Feeding the patients with upper gastrointestinal bleeding

Early nutrition is safe and does not increase complications after upper gastrointestinal bleeding-a systematic review and meta-analysis of randomized controlled trials

Despite a lack of evidence, patients are often not fed for 48-96 h after upper gastrointestinal bleeding (UGIB); however, many trials have demonstrated the benefits of early nutrition (EN). We conducted a meta-analysis of randomized controlled trials (RTCs) to evaluate the outcomes of EN compared to delayed nutrition (DN) after UGIB. The protocol was registered on PROSPERO (CRD42022372306). PubMed, Embase, CENTRAL, Scopus, and Web of Science were searched on the 27th of April 2024 to identify eligible RCTs. The primary outcomes were early (within 7 days) and late (within 30-42 days) mortality and rebleeding. Pooled risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) were calculated using a random-effects model. A total of 10 trials with 1051 patients were included in the analysis. Early mortality was not significantly different between the two groups (RR 1.20, CI 0.85-1.71, I2 = 0%), whereas late mortality was reduced to a clinically relevant extent in the EN group (RR 0.61, CI 0.35-1.06, I2 = 0%). When comparing the two groups, we found no significant difference in terms of early and late rebleeding (RR 1.04, CI 0.66-1.63, I2 = 0% and RR 1.16, CI 0.63-2.13, I2 = 0%, respectively). Our analysis also showed that the length of hospital stay was reduced in the EN group compared to the DN group (MD -1.22 days, CI: -2.43 to -0.01, I2 = 94%). In conclusion, compared with DN, EN (within 24 h) appears to be a safe intervention and could reduce the length of hospital stay without increasing the risk of complications after UGIB.

Early feeding reduces length of hospital stay in patients with acute lower gastrointestinal bleeding: A large multicentre cohort study

AIM

No studies have compared the clinical outcomes of early and delayed feeding in patients with acute lower gastrointestinal bleeding (ALGIB). This study aimed to evaluate the benefits and risks of early feeding in a nationwide cohort of patients with ALGIB in whom haemostasis was achieved.

METHODS

We reviewed data for 5910 patients with ALGIB in whom haemostasis was achieved and feeding was resumed within 3 days after colonoscopy at 49 hospitals across Japan (CODE BLUE-J Study). Patients were divided into an early feeding group (≤1 day, n = 3324) and a delayed feeding group (2-3 days, n = 2586). Clinical outcomes were compared between the groups by propensity matching analysis of 1508 pairs.

RESULTS

There was no significant difference between the early and delayed feeding groups in the rebleeding rate within 7 days after colonoscopy (9.4% vs. 8.0%; p = 0.196) or in the rebleeding rate within 30 days (11.4% vs. 11.5%; p = 0.909). There was also no significant between-group difference in the need for interventional radiology or surgery or in mortality. However, the median length of hospital stay after colonoscopy was significantly shorter in the early feeding group (5 vs. 7 days; p < 0.001). These results were unchanged when subgroups of presumptive and definitive colonic diverticular bleeding were compared.

CONCLUSION

The findings of this nationwide study suggest that early feeding after haemostasis can shorten the hospital stay in patients with ALGIB without increasing the risk of rebleeding.

Nasoenteric Tube Placement in Patients with Esophageal Varices: A Review of the Current Evidence and Society Guidelines

Esophageal varices are a common complication of portal hypertension and variceal bleeding can be associated with significant morbidity and mortality. Hospitalized patients with cirrhosis might require nasoenteric tube (NET) placement, commonly for nutritional support and/or medication administration. However, the fear of causing massive variceal bleeding among clinicians might lead to hesitancy or complete avoidance of NET placement in patients who either have a known history of esophageal varices or are at risk to have them. Several experts and society guidelines addressed this concern with variable recommendations and degrees of evidence. In this article, we present an extensive review of the literature and latest society guidelines that address the safety of NET placement in patients with esophageal varices.

Intensive care management of acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.

Early versus delayed feeding after therapeutic endoscopic procedures: Meta-analysis of randomized controlled trials

INTRODUCTION

Early feeding was previously considered to increase the risk of postprocedural bleeding. However, many trials have demonstrated the benefits of early feeding after therapeutic endoscopic procedures. We conducted a meta-analysis of randomized controlled trials to evaluate the safety and outcomes between early feeding and delayed feeding after therapeutic endoscopic procedures.

METHODS

Medline (PubMed), Embase, Google Scholar, the Cochrane Library, and clinicaltrials.gov were searched to identify randomized controlled trials that met our inclusion criteria. The pooled data for the mortality rate, postprocedural bleeding rate, and length of hospital stay were analyzed.

