doi:10.1002/jgh3.12033
BR IE F RE PORT
Non-liquid as initial meal in mild acute pancreatitis: Renewed meta-analysis Yin Wang
and Tai-Yun Zhao
Department of Gastroenterology, The People’s Hospital of Bozhou, Bozhou, China
Key words clear-liquid diets, mild acute pancreatitis, non-liquid diets.
Correspondence Yin Wang, Department of Gastroenterology, The People’s Hospital of Bozhou, Duzhong Road, Bozhou 236800, Anhui Province, China. Email:
[email protected] Declaration of conflict of interest: None. Author contribution: The research was designed by Tai-Yun Zhao and performed by Yin Wang; the data were extracted by Tai-Yun Zhao and analyzed by Yin Wang; Tai-Yun Zhao and Yin Wang wrote the paper. Financial support: None.
We have reviewed the article titled, “Three initial diets for management of mild acute pancreatitis: a meta-analysis”,1 which strongly attracted our interest. This meta-analysis indicated that the non-liquid, soft, solid diets did not increase pain recurrence after re-feeding when compared with the clear-liquid diet. The non-liquid diets could reduce the length of hospitalization. While these results differ greatly from the common clinical practice, the time and method of resumption of feeding after mild acute pancreatitis (MAP) is based upon resolution of the signs and symptoms of acute pancreatitis, and patients are typically placed on a clear liquid diet. If the diet is tolerated (such as no recurrence of pain or vomiting), the diets of patients are extended to full liquids or low-fat solids. The previous meta-analysis included three papers,2–4 considering unclear subgroups, significant heterogeneity, a small sample size, and a confusing conclusion. We performed a renewed meta-analysis to take the non-liquid as the initial meal in MAP included in the latest paper.5
We identified all randomized controlled trials (RCTs) concerning the diets for managing MAP by searching the PubMed/ Medicine, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) databases up to February 2017; data were analyzed using Stata12.0 (StataCorp, College Station, TX, USA) and pooled for summary estimates. We expressed results of dichotomous outcomes as relative risk (RR) and mean difference (MD) with 95% CIs for continuous outcomes. Heterogeneity assessment was performed using the I2 index and chi-square test. We used a randomized-effect model for calculations of summary estimates. The primary outcome was the post-re-feeding length of hospitalization (PRLOH) and the secondary outcomes were recurrence of pain and total length of hospitalization (TLOH). Four RCTs and 492 patients were included in this metaanalysis. All papers had a Jadad scoring of 5 (Table 1), and nonliquid diets significantly decreased the PRLOH and TLOH when compared to liquid diets (−0.76 [−1.33, −0.19], I2 = 87.2%,
Table 1 Results on length of hospitalization, TLOH, and recurrence of pain Moraes et al.2
Type
Number PRLOH (days) TLOH (days) Recurrence of pain (n)
Jacobson et al.3
Sathiaraj et al.4
Rajkumar et al.5
Solid
Soft
Liquid
Solid
Liquid
Soft
Liquid
Soft
Liquid
70 5.8 1.1 7.5 3.5 15
70 7.4 1.5 8.2 2.4 12
70 7.3 1.6 8.2 2.6 14
55 1.71 2.04 4 (3–6) 6
66 1.68 1.85 4 (3–5) 4
49 4.18 2.86 5.92 2.978 4
52 6.75 3.37 8.71 4.995 3
30 4.23 2.08 1.96 1.63 6
30 6.91 2.43 4.10 1.64 6
PRLOH, post-re-feeding length of hospitalization; TLOH, total length of hospitalization. JGH Open: An open access journal of gastroenterology and hepatology (2018) 1–3
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© 2018 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Diets in the mild acute pancreatitis
Figure 1
Y Wang and T-Y Zhao
Outcomes in non-liquid diet versus liquid diet with length of hospitalization and total length of hospitalization.
