Therapeutics

Review: In adult inpatients with mild Vaughn VM, Shuster D, Rogers MAM, et al. Early versus delayed
feeding in patients with acute pancreatitis: a systematic review.
or moderate acute pancreatitis, early Ann Intern Med. 2017;166:883-92.

feeding may reduce length of stay

Clinical impact ratings:

Question Source of funding: No external funding.

In adults hospitalized with pancreatitis, what is the effect of early For correspondence: Dr. V. Chopra, Division of Hospital
compared with delayed feeding on length of stay, mortality, and Medicine, University of Michigan, Ann Arbor, MI, USA.
readmission? E-mail vineetc@umich.edu.
Review scope Commentary
Included studies compared early (feeding started 48 h after AP is a common cause of hospitalization, is increasing in inci-
admission) and delayed (feeding started > 48 h after admission) dence, and accounts for substantial morbidity and costs. Enteral
enteral nutrition in adults with mild, moderate, or severe acute feeding is recommended over total parenteral nutrition because
pancreatitis (AP). Exclusion criteria were comparisons of enteral it has lower costs and fewer risks (1). The timing (early vs delayed) and
and parenteral nutrition, feeding formulas, or different forms of type (tube-feeding vs oral) of enteral feeding may vary, depending on
enteral nutrition without varying timing of feeding. Primary out- the severity of AP and on individual patient factors.
comes were length of hospital stay, mortality, hospital readmis-
The systematic review by Vaughn and colleagues found that
sion, and adverse events.
early feeding was well tolerated, did not increase adverse
Review methods events regardless of AP severity, and reduced length of hospital
stay in patients with mild AP. Complications (e.g., pancreatic
MEDLINE, EMBASE/Excerpta Medica, Cochrane Library,
necrosis or organ failure) did not differ between early and de-
CINAHL, and Web of Science (all to Jan 2017); ClinicalTrials.gov
layed feeding in patients with predicted severe AP.
(to Dec 2016); and reference lists were searched for full-text arti-
cles, abstracts, and posters of randomized controlled trials As is the case with most studies of AP, cross-study comparisons
(RCTs). Content experts were contacted. 11 RCTs (8 peer- were hindered by the use of a range of denitions, protocols,
reviewed full-text, 3 abstracts, n = 970) met selection criteria. criteria, and outcomes. Nevertheless, the ndings reinforce the
Patients had mild to moderate (7 RCTs, n = 481) or severe (4 recommended strategy of attempting early oral feeding in pa-
RCTs, n = 489) AP. Risk for bias was low (4 RCTs), high (2 RCTs), tients with mild AP using a low-fat solid diet as the rst meal (1).
or unclear (5 RCTs); because no trials could be blinded and In patients with predicted severe AP, data are more limited.
length of stay is an objective outcome, the authors scored each Questions remain about the preferred route, type of diet, and
RCT as low risk for bias for blinding. Heterogeneity of patients, precise timing of feeding in patients with severe AP.
feeding protocols, and outcome measurements precluded
meta-analysis. Overall, enteral feeding is preferred for all patients with AP and
can begin as soon as clinically tolerated. Oral feeding is reason-
Main results able, but tube-feeding should be considered if oral intake is not
The main results are in the Table. No deaths were reported in feasible or inadequate after 3 to 5 days (2). Further studies in
the trials of mild to moderate AP. Early feeding did not increase severe AP, with comparable protocols and outcomes, are
feeding intolerance, nausea, vomiting, or abdominal pain in needed to determine the optimal timing, method, and benet
mild to moderate or severe disease. In severe AP, groups did of enteral feeding for these patients.
not differ for necrotizing pancreatitis. Dennis Yang, MD
Christopher E. Forsmark, MD
Conclusion University of Florida
Early feeding may reduce length of stay in adults hospitalized Gainesville, Florida, USA
with mild or moderate acute pancreatitis compared with de-
layed feeding. References
1. Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenter-
ology. American College of Gastroenterology guideline: management of
acute pancreatitis. Am J Gastroenterol. 2013;108:1400-15; 1416.
Early vs delayed feeding in adults hospitalized for acute 2. Bakker OJ, van Brunschot S, van Santvoort HC, et al; Dutch Pancreatitis
pancreatitis* Study Group. Early versus on-demand nasoenteric tube feeding in acute
pancreatitis. N Engl J Med. 2014;371:1983-93.
Outcomes Severity of Number Results of early vs
pancreatitis of RCTs (n) delayed feeding
(risk for bias [RFB])
Length of stay Mild/moderate 7 (481) Reduced in 4 RCTs (2 low,
2 unclear RFB)
No difference in 3 RCTs (1 low,
1 high, 1 unclear RFB)
Severe 3 (462) Reduced in 1 RCT
(unclear RFB)
No difference in 2 RCTs
(1 low, 1 unclear RFB)
Mortality Severe 2 (419) No difference in 2 RCTs
(1 low, 1 unclear RFB)
Hospital Mild/moderate 2 (94) No difference in 2 RCTs
readmission (2 low RFB)

*RCT = randomized controlled trial.

doi:10.7326/ACPJC-2017-167-8-044

2017 American College of Physicians JC44 ACP Journal Club Annals of Internal Medicine 17 Oct 2017

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