When can feeding be resumed in a patient with stress-induced gastritis?

When to Resume Feeding in Stress-Induced Gastritis

Feeding should be initiated within 24-48 hours once active bleeding has stopped and hemodynamic stability is achieved, as early enteral nutrition protects against further stress ulceration and improves outcomes in critically ill patients. 1

Initial Assessment and Stabilization

Before resuming feeding, ensure the following conditions are met:

• Active bleeding has ceased with no signs of rebleeding (no hematemesis, melena, or hemodynamic instability) 1
• Hemodynamic stability is achieved (adequate blood pressure, heart rate, and tissue perfusion) 1
• No evidence of ongoing gastric distension or mechanical obstruction 1

The main concern with delaying feeding is the fear of rebleeding that would obscure endoscopic visualization, but evidence shows prolonged fasting beyond 48-72 hours is unnecessary and potentially harmful due to increased risk of recurrent stress ulceration 1

Timing Algorithm for Feed Resumption

For Active Upper GI Bleeding:

1. Delay feeding during active hemorrhage 1
2. Initiate feeding within 24-48 hours after bleeding cessation and hemodynamic stabilization 1
3. Do not extend NPO status beyond 48-72 hours unless high rebleeding risk persists 1

For Hemodynamically Stable Patients:

• Begin enteral nutrition within 24-48 hours of ICU admission, even in patients at risk for stress gastropathy 1, 2
• Early feeding (within 24-48 hours) reduces infectious complications by 50% compared to delayed nutrition 2

Feeding Protocol

Start conservatively and advance gradually:

• Initial rate: Begin at 10-20 mL/hour via nasogastric or nasojejunal tube 2, 3
• Energy targets during acute phase: Limit to 20-25 kcal/kg/day for the first 72-96 hours to avoid overfeeding 1
• Advancement: Increase gradually over 5-7 days to reach full caloric goals 2
• Protein provision: Target 1.3-2.0 g/kg/day even during hypocaloric feeding 2

Route Selection

Gastric feeding is the preferred initial route:

• No significant difference in efficacy between gastric and jejunal feeding in most critically ill patients 1
• Switch to jejunal feeding only if gastric intolerance develops (persistent high gastric residual volumes >500 mL/6 hours despite prokinetics) 1
• Fine-bore nasogastric tubes do not cause variceal bleeding and are safe to use 1

Formula Selection

• Use standard whole protein commercial formulas for most patients 1, 2
• Peptide-based formulas show no clinical advantage and are more expensive 1
• Commercial formulas are superior to kitchen-made feeds due to consistent nutritional content and reduced contamination risk 2

Management of Feeding Intolerance

If gastric residual volumes are elevated:

1. First-line: Administer intravenous erythromycin 100-250 mg three times daily for 24-48 hours 1
2. Alternative: Use metoclopramide 10 mg 2-3 times daily or combination therapy 1
3. If persistent intolerance: Consider post-pyloric (jejunal) feeding 1, 3
4. Do not stop feeding for gastric residuals <500 mL/6 hours 1

Critical Pitfalls to Avoid

Do not prolong fasting unnecessarily: Enteral nutrition itself provides protection against stress ulceration and maintains gut integrity 1, 4

Avoid overfeeding in the acute phase: Providing >25 kcal/kg/day during the first 72-96 hours is associated with worse outcomes 1

Do not routinely use parenteral nutrition: Enteral feeding is superior and should be the first-line approach unless contraindicated 1, 2

Monitor for refeeding syndrome: In malnourished patients, start with lower calories (5-15 kcal/kg/day) and supplement thiamine before carbohydrate reintroduction 5

Stress Ulcer Prophylaxis Considerations

• Continue acid suppression (proton pump inhibitors or H2-receptor antagonists) in high-risk patients even after feeding resumes 1
• Risk factors warranting prophylaxis: Mechanical ventilation >48 hours, coagulopathy, traumatic brain injury, burns >35% body surface area 1, 6
• Consider discontinuing prophylaxis once patients tolerate full enteral nutrition goals, as enteral feeding itself provides gastroprotection 4
• One study showed 0.5% incidence of clinically significant bleeding in mechanically ventilated trauma patients receiving enteral nutrition without pharmacologic prophylaxis 4

Special Populations

Septic patients: Early progressive enteral nutrition after hemodynamic stabilization is recommended, with energy targets reached progressively over several days 1

Patients with intra-abdominal hypertension: Initiate feeding but monitor intra-abdominal pressure closely and temporarily reduce or discontinue if pressure increases 1

Traumatic brain injury (Cushing's ulcers): These patients remain at higher risk; maintain acid suppression and advance feeding cautiously 7