ICU · GI & nutrition

Acute pancreatitis: ERAS and early enteral nutrition

Also known as Nutrition in acute pancreatitis · Early feeding in pancreatitis · NPO vs early enteral nutrition · ERAS in pancreatitis · Nasogastric vs nasojejunal feeding in pancreatitis · Total parenteral nutrition in pancreatitis · Pancreatic rest · Gut mucosal integrity in critical illness

Nutritional management of acute pancreatitis has undergone one of the most complete paradigm reversals in modern critical care: the dogma of prolonged NPO ('resting the pancreas'), taught for most of the 20th century, has been REPLACED by early enteral nutrition (EN) commenced within 24-48 hours. Multiple meta-analyses and the ACG, IAP/APA, and AGA guidelines now recommend early oral or NG feeding as the standard of care. Mechanism: EN maintains gut mucosal integrity, prevents bacterial translocation and infected pancreatic necrosis, and attenuates the systemic inflammatory response — benefits that intravenous nutrition cannot reproduce. Route: oral first (mild disease); nasogastric (NG) is the preferred tube route because non-inferiority RCTs (Singh/Eatock) show NG is non-inferior to nasojejunal (NJ) and is cheaper, easier, and faster to place. NJ is reserved for NG failure or severe gastroparesis. The 'pancreatic rest' concept — that NJ feeding 'spares' the pancreas — is physiologically DISPROVEN. Composition: standard polymeric formula; a large database study found no benefit of elemental formula. Total parenteral nutrition (TPN): reserved for the small minority in whom EN is contraindicated or still fails after about a week (day 8 in EPaNIC); early TPN INCREASES infection and cholestasis, and — per EPaNIC and TGC-Fast — does not improve outcome. Probiotics must NOT be given prophylactically: PROPATRIA showed a 2.5-fold increase in mortality (RR 2.53) and 9 cases of bowel ischaemia (8 fatal). Metabolic support: moderate glycaemic control (TGC-Fast found tight 4.4-6.1 mmol/L control conferred no benefit), correct electrolyte derangements, and give thiamine before the first feed in alcohol-related disease to prevent Wernicke and refeeding syndrome. WATERFALL supports moderate goal-directed lactated Ringer resuscitation over aggressive boluses.