Practice Changing: Start early oral feeding within 24 hours as tolerated rather than delaying oral nutrition in initial management of acute pancreatitis

The American Gastroenterological Association (AGA) Clinical Practice Guideline Committee developed guidelines on the initial management of acute pancreatitis within the first 48-72 hours of admission.  This period is significant as appropriate and timely management can influence the course of disease and duration of hospitalization.

The guideline has challenged many traditional practices that have continued over the years in the management of acute pancreatitis and includes many new recommendations such as goal-directed fluid replacement, early (within 24 hours) enteral feeding including for those who are unable to tolerate oral feeding, and cholecystectomy prior to discharge for patients with biliary pancreatitis.

Some key recommendations are:

• Goal-directed therapy for fluid management is recommended; the guideline advices against use of hydroxyethyl starch fluids.
• Prophylactic antibiotics are not recommended in patients with severe and necrotizing acute pancreatitis.
• Enteral rather than parenteral nutrition for patients who are unable to feed orally.
• Early oral feeding (within 24 hours) as tolerated is recommended, rather than keeping the patient nil by mouth as has been done traditionally.
• Either nasogastric or nasojejunal route can be used in patients with predicted severe or necrotizing pancreatitis who require enteral tube feeding.
• Compared with conservative management, urgent ERCP had no impact on outcomes, including mortality
• In patients with acute biliary pancreatitis, cholecystectomy is advised during the initial admission rather than post-discharge to prevent recurrent biliary events.
• A brief alcohol intervention is recommended during admission in patients with acute alcoholic pancreatitis.

(Source: Crockett SD, Wani S, Gardner TB, et al; American Gastroenterological Association Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on initial management of acute pancreatitis. Gastroenterology. 2018;154:1096-101).

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA