When should patients with acute pancreatitis be kept NPO (nothing by mouth)?

Timing of Oral Feeding in Acute Pancreatitis

Patients with acute pancreatitis should be started on early oral feeding within 24 hours of admission rather than being kept NPO (nil per os). 1

Evidence-Based Approach to Nutrition in Acute Pancreatitis

Initial Management

• Traditional practice of keeping patients NPO to "rest the pancreas" is no longer supported by evidence
• Early oral feeding (within 24 hours) is associated with:
  • 2.5-fold lower risk of interventions for pancreatic necrosis 1
  • Trends toward lower rates of infected peripancreatic necrosis 1
  • Reduced risk of multiple organ failure 1
  • Protection of gut mucosal barrier and reduced bacterial translocation 1, 2

Practical Implementation

1. First 24 hours: Begin oral feeding as tolerated rather than keeping NPO 1

   • Various diets have been successful including low-fat, normal fat, soft or solid consistency
   • Clear liquid diet is not specifically required to start 1

2. If oral feeding is not tolerated (due to pain, vomiting, or ileus):

   • Delay feeding beyond 24 hours if necessary 1
   • Consider enteral nutrition via tube feeding 1, 2
   • Either nasogastric or nasoenteral (nasoduodenal/nasojejunal) routes are acceptable 1

3. If enteral nutrition is required:

   • Strongly prefer enteral over parenteral nutrition 1, 2
   • Enteral nutrition reduces:
     • Risk of infected peripancreatic necrosis (OR 0.28) 1
     • Single organ failure (OR 0.25) 1
     • Multiple organ failure (OR 0.41) 1

Nutritional Considerations

• When refeeding (typically 3-7 days), diet should consist of:

  • Rich in carbohydrates
  • Moderate protein (1.2-1.5 g/kg/day)
  • Moderate fat (up to 2 g/kg/day)
  • Total energy intake of 25-35 kcal/kg/day 2

• For tube feeding, consider:

  • Peptide-based formulas (safely recommended) 2
  • Standard formulas if tolerated 2
  • Gradually withdraw tube feeding as oral intake improves 2

Common Pitfalls to Avoid

1. Unnecessary NPO orders: Routine or empiric NPO status should generally be avoided in favor of feeding trials 1

2. Overreliance on parenteral nutrition: Parenteral nutrition is associated with higher rates of complications compared to enteral nutrition 1, 2

3. Waiting too long to initiate feeding: Delaying nutrition beyond 24 hours is associated with worse outcomes 1, 2

4. Assuming all patients need clear liquids first: Various diets have been successful; clear liquids are not specifically required 1

5. Ignoring feeding intolerance: Some patients may require delayed feeding or tube feeding if they experience pain, vomiting, or ileus 1

The evidence strongly supports early oral feeding in acute pancreatitis, challenging the traditional practice of keeping patients NPO. This approach has been shown to improve outcomes including reduced risk of interventions for necrosis and trends toward lower rates of complications.