New options for enteral nutrition in patients with severe acute pancreatitis

A research team from Italy assessed the rate of spontaneous tube migration and compared the effects of naso-gastric and naso-intestinal (beyond the ligament of Treitz) feeding in severe acute pancreatitis (SAP). They found that spontaneous distal tube migration is successful in 40 percent of SAP patients, with higher computed tomography severity index predicting intragastric retention; in such cases enteral nutrition by nasogastric tubes seems to provide a pragmatic alternative opportunity with similar outcomes.

Severe acute pancreatitis (SAP) requires an adequate nutritional support. Enteral nutrition (EN) should be preferred to total parenteral nutrition in patients with SAP, as it is associated with reduced mortality and complications. However, in clinical practice EN is employed far less frequently than it should. The main obstacle to EN diffusion is that it is considered complicated, as to ensure full pancreatic rest, nutrition tubes should be placed in the jejunum, requiring often troublesome procedures. In the past few years, it has been proposed that EN through nasogastric (NG) tubes may be a simple, safe and equally valid alternative to nasojejunal tubes.

A research article published on August 7, 2010 in the World Journal of Gastroenterology addresses this question. The authors speculated that a pragmatic possibility in real-world clinical practice would be to employ NG feeding whenever tube migration to the jejunum of bedside inserted feeding tubes does not occur spontaneously. They therefore aimed at assessing the rate of spontaneous distal migration of EN tubes in patients with predicted SAP, to identify possible factors associated with it, and to compare the safety and tolerability of EN with an elemental formula in patients who started nutrition with a "proximal", NG or a "distal", naso-intestinal tube, depending on the success of spontaneous tube migration.

This is the first study of its kind observing the outcome of EN in SAP patients in a "real world" clinical setting, with the study protocol driven by the need to have more solid grounds in making clinical decisions about everyday medical care circumstances. Both the proximal and the distal enteral approaches resulted to be feasible, safe and effective in most patients. This issue has a relevant impact on everyday clinical practice as the main limit to EN usage in AP is the technical difficulty in obtaining small bowel access.