Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis.

BACKGROUND This prospective study was designed to compare the safety, efficacy, cost, and impact on patient outcome of early total enteral nutrition (TEN) vs total parenteral nutrition (TPN) in acute pancreatitis. METHODS Patients admitted with acute pancreatitis or an acute flare of chronic pancreatitis, characterized by abdominal pain and elevated serum amylase and lipase, were randomized to receive either isocaloric and isonitrogenous TEN (via a nasojejunal feeding tube placed endoscopically) or TPN (via a central or peripheral line) started within 48 hours of admission. RESULTS Thirty patients were studied over 32 admissions (TEN given on 16 and TPN on 16) for acute pancreatitis. There were no differences on admission in mean age, Ranson criteria, multiple organ failure score (MOF), or APACHE III score between TEN and TPN groups. Although slower to approach goal feeding over the first 72 hours of admission, TEN patients received 71.3% goal calories by day 4 vs 85.2% for TPN patients (not significant). There were no deaths and no differences between groups in serial pain scores, days to normalization of amylase, days to diet by mouth, serum albumin levels, or percent nosocomial infection. However, the mean cost of TPN per patient was over four times greater than that for TEN ($3294 vs $761, respectively, p < .001). Mean serial Ranson criteria, APACHE III, and MOF scores recorded every 2 to 3 days decreased in the TEN group, whereas those in the TPN group increased. Only the difference in the third Ranson criteria (mean 6.3 days after admission) for the TEN and TPN groups (0.5 vs 2.8, respectively) reached statistical significance (p = .002). Stress-induced hyperglycemia was worse in the TPN group, as serum glucose levels increased significantly over the first 5 days of hospitalization (p < .02), whereas those in the TEN group showed no significant change. An exacerbation of pancreatitis, occurring in one TEN patient when the nasojejunal tube was dislodged into the stomach, resolved after placement back in the jejunum. Three patients who became asymptomatic and normalized amylase on TEN flared upon advancing to diet by mouth. CONCLUSIONS TEN for acute pancreatitis is as safe and effective, but is significantly less costly than TPN. Compared with TPN, TEN may promote more rapid resolution of the toxicity and stress response to pancreatitis. TEN via jejunal feeding should be used preferentially in this disease setting.