RESULTS

A total of seven trials consisting of 717 patients were reviewed. These seven trials examined various therapeutic endoscopic procedures. Three trials included patients undergoing endoscopic hemostasis for upper gastrointestinal bleeding, two included patients undergoing esophageal variceal ligation, and two included patients with gastric neoplasm treated with endoscopic submucosal dissection. Although no significant differences were observed in the postprocedural bleeding rate or the mortality rate between patients who received early feeding and those who received delayed feeding, early feeding resulted in shorter hospital stays (weighted mean difference -1.04, 95% confidence interval -1.45 to 0.63).

CONCLUSION

Early feeding appears to be a safe management method for patients undergoing therapeutic endoscopic procedures. Therefore, we recommend early feeding for these patients.

When Can we Feed after a Gastrointestinal Bleed?

PURPOSE OF REVIEW

Gastrointestinal (GI) bleeding can carry minimal or significant risk for recurrent hemorrhage. Timing of feeding after GI bleeding remains an area of debate, and here we review the evidence supporting recommendations.

RECENT FINDINGS

Improved understanding of the pathophysiology of GI bleeding and the evolution of treatment strategies has significantly altered the management of GI bleeding and the associated propensity for rebleeding. Early feeding following peptic ulcer bleeding remains ill-advised for high risk lesions while early initiation of liquid diets following cessation of esophageal variceal bleeding is appropriate and shortens hospital stays. Time to feeding following GI bleeding is inherently based on the disease etiology, severity, and risk of recurrent hemorrhage. With evolving standards of care, rates of rebleeding following endoscopic hemostasis are decreasing. Some evidence exists for early feeding however, larger multi-center trials are needed to help optimize timing of feeding in higher risk lesions.

Safety and Feasibility of Early Oral Nutrition after Endoscopic Treatment for Patients with Liver Cirrhosis: A Historical-prospective, Comparative-Effectiveness Study

BACKGROUND

This study aimed to evaluate the safety and efficacy of early oral nutrition (EON) after endoscopic treatment compared with parenteral nutrition (PN) for patients with gastroesophageal variceal bleeding varices as cirrhotic complications.

METHODS

This historical-prospective study enrolled patients from Qilu Hospital of Shandong University in China with gastroesophageal varices as cirrhotic complications and undergoing endoscopic therapy. A total of 197 patients who fasted for 4 h after treatment were prospectively enrolled as the oral nutrition group whereas those who fasted for more than 48 h were retrospectively matched in a ratio of 1:1 as the parenteral nutrition group. The primary endpoint was variceal re-bleeding, whereas the secondary endpoints were mortality and adverse events during the 42-day follow-up. Hospitalisation duration and expenses, levels of inflammatory factors, defecation time, and the satisfaction of patients were evaluated.

RESULTS

During the 42-day follow-up, no significant difference was observed in the rate of variceal re-bleeding (P = 0.586) and morality (P = 1.000) between the oral nutrition group and the parenteral nutrition group. However, the average days of hospitalisation (P < 0.001) and expenses (P < 0.001) were significantly decreased in the oral nutrition group. Furthermore, C-reactive protein lever (P = 0.002) and defecation time (P < 0.001) were lower, whereas the satisfaction rate was higher (P < 0.001) in the oral nutrition group than those in the parenteral nutrition group. Linear regression analysis showed that tissue adhesive dosage was related to diet time (P = 0.038, 95% CI: 0,135-4.516).

CONCLUSIONS

EON was proven to be safe, feasible, and hence, recommended after endoscopic treatment in patients with cirrhosis. This article is protected by copyright. All rights reserved.

Nutrition in Chronic Liver Disease: Consensus Statement of the Indian National Association for Study of the Liver

Malnutrition and sarcopenia are common in patients with chronic liver disease and are associated with increased risk of decompensation, infections, wait-list mortality and poorer outcomes after liver transplantation. Assessment of nutritional status and management of malnutrition are therefore essential to improve outcomes in patients with chronic liver disease. This consensus statement of the Indian National Association for Study of the Liver provides a comprehensive review of nutrition in chronic liver disease and gives recommendations for nutritional screening and treatment in specific clinical scenarios of malnutrition in cirrhosis in adults as well as children with chronic liver disease and metabolic disorders.