P < 0.05; −0.70 [−1.27, −0.13], I2 = 81.9%, P < 0.05) (Fig. 1). But the subgroup showed no difference in PRLOH and TLOH for soft diets compared to liquid diets (−0.12 [−1.38, 0.13], I2 = 89.6%, P < 0.05; −0.63 [−1.35,−0.08], I2 = 88.5%, P < 0.05). There was no difference in the recurrence of pain after re-feeding, when comparing the non-liquid diets with clear-liquid diets (RR = 1.09 [0.70, 1.70] I2 = 0, P = 0.804]. The results of the renewed meta-analysis were similar to the former, as this result subverts our traditional diets.6–8 Some people believe that eating too early can increase the burden on the pancreas and worsen the symptoms.9,10 Because the sample size was larger than before, these data are also useful. Before the nonliquid diets can be recommended as the preferred re-feeding treatment option for MAP, some aspects need to be considered. First, the types and dosages of no-liquid diets used in trials have been varied and it is currently unclear which specific species, strain, dose, and regimens are the most efficient, meanwhile these different diets may be the major causes of significant heterogeneity. Second, once treatments with no-liquid diets are initiated, the duration and end point of treatment remain unclear. Third, the pathophysiological mechanisms of the aforementioned results are unclear. Future research should focus on these aspects to better elucidate how diets best fit into the treatment algorithm for MAP.
Acknowledgment
2
JGH Open: An open access journal of gastroenterology and hepatology (2018) 1–3
We thank Wen-Bo Meng for the meta-analysis.
References 1 Meng WB, Li X, Li YM, Zhou WC, Zhu XL. Three initial diets for management of mild acute pancreatitis: a meta-analysis. World J. Gastroenterol. 2011; 17: 4235–41. https://doi.org/10.3748/wjg.v17. i37.4235. 2 Moraes JM, Felga GE, Chebli LA et al. A full solid diet as the initial meal in mild acute pancreatitis is safe and result in a shorter length of hospitalization: results from a prospective, randomized, controlled, double-blind clinical trial. J. Clin. Gastroenterol. 2010; 44: 517–22. https://doi.org/10.1097/MCG.0b013e3181c986b3. 3 Jacobson BC, Vander Vliet MB, Hughes MD, Maurer R, McManus K, Banks PA. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis. Clin. Gastroenterol. Hepatol. 2007; 5: 946–951; quiz 886. https://doi.org/10.1016/j.cgh.2007.04.012. 4 Sathiaraj E, Murthy S, Mansard MJ, Rao GV, Mahukar S, Reddy DN. Clinical trial: oral feeding with a soft diet compared with clear liquid diet as initial meal in mild acute pancreatitis. Aliment. Pharmacol. Ther. 2008; 28: 777–81. https://doi.org/10.1111/j.13652036.2008.03794.x.
© 2018 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.
Y Wang and T-Y Zhao
Diets in the mild acute pancreatitis
5 Rajkumar N, Karthikeyan VS, Ali SM, Sistla SC, Kate V. Clear liquid diet vs soft diet as the initial meal in patients with mild acute pancreatitis: a randomized interventional trial. Nutr. Clin. Pract. 2013; 28: 365–70. https://doi.org/10.1177/0884533612466112. 6 Chebli JM, Gaburri PD, De Souza AF et al. Oral refeeding in patients with mild acute pancreatitis: prevalence and risk factors of relapsing abdominal pain. J. Gastroenterol. Hepatol. 2005; 20: 1385–9. 7 O’Keefe SJ, Lee RB, Li J, Stevens S, Abou-Assi S, Zhou W. Trypsin secretion and turnover in patients with acute pancreatitis. Am. J. Physiol. Gastrointest. Liver Physiol. 2005; 289: G181–7.
8 Qader SS, Ekelund M, Andersson R, Obermuller S, Salehi A. Acute pancreatitis, expression of inducible nitric oxide synthase and defective insulin secretion. Cell Tissue Res. 2003; 313: 271–9. 9 Zhou ZG, Chen YD, Sun W, Chen Z. Pancreatic microcirculatory impairment in experimental acute pancreatitis in rats. World J. Gastroenterol. 2002; 8: 933–6. 10 Zhou Z, Zhang Z, Yan L et al. The feature of pancreatic microcirculatory impairment in caerulein induced acute pancreatitis. Zhonghua Waike Zazhi. 1999; 37: 138–40, 149.
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© 2018 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.
