Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 143

Traditionally, refeeding in acute pancreatitis (AP) has been initiated when serum levels of pancreatic enzymes are decreasing, intestinal peristalsis is present, and patients are free from abdominal pain and fever. Oral intake has usually been started with clear liquids followed by solid low‐fat meals with increasing caloric content over a period of three to six days in order to minimize pancreatic stimulation and the risk for abdominal pain and AP relapse [1]. A concern that refeeding will lead to cholecystokinin release, stimulation of exocrine pancreatic secretion, and aggravation of pancreatitis has been the theoretical basis of the traditional “nil by mouth” management in the early phase of AP. However, this concept has been challenged in a number of recently published studies investigating either the optimal time for refeeding [2,3] or the optimal schedule [4–7].

Recent guidelines and technical reviews have recommended early oral feeding in mild (interstitial) AP [8–10]. In patients with predicted severe or necrotizing AP, hospital stay is typically prolonged, and patients are often intolerant to oral feeding for a longer period of time. In these latter groups of patients, establishing a definite diagnosis of severe or necrotizing AP usually occurs between three and five days after initial presentation, a time when nasogastric or nasojejunal feeding is recommended to maintain the gut‐mucosal barrier and to prevent infection of necrosis.

In this chapter, the following points are addressed: what is the optimal timing of oral refeeding in AP, how must the reintroduction of oral intake be scheduled, and what are the predictors of oral feeding intolerance in AP patients? As already mentioned, patients with predicted severe AP used to have more prolonged hospital stay, multiorgan failure and intensive care requirements, and hence oral refeeding in this group of patients does not constitute the main problem as nutritional requirements are supplemented mainly with enteral nutrition via the nasogastric or nasojejunal route.