New recommendations for severe acute pancreatitis

If you work in acute care, treating patients with acute pancreatitis is probably old hat. NPO, clear liquid diet, you know the drill. Or, do you? New recommendations are challenging the traditional treatment pathways and will give you something new to talk about with your interdisciplinary team.

First things first

Acute pancreatitis is a condition that can range from very mild (patient is reporting mild abdominal pain) to quite severe (get the crash cart). As such, our nutrition recommendations can vary dramatically based on the severity of the condition.

As long as the patient can tolerate it, we now know that early oral or enteral feeding within the first 24 hours is best for both mild and severe cases. And get ready for this: there’s no need to start with clear liquids!

Studies show no difference in patient tolerance to liquid, solid, soft, low-fat, or regular-fat diets. It turns out that feeding into the gut can help reduce the progression and severity of acute pancreatitis, primarily by preserving the integrity of the gut and preventing bacterial location. So, first find out if your patient can eat by mouth. If not, start tube feeding.  (That’s right, I didn’t say TPN. Read on…)

EN, not PN

Old-school treatment for pancreatitis involved resting the pancreas. It’s inflamed and angry — don’t bother it.  As a result, nutrition therapy boiled down to NPO or parenteral nutrition, the only two options that don’t provide nutrition into the gut and stimulate the release of pancreatic enzymes. As it turns out, enteral nutrition is an option and is actually the best option.

This may not be news to you. Small bowel tube feeding into the jejunum has been recommended for years as a way to reap the benefits of feeding the gut without stimulating the pancreas. But many facilities have difficulty placing nasojejunal tubes safely and successfully. As a result, small bowel tube feeding simply wasn’t feasible. Wait, don’t order the TPN just yet; there’s more.

Recently, researchers have been studying nasogastric feeding for acute pancreatitis patients. (Are you ready for this?) They have found that there is no significant difference between gastric and small bowel feeding when it comes to complications like, diarrhea, abdominal distension, exacerbation of pain, or having to resort to TPN. And usually, about 75 to 80 percent of the amount of enteral nutrition that was prescribed was delivered. That is to say, NG tube feeding is safe, well-tolerated, and appropriate for acute pancreatitis patients.

Now it’s up to you

That’s right! Now that you know what’s actually best practice for your acute pancreatitis patients, it’s time to act on it. Share the good news with your docs and nurses. And next time your pancreatitis patient is working on NPO day nine, go find an NG tube and make some magic happen.

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References:

Yao H, He C, Deng L, Liao G. Enteral versus parenteral nutrition in critically ill patients with severe pancreatitis: a meta-analysis. European Journal of Clinical Nutrition. 2018;72:66-68.

Wu P, Li L, Sun W. Efficacy comparisons of enteral nutrition and parenteral nutrition in patients with severe acute pancreatitis: a meta-analysis from randomized controlled trials. Bioscience Reports. https://doi.org/10.1042/BSR20181515

Nally DM, Kelly EG, Clarke M, Ridgway P. Nasogastric nutrition is efficacious in severe acute pancreatitis: a systematic review and meta-analysis. British Journal of Nutrition. 2014;112:1769-78.

Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology Guidelines: management of acute pancreatitis. American Journal of Gastroenterology. 2013:1-16.

Crockett S, Wani S, Gardner TB, Falck-Ytter Y, Barkun AN. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. 2018;154:1096-1101.