Consider Enteral Feedings in Pancreatitis and Enterocutaneous Fistulae
Christopher J. Sonnenday MD, MHS
Classic surgical teaching has historically dictated that minimization of enteric flow by withholding enteral feeds is essential to the management of patients with disruption of the normal continuity of the gastrointestinal tract (i.e., enterocutaneous fistula). The use of parenteral nutrition thus became fundamental to the treatment of enterocutaneous fistulae, as well as to the management of severe acute pancreatitis, where enteral feeds that stimulate pancreatic exocrine were believed to contribute to exacerbation of the complex course of that disease. However, with a preponderance of evidence in favor of the benefits of enteral nutrition in critical illness, clinicians have sought ways to provide enteral nutrition even in these disease states where it was previously thought to be deleterious.
What to Do
In the case of proximal enterocutaneous fistulae (e.g., esophageal, gastric, duodenal, proximal jejunum), distal jejunal feeds are always preferable to parenteral nutrition and should be the mainstay of therapy. The nutritional requirements for patients with enterocutaneous fistula may be excessive because of the significant gastrointestinal (GI) protein losses and catabolism associated with these conditions. It may be prudent to maintain the patient on parenteral nutrition until enteral feeds are advanced and optimized. Optimal caloric support is frequently not possible for 4 to 5 days following initiation of enteral feeds, and parenteral nutrition can bridge that gap in critically ill patients. In the case of a more proximal fistula, it is often possible to cannulate the distal limb of the fistula itself to feed the distal small bowel. Such procedures often require expert interventional radiologists and should not be performed without the guidance of an experienced GI surgeon.
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