Nutrition Risk Assessment Using the Modified NUTRIC Score in Cirrhotic Patients with Acute Gastroesophageal Variceal Bleeding: Prevalence of High Nutrition Risk and its Independent Prognostic Value

Malnutrition is associated with adverse outcomes in patients with liver cirrhosis. Relevant data about nutrition risk in critically ill cirrhotic patients are lacking. The modified Nutrition Risk in Critically Ill (mNUTRIC) score is a novel nutrition risk assessment tool specific for intensive care unit (ICU) patients. This retrospective study was conducted to evaluate the prevalence and prognostic significance of nutrition risk in cirrhotic patients with acute gastroesophageal variceal bleeding (GEVB) using mNUTRIC scores computed on admission to the intensive care unit. The major outcome was 6-week mortality. One-hundred-and-thirty-one admissions in 120 patients were analyzed. Thirty-eight percent of cirrhotic patients with acute GEVB were categorized as being at high nutrition risk (a mNUTRIC score of ≥5). There was a significantly progressive increase in mortality associated with the mNUTRIC score (χ2 for trend, p < 0.001). By using the area under a receiver operating characteristic (ROC) curve, the mNUTRIC demonstrated good discriminative power to predict 6-week mortality (AUROC 0.859). In multivariate analysis, the mNUTRIC score was an independent factor associated with 6-week mortality. In conclusion, the mNUTRIC score can serve as a tool to assess nutrition risk in cirrhotic patients with acute GEVB.

Early enteral nutrition versus delayed enteral nutrition in patients with gastrointestinal bleeding: A PRISMA-compliant meta-analysis

BACKGROUND

Controversy persists about whether early enteral nutrition administration is related to worse prognosis than delayed enteral nutrition for patients with gastrointestinal bleeding.

OBJECTIVES

To systematically evaluate the effect of early enteral nutrition on the patient with gastrointestinal bleeding through the meta-analysis.

METHODS

Such electronic databases including PubMed, EMBASE, Cochrane Library, CNKI, and CBM were searched from 1985 to March 2018. Randomized controlled trials that compared early enteral nutrition versus delayed enteral nutrition in patients with gastrointestinal bleeding were considered eligible. Data extraction and the methodological quality assessment of the included trials were carried out according to the Cochrane Handbook. We calculated the pooled risk ratio, weighted mean difference, and the corresponding 95% confidential interval using RevMan5.3.

RESULT

A total of 5 trials involving 313 patients were included. Compared with delayed enteral nutrition, there was a tendency for a decreased rebleeding rate in the early enteral nutrition group, but the trend was not statistically significant (risk ratio = 0.75, 95% confidential interval: 0.34-1.64, I = 0). As for mortality within 30 days, no significant difference was found between the 2 groups (risk ratio = 0.74, 95% confidential interval: 0.23-2.39, I = 0). In addition, the pooled analysis showed that early enteral nutrition was related to reduced hospitalized days (weighted mean difference = -1.69, 95% confidential interval: -2.15 to -1.23; I = 27%) CONCLUSION:: For patients with gastrointestinal bleeding, early enteral nutrition within 24 hours does not result in the significantly higher risk of rebleeding and mortality compared with delayed enteral nutrition, but decrease hospitalized days. Patients who are at low risk for rebleeding can be fed early and discharged early. However, larger, high-quality randomized controlled trials are needed to verify these findings, and when the gastrointestinal bleeding patient start enteral nutrition is worth studying.

Banana may be forbidden after endoscopic variceal ligation: a case report

Acute variceal hemorrhage (AVH) is a devastating complication of liver cirrhosis. Endoscopic variceal ligation (EVL) is a useful endoscopic treatment for AVH with few complications. However, the issue regarding management of early re-bleeding after EVL still needs to be concerned. Furthermore, the dietary principle after EVL is unclear. There is no consensus regarding what food should be eaten after EVL. In this paper, we reported a patient who ate a banana after an EVL and then developed early re-bleeding episodes.

EASL Clinical Practice Guidelines on nutrition in chronic liver disease

A frequent complication in liver cirrhosis is malnutrition, which is associated with the progression of liver failure, and with a higher rate of complications including infections, hepatic encephalopathy and ascites. In recent years, the rising prevalence of obesity has led to an increase in the number of cirrhosis cases related to non-alcoholic steatohepatitis. Malnutrition, obesity and sarcopenic obesity may worsen the prognosis of patients with liver cirrhosis and lower their survival. Nutritional monitoring and intervention is therefore crucial in chronic liver disease. These Clinical Practice Guidelines review the present knowledge in the field of nutrition in chronic liver disease and promote further research on this topic. Screening, assessment and principles of nutritional management are examined, with recommendations provided in specific settings such as hepatic encephalopathy, cirrhotic patients with bone disease, patients undergoing liver surgery or transplantation and critically ill cirrhotic patients.

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

Purpose

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.

Methods

We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.

Results

We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.

Conclusions

We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-016-4665-0) contains supplementary material, which is available to authorized users.

