What is the recommended diet for a patient with acute pancreatitis?

Dietary Management in Acute Pancreatitis

Start a low-fat, soft oral diet as soon as the patient is clinically ready—typically within 24 hours of admission—regardless of serum lipase levels, as early feeding reduces complications and hospital stay without causing harm. 1, 2

Timing of Oral Feeding

• Initiate oral feeding within 24 hours of admission rather than keeping the patient nil per os (NPO), as this approach significantly reduces hospital length of stay and complications 1, 2
• Begin feeding as soon as the patient feels hungry and has no nausea or vomiting, without waiting for pancreatic enzyme levels to normalize 1, 2
• In mild acute pancreatitis, immediate oral feeding is safe and may accelerate recovery compared to traditional fasting (4 vs. 6 days hospital stay) 3

Specific Dietary Composition

Macronutrient Distribution:

• Carbohydrates: Diet should be rich in carbohydrates as the primary energy source 1, 4
• Protein: Moderate protein content of 1.2-1.5 g/kg body weight/day for severe cases 1, 4
• Fat: Moderate fat content is acceptable; severe fat restriction is unnecessary unless steatorrhea develops 1, 4
• Total energy: Target 25-35 kcal/kg body weight/day in severe cases 1, 4

Feeding Pattern:

• Provide small meals 5-6 times per day to improve tolerance 1
• Gradually increase calories with careful supplementation of fat over 3-6 days 1

When Oral Feeding Is Not Tolerated

If the patient cannot tolerate oral intake, enteral nutrition is strongly preferred over parenteral nutrition because it reduces mortality, organ failure, and infectious complications including infected pancreatic necrosis 5, 2

Route Selection:

• Both gastric (nasogastric) and jejunal (nasojejunal) feeding routes are safe and effective 5, 6
• Post-pyloric jejunal feeding can be initiated within 24-48 hours and causes minimal pancreatic stimulation 5, 7
• Enteral nutrition maintains gut mucosal barrier integrity and prevents bacterial translocation that can seed pancreatic necrosis 5

Parenteral Nutrition:

• Total parenteral nutrition (TPN) should be avoided as it increases infectious complications compared to enteral feeding 5
• Partial parenteral nutrition may be considered only to supplement enteral feeding if caloric requirements cannot be met enterally 5

Special Considerations for Severe Pancreatitis

Intra-abdominal Pressure Monitoring:

• In patients with intra-abdominal pressure (IAP) >15 mmHg, initiate enteral nutrition via nasojejunal route starting at 20 mL/h, increasing according to tolerance 5
• Temporarily reduce or discontinue enteral nutrition if IAP values increase further 5
• If IAP >20 mmHg or abdominal compartment syndrome develops, stop enteral nutrition and initiate parenteral nutrition 5

Common Pitfalls to Avoid

• Do not delay oral feeding unnecessarily—the outdated practice of prolonged "bowel rest" increases morbidity and mortality 1, 6, 8
• Do not wait for pancreatic enzymes to normalize before initiating feeding; enzyme levels do not predict feeding tolerance 1, 2
• Do not excessively restrict fat—moderate fat intake is acceptable and provides necessary calories 1
• Do not use parenteral nutrition as first-line therapy when enteral feeding is possible 5, 2

Monitoring During Refeeding

• Approximately 21% of patients may experience pain relapse during oral refeeding, most commonly on days 1-2 1
• Risk factors for pain relapse include serum lipase >3 times upper limit of normal and higher CT-Balthazar scores 1
• Pain relapse does not necessarily indicate feeding intolerance and should be managed symptomatically while continuing nutritional support 1