Early nasogastric tube feeding versus nil-by-mouth in patients with mild and moderate acute pancreatitis: A randomized controlled trial

Introduction: Early enteral tube feeding reduces morbidity and mortality in patients with severe acute pancreatitis (AP) and is a standard of care. In contrast patients with less severe disease are traditionally managed by nil-by-mouth (NBM) while they still have pain. And following the introduction of oral food a proportion of patients have a relapse of pain and possible prolonged hospitalization. It is hypothesized that early enteral feeding in patients with mild and moderate AP would improve tolerance of subsequent oral refeeding, promote intestinal motility and reduce the incidence of ileus. The study aim was to compare the safety, tolerance and efficacy of early nasogastric tube feeding (NGF) versus NBM regimen in patients with mild and moderate AP. Methods: A pilot randomized controlled trial in patients with mild and moderate AP was conducted between February 2010 and March 2011. The severity of AP was defined on the basis of determinants-based classification of severity. The patients in the intervention group were NBM until NGF was commenced within 24h of hospital admission and continued until the treating team decided to introduce oral food. The patients in the control group were kept NBM until the treating team decided to introduce oral food. Results: There were 17 patients randomly allocated to NGF group and 18 to the NBM group. At baseline, the two groups did not have any significant differences in terms of demographic, anthropometric, and laboratory data. The visual analogue pain score decreased to a significantly greater extent in the NGF group (from median 9 (range 7- 9) at baseline to 1 (0 - 3) at 72h after randomization) compared with the NBM group (from 7 (5 - 9) to 3 (1 - 4) (p = 0.036). The number of patients not requiring opiates at 48 hours was significantly different (p=0.024) between NGF (9/17) and NBM (3/18) (Table). The use of NGF resulted in a significantly fewer patients requiring opiates from baseline to 72h after randomization and from 24h to 48h after randomization (Table). Oral feeding intolerance was observed in 1/17 patient in the NGF group and 9/18 patients in the NBM group (p = 0.004). Time from admission until tolerance of oral food was 5 (4-7) days in the NGF group and 7 (5-9) days in the NBM group (p = 0.162). Time from introduction of oral food until hospital discharge was 3 (1-6.5) days in the NGF group and 4 (2-7) days in the NBM group (p = 0.370). The total length of hospital stay in the NGF group was 9 (5-12) days as compared with 8.5 (6-13) days in the NBM group (p = 0.91). Conclusion: NGF commenced within 24h of hospital admission is safe and well tolerated in patients with mild and moderate acute pancreatitis. Further, when compared with NBM, it significantly reduces the intensity and duration of initial abdominal pain, need for opiates, and risk of oral refeeding intolerance. (Table Presented).