Malnutrition and Nutritional Support in Alcoholic Liver Disease: a Review

Malnutrition is associated with alcoholic liver disease (ALD) and related complications such as hepatic encephalopathy and increased rate of infections. Avoidance of prolonged fasting and overly restrictive diets is important to avoid poor nutrition. Adequate intake of calories, protein, and micronutrients via frequent small meals and evening supplements and/or enteral and parenteral nutrition when indicated has been associated with reduced mortality and morbidity in patients with ALD. Modification of protein/fat sources and composition in addition to probiotic supplementation are promising interventions for decreased progression of ALD and its complications.

Fasting for haemostasis in children with gastrointestinal bleeding

BACKGROUND

Gastrointestinal bleeding refers to loss of blood from any site of the digestive tract. In paediatric clinical practice, it is usually a complaint of children attending the emergency department as a symptom of diseases such as ulcers, gastric or oesophageal varices, gastritis, Mallory-Weiss tears, anorectal fissures, allergic colitis, infectious colitis, intussusception, Henoch-Schonlein purpura, and Meckel's diverticulum; it also occurs with high incidence in critically ill children hospitalised in intensive care units and is caused by stress-induced gastropathy. No matter what the cause of gastrointestinal bleeding, fasting is believed to be necessary due to the fear that eating may affect haemostasis or aggravate bleeding.

OBJECTIVES

To assess the effects and safety of fasting for haemostasis in gastrointestinal bleeding in children.

SEARCH METHODS

We searched EBM Reviews - the Cochrane Central Register of Controlled Trials (CENTRAL) (May 2016), Ovid MEDLINE(R) (1946 to 3 May 2016), EMBASE (1980 to 2016 Week 18), Chinese Biomedical Database (CBM) (1978 to 3 May 2016), China National Knowledge Infrastructure (CNKI) (1979 to 3 May 2016), VIP Database (1989 to 4 May 2016) and Wanfang Data (1990 to 4 May 2016). We used no restrictions on language or study setting and limited searches in CNKI and Wanfang Data to the medical field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs in children with gastrointestinal bleeding that compared fasting with feeding.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the literature search results, and there were no disagreements.

MAIN RESULTS

We identified no RCTs or quasi-RCTs that compared the effects and safety of fasting with feeding for haemostasis in children with gastrointestinal bleeding. No study fulfilled the criteria for considering studies for our review.

AUTHORS' CONCLUSIONS

There is currently no information available from RCTs or quasi-RCTs to support or refute the use of fasting for haemostasis in children with gastrointestinal bleeding.

Frequency and Appropriateness of Fasting Orders in the Hospital

OBJECTIVE

To evaluate the frequency and appropriateness of nil per os (nothing by mouth) (NPO) orders and determine the number of meals missed because of these orders among hospitalized patients.

PATIENTS AND METHODS

We retrospectively analyzed inpatient NPO orders at an academic institution in the United States. The frequency and duration of NPO orders and the number of meals missed because of these orders were assessed for adult patients admitted to the hospital medicine services from January 1, 2013, through December 31, 2013, with a hospital stay of 2 or more and 30 or fewer days. Two blinded reviewers assessed if the order could be avoided or the period shortened for a random sample of NPO orders of 120 or more minutes' duration that were written for patients on the general medicine ward.

RESULTS

A total of 3641 NPO orders were identified. At least one NPO order was placed in 46.6% of the admissions (2211 of 4743). The median duration of NPO orders was 12.8 hours (interquartile range, 9.2-17.3 hours), resulting in 2 (interquartile range, 1-4) missed meals. Of 1130 NPO orders reviewed, 263 (23.3%; 95% CI, 20.9%-25.8%) were deemed avoidable (κ statistic, 0.68), and 482 (42.7%) were unavoidable but led to more missed meals than needed. Taken together, patients could have had 44.8% of the meals (1085 of 2424; 95% CI, 42.8%-46.7%) missed due to NPO orders.

CONCLUSION

Approximately half of the patients admitted to the hospital medicine services experienced a period of fasting. One in 4 NPO orders and nearly half of missed meals could have been avoided. Further study is warranted to assess the generalizability of our findings.

Nutrition assessment and support in children with end-stage liver disease

Malnutrition is a treatable complication in children with end-stage liver disease (ESLD). Biliary atresia and other cholestatic disorders are the most frequent cause of ESLD in children. No single variable provides adequate information about nutrition status, yet effective nutrition support is the one intervention known to improve pre- and posttransplant outcomes. A proactive approach consisting of screening anthropometry interpreted using appropriate growth references, recognition of clinical manifestations associated with micronutrient deficiency, and timely aggressive nutrition support is of a paramount importance to maximize anabolism and optimize outcomes. This article presents the principles of nutrition assessment, intervention, and monitoring in children with ESLD.