When to initiate oral feedings in acute pancreatitis due to gallstones (cholelithiasis)?

From the Guidelines

Early oral feeding is recommended for patients with mild gallstone pancreatitis, ideally within 24 hours of admission if pain is controlled, nausea has subsided, and inflammatory markers are improving. For moderate to severe cases, nutrition should be initiated within 24-72 hours, preferably via the enteral route if the patient cannot tolerate oral intake 1. Enteral feeding is preferred over parenteral nutrition as it maintains gut barrier function, reduces bacterial translocation, and decreases infectious complications. The feeding tube should be placed beyond the ligament of Treitz (nasojejunal) in severe cases to minimize pancreatic stimulation.

Key Considerations

• If oral feeding is possible, a low-fat diet is appropriate initially 1.
• Nutritional support should provide 25-35 kcal/kg/day with adequate protein (1.2-1.5 g/kg/day) 1.
• Early feeding helps preserve intestinal integrity, reduces infection risk, shortens hospital stays, and supports the resolution of the inflammatory process.
• Delaying nutrition beyond 72 hours is associated with increased complications and mortality, particularly in severe pancreatitis 1.

Enteral vs Parenteral Nutrition

• Enteral nutrition (EN) is preferred over parenteral nutrition (PN) in patients with acute pancreatitis (AP) as it reduces complication rates, multi-organ failure, and mortality 1.
• EN should be started early, within 24-72 hours of admission, in case of intolerance to oral feeding 1.

Timing of Initiation

• Several meta-analyses have investigated the clinical effects and tolerance of early EN in patients with AP, revealing that early EN is feasible, safe, and well-tolerated, and associated with substantial clinical benefits regarding mortality, organ failure, and infectious complications 1.

From the Research

Timing of Feedings in Gallstone Pancreatitis

• The optimal timing for feedings in gallstone pancreatitis is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
• However, it is mentioned that fluid therapy and enteral nutrition are vital components in the management of acute pancreatitis 4.
• The American College of Gastroenterology Guidelines suggest that nutrition plays an important role in treating patients with acute pancreatitis, and the safety of early refeeding and importance in preventing complications from acute pancreatitis are addressed 6.
• There is no specific guidance on when to start feedings in gallstone pancreatitis, but it is implied that early nutrition is important in the management of the disease 4, 6.

General Management of Gallstone Pancreatitis

• Gallstone pancreatitis is a common cause of acute pancreatitis, and its management depends on the severity of the disease 2, 3, 4, 5.
• Patients with mild disease can undergo same-admission cholecystectomy, while those with severe disease may require delayed cholecystectomy 5.
• Endoscopic retrograde cholangiopancreatography (ERCP) is only useful for patients with suspected cholangitis or biliary obstruction 5.
• The management of gallstone pancreatitis requires a multidisciplinary approach, including close clinical observation and coordination between surgeons, radiologists, gastroenterologists, and intensivists 2, 5.