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What are the Predictors of Oral Feeding Intolerance in AP Patients?
ОглавлениеThere is significant concern about the relapse of gastrointestinal symptoms and pancreatitis following oral refeeding after AP since, the burden of oral feeding intolerance can be high. Some studies have shown that patients with oral feeding intolerance have significantly longer length of hospitalization [14–16], while others have demonstrated a reduced quality of life during hospitalization [17]. There is also evidence suggesting that these patients are at increased risk of early readmission if they are discharged with ongoing gastrointestinal symptoms, or are unable to tolerate a full diet at discharge [18].
A recent systematic review analyzed the current body of evidence and the incidence and predictors of oral feeding intolerance [19]. By evaluating 2024 patients in 22 studies these authors showed a global incidence of oral feeding intolerance of 16% (Table 11.2) [2–6,11,12,14–17,20–29]. The study found no relationship between the risk of developing oral feeding intolerance and age, sex, duration of symptoms before hospital admission, or etiology of AP. However, patients with blood lipase levels prior to refeeding of more than 2.5 times the upper limit of normal and those with (peri)pancreatic collections and pleural effusions were at increased risk of developing oral feeding intolerance [19]. However, daily monitoring of serum lipase levels is not currently recommended in clinical practice and is associated with additional time and financial costs. Furthermore, the impact of monitoring serum lipase levels on risk of developing oral feeding intolerance has not been shown in other studies [11]. On the other hand, the practical significance of (peri)pancreatic collections as potential predictors of oral feeding intolerance is limited (given the need for early CT imaging, which is not routinely conducted prior to oral refeeding), and its presence leads to categorization of the episode of AP as moderately severe (and not mild) according to the Revised Atlanta Classification [30].
Table 11.2 Characteristics of studies included in systematic review.
| Author | Year | Setting | Study design | Total no. of AP patients included | No. of AP patients included in meta‐analysis | Age, mean | Sex, no. (%) | Etiology, no. (%) | |||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Male | Female | Biliary | Alcohol | Other | |||||||
| Bakker et al. [21] | 2014 | Netherlands | Multicenter randomized controlled trial | 205 | 104 | 65 | 59 (57) | 45 (43) | 56 (54) | 23 (22) | 25 (24) |
| Chebli et al. [15] | 2005 | Brazil | Multicenter prospective observational study | 130 | 130 | 47 | 67 (52) | 63 (48) | 60 (46) | 42 (32) | 28 (22) |
| Ciok et al. [27] | 2003 | Poland | Prospective observational study | 214 | 214 | 46 | 102 (48) | 112 (52) | 106 (50) | 62 (29) | 46 (21) |
| Eckerwall et al. [28] | 2006 | Sweden | Retrospective observational study | 99 | 99 | 60 | 64 (65) | 35 (35) | 31 (31) | 30 (30) | 38 (38) |
| Eckerwall et al. [2] | 2007 | Sweden | Randomized controlled trial | 60 | 30 | 52 | 14 (47) | 16 (53) | 14 (47) | 5 (17) | 11 (37) |
| Francisco et al. [14] | 2012 | Spain | Retrospective observational study | 232 | 232 | 74 | 122 (53) | 110 (47) | 150 (65) | 25 (11) | 57 (24) |
| Jacobson et al. [5] | 2007 | USA | Randomized controlled trial | 121 | 66 | 47 | 34 (52) | 32 (48) | 15 (23) | 19 (29) | 32 (48) |
| Lariño‐Noia et al. [14] | 2014 | Spain | Randomized controlled trial | 72 | 17 | 69 | 8 (47) | 9 (53) | 9 (53) | 3 (18) | 5 (29) |
| Levy et al. [16] | 1997 | France | Multicenter prospective observational study | 116 | 116 | 51 | 74 (64) | 42 (36) | 54 (47) | 36 (31) | 26 (22) |
| Levy et al. [26] | 2004 | France | Multicenter nonrandomized trial | 23 | — | 51 | 15 (65) | 8 (35) | 7 (30) | 11 (48) | 5 (22) |
| Li et al. [12] | 2013 | China | Randomized controlled trial | 149 | 74 | 49 | 47 (64) | 27 (36) | 37 (50) | 19 (26) | 18 (24) |
| Moraes et al. [6] | 2010 | Brazil | Randomized controlled trial | 210 | 70 | 48 | 33 (47) | 37 (53) | 32 (46) | 16 (23) | 22 (31) |
| Pandey et al. [20] | 2004 | India | Randomized controlled trial | 28 | 15 | 45 | 6 (40) | 9 (60) | 5 (33) | 7 (47) | 3 (20) |
| Pendharkar et al. [17] | 2015 | New Zealand | Prospective observational study | 131 | 131 | 51 | 62 (47) | 69 (53) | 61 (46) | 39 (30) | 31 (24) |
| Petrov et al. [24] | 2013 | New Zealand | Randomized controlled trial | 35 | — | 54 | 18 (51) | 17 (49) | 20 (57) | 8 (23) | 7 (20) |
| Pupelis et al. [25] | 2006 | Latvia | Nonrandomized trial | 29 | — | 52 | 21 (72) | 8 (28) | 11 (38) | 18 (62) | — |
| Qin & Qiu [22] | 2002 | China | Randomized controlled trial | 204 | 99 | 57 | 65 (66) | 34 (34) | — | — | — |
| Rajkumar et al. [4] | 2013 | India | Randomized controlled trial | 60 | 30 | 36 | 28 (93) | 2 (7) | 2 (7) | 27 (90) | 1 (3) |
| Ren et al. [29] | 2015 | China | Retrospective observational study | 323 | — | — | — | — | — | — | — |
| Sathiaraj et al. [7] | 2008 | India | Randomized controlled trial | 101 | 52 | 39 | 44 (85) | 8 (15) | 9 (17) | 25 (48) | 18 (35) |
| Teich et al. [3] | 2010 | Germany | Multicenter randomized controlled trial | 143 | — | 47 | 50 (35) | 93 (65) | 43 (30) | 64 (45) | 36 (25) |
| Zhao et al. [23] | 2015 | China | Randomized controlled trial | 138 | 71 | 48 | 43 (61) | 28 (39) | 16 (22) | 14 (20) | 41 (58) |
Moreover, it is important to keep in mind that many patients experience gastrointestinal symptoms after refeeding. In the study published by our group, up to 53% of all patients experienced gastrointestinal symptoms after refeeding. These were mainly meteorism and postprandial fullness of mild degree that only led to refeeding cessation in three cases. Abdominal pain was registered in 21 of 72 (29%) patients, but was severe enough to interrupt refeeding in only 4 of 72 (5.6%) cases (two of whom had signs of relapse of AP) [11].
