Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 138

The previous section established why nutritional intervention is important in the treatment of AP. The next crucial question in the management of AP is when to initiate nutritional intervention in the treatment process.

It is common practice to wait until pancreatic enzyme levels have normalized, and abdominal pain and nausea are resolved, before commencing oral refeeding, as recommended in numerous guidelines [23]. Traditionally, patients following a conventional refeeding protocol are started on a hypocaloric clear liquid diet, and if this first meal is well tolerated, light diet (modified in texture) and full diet (solid with calorie and fat content of a normal or low‐fat diet) are introduced in a stepwise manner until the patient can tolerate a full oral diet [24]. As widely practiced as this protocol is, in actuality many randomized controlled trials have shown that immediate oral refeeding with a normal diet is safe in predicted mild pancreatitis and may even lead to a shorter hospital stay. A large multicenter study by Teich et al. [25] randomized 143 patients with mild AP to either lipase‐directed refeeding (when lipase had normalized to less than twice the upper limit of normal) or patient‐directed refeeding (when opioid analgesics were no longer needed) and showed that there was no difference in length of hospitalization and that pain levels were similar in both groups. It should be noted that recruitment to this study was prematurely terminated due to poor accrual rate, which may have influenced study results. Using subjective signals to begin refeeding, Larino‐Noia et al. [26] randomized patients to receive oral nutrition either by standard procedure or early refeeding as determined by presence of bowel sounds. Not only did the authors find that early refeeding based on symptom improvement was safe, but also that when the earlier fed patients were given a full caloric diet immediately, they had a reduced length of hospitalization, suggesting there is clinical benefit to early refeeding. Eckerwall et al. [27] randomized 60 patients to two treatment groups, fasting or immediate oral feeding, and found that there was no significant difference between treatment groups for amylase or SIRS; furthermore, immediate oral refeeding leads to a shorter hospital stay (four versus six days). Thus, in mild acute pancreatitis, immediate oral feeding is feasible and safe and may accelerate recovery without adverse gastrointestinal events. Moraes et al. [28] reiterated this in their randomized controlled double‐blind trial in which 210 patients were randomized to receive one of three diets (clear liquid, soft, or full solid) as the initial meal during oral refeeding and monitored for relapse of pain, dietary intake, and length of stay. Results revealed no difference in pain relapse rates during refeeding between the three diet arms, and actually a shorter length of stay (median of –1.5 days) among patients receiving a full solid diet without abdominal pain relapse. A recent meta‐analysis pooled oral feeding intolerance (OFI) from 17 studies and found that serum lipase, pleural effusion, and peripancreatic collections were significantly different between patients who developed OFI and those who did not [29]. In particular, patients who developed OFI had lipase levels at least 2.5 times higher than those who did not develop OFI. A randomized controlled trial is warranted to compare lipase‐directed refeeding to conventional stepwise refeeding, and to determine whether a serum lipase threshold can be used as a signal for the optimal time to begin refeeding. In general, however, patients with mild acute pancreatitis can be fed a solid diet (usually low fat) as soon as they are able to tolerate it.