Eating after mild pancreatitis

Abstract

See article in J. Gastroenterol. Hepatol. 2005; 20: 1385‐1389. ‘Resting the pancreas’ has been a central dogma in the early management of acute pancreatitis. Every patient admitted with acute pancreatitis was made strictly ‘nil by mouth’ and had a naso-gastric tube to empty the stomach. When the patient was deemed to have severe pancreatitis, nutritional support was provided by total parenteral nutrition. Even a decade ago John Ranson reviewed the role of nutritional support in acute pancreatitis and underlined the primacy of parenteral feeding. 1 He stated that jejunal feeding was ‘not a therapeutic option early in the course of pancreatitis because of the associated paralytic ileus’. The avoidance of enteral feeding was also supported by the belief that stimulation of pancreatic exocrine secretion would exacerbate the severity of acute pancreatitis. How things have changed. In the absence of direct clinical evidence to support the concept of pancreatic rest, many patients are now allowed to drink limited clear fluids by mouth as soon as there is resolution of abdominal pain. There is no evidence to show that the naso-gastric tube alters the course of pancreatitis. Randomized trials have now defined best practice as the commencement of enteral nutrition (EN) in all patients with predicted moderate to severe acute pancreatitis and as soon as they are hemodynamically stable. 2 A naso-jejunal tube, often placed by the radiologist using fluoroscopic guidance, best delivers EN. Compared with total parental nutrition (TPN), the advantages of EN are safety, ease of administration, cost, and it is associated with lower markers of inflammation and pancreatitis severity. Parenteral nutrition is still sometimes required, but in a secondary role when the full calorie and protein requirements cannot be tolerated by the enteral route. It was no surprise to find that 2 weeks of total parenteral nutrition in patients with acute pancreatitis only managed to preserve body composition, and could only improve total body protein in the absence of sepsis or recent surgery. 3