 days respectively; p=0.047). The incidence of recurrent pancreatitis at the 3 month follow-up was not significantly different between groups (3 fasting, 2 oral feed; p= 0.30).
"In mild acute pancreatitis, immediate oral feeding was feasible and safe and may accelerate recovery without adverse gastrointestinal events."
This study is remarkable in that it challenges the widely practiced, but completely untested assumption that pancreatic rest is beneficial or necessary in the setting of acute pancreatitis. There are, of course, limitations to this study, but the investigators are to be congratulated for efforts to replace dogma with data.
One limitation of this study is the inability to conduct research of this nature in a double-blind fashion. Interpretations of nausea, pain by the visual analog scale (VAS) and even readiness for discharge are all potentially influenced in this setting. Another limitation we noted was the clinical/lab diagnosis of pancreatitis with a lack of any radiologic confirmation (CT scan) for the presence of pancreatitis. This study utilized pancreas-specific amylase which has been reported to have improved specificity compared to total serum amylase. 1
However, the primary discussion point during our journal club was that the results of this study may only apply to patients with mild pancreatitis that receive oral intake within 48 hours after the onset of abdominal pain. The criteria for entry into this study strictly excluded all patients that had abdominal pain > 48 hours, and there may be a "window of opportunity" for introduction of enteral nutrients in acute, mild pancreatitis.2 The early introduction of foods is (of course) what was being tested, but we felt it was important to point out that the study results may not apply to all patients with pancreatitis, or even all those with mild pancreatitis if introduction of food is delayed. One last point that we discussed was that the type and amounts of food actually ingested were not reported.
Our Take Home message:
Early introduction of oral intake "as tolerated" within 48 hours of onset of abdominal pain appears safe, and may have advantages in patients with mild acute pancreatitis. It remains unknown if these results would apply to patients with more severe disease, or those that have delayed reintroduction of oral intake.
Yang RW, Shao ZX, Chen YY, et al. Lipase and pancreatic amylase activities in diagnosis of acute pancreatitis in patients with hyperamylasemia. Hepatobiliary Pancreat Dis Int. 2005;4(4):600-3.
McClave S. Nutrition Support in Acute Pancreatitis. Gastroenterology Clinics of North America. 2007; 36(1):65-74.
We have had several requests for a re-run of our last year's playful "April 1st edition" of the e-journal club, but now fully understand and agree with the need to avoid any satire/humor on a university hospital website. Regretfully, we have not found an appropriate outlet for our interpretation of the "lighter side of nutrition support" (outside of our PowerPoint presentations).
NEXT WEEKEND WARRIOR ADVANCED NUTRITION SUPPORT PROGRAM:
The next University of Virginia Health System "Weekend Warrior" Mini Nutrition Support Traineeship will be held on Saturday and Sunday, May 31 - June 1 , 2008. Topics include a variety of enteral and parenteral nutrition issues, fluid and electrolytes, feeding the obese patient, feeding the post-surgical patient, and more. In-depth, fully referenced syllabus provided. 14 CPE hours. Maximum of 27 participants. For more information, go to: http://www.healthsystem.virginia.edu/pub/digestive-health/nutrition/education.html or contact Stacey McCray at firstname.lastname@example.org.
Check out the latest Practical Gastroenterology articles/info at: http://www.healthsystem.virginia.edu/pub/digestive-health/nutrition/resources.html
Perks P, Abad-Jorge A. Nutritional Management of the Infant with Necrotizing Enterocolitis. Practical Gastroenterology 2008;XXXII(2):46-60.
Procaccini N, Nemergut EC. Percutaneous Endoscopic Gastrostomy in the Patient with Amyotrophic Lateral Sclerosis: Risk vs Benefit? Practical Gastroenterology 2008;XXXII(3):24.
Joe Krenitsky MS, RD
Carol Parrish RD, MS
PS - Please feel free to forward this on to friends and colleagues.