The oral refeeding trilemma of acute pancreatitis: what, when and who?

Abstract

Tolerance of oral refeeding is an essential goal of nutritional management of acute pancreatitis. However, oral feeding intolerance remains one of the most common complications in patients with this disease. It often results in longer periods of hospitalization, increased treatment costs, increased risk of readmission, and reduced quality of life. The traditional practice involves keeping patients nil by mouth followed by gradual stepwise reintroduction of food. However, it does not have a solid evidence base and, hence, there is increasing interest in determining alternative strategies that may be beneficial in reducing the occurrence of oral feeding intolerance. This review focuses on the randomized controlled trials that investigated the key questions informing the nutritional management of acute pancreatitis: when to feed, what to feed and who is in charge of the decision-making.

Keywords:

• acute pancreatitis
• gut rousing
• nutritional management
• oral feeding intolerance
• oral refeeding
• patient-centered care

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Oral feeding intolerance is a common complication in acute pancreatitis that has a considerable burden.

• Light and full diets as the first meal are as well tolerated as a clear liquid diet, and may reduce the length of hospitalization.

• As a guideline, feeding of patients with acute pancreatitis should, in general, be started on the second day after hospital admission: enteral tube feeding in patients with gut dysfunction and oral refeeding in patients with normal gut function.

• ‘Gut rousing’ is a valuable framework to direct further research on early management of patients with acute pancreatitis, including interventional studies of different oral refeeding practices.

• Individualized patient-directed refeeding regimes have the potential to reduce hospital length of stay without increasing the risk of oral feeding intolerance.

• Refeeding decisions should be coherent between wider treating teams and with a patient-centered focus.