Duration of Fasting During Acute Variceal Bleeding in Chronic Liver Disease: Perceptions and Practices of Gastroenterologists

We read with great interest the guidelines on nutrition by the Indian National Association of Study of Liver in patients with chronic liver disease.1Puri P. Dhiman R.K. Taneja S. et al.Nutrition in chronic liver disease: consensus statement of the Indian National Association for Study of the Liver.J Clin Exp Hepatol. 2021; 11: 97-143https://doi.org/10.1016/j.jceh.2020.09.003Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar One of the important points highlighted in the current guideline is the role of early enteral nutrition in patients with acute variceal bleeding (AVB). This is in contrast to the European Association of Study of Liver disease recommendation of systemic fasting of 48–72 h during AVB.2Merli M. Berzigotti A. Zelber-Sagi S. et al.EASL clinical practice guidelines on nutrition in chronic liver disease.J Hepatol. 2019; 70: 172-193https://doi.org/10.1016/j.jhep.2018.06.024Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar The concerns for reservation of early feeding are increase in portal pressures after meals and exacerbation of hyper ammonia with protein containing diet. However, the same has not been demonstrated conclusively.3Hébuterne X. Vanbiervliet G. Feeding the patients with upper gastrointestinal bleeding.Curr Opin Clin Nutr Metab Care. 2011; 14: 197-201https://doi.org/10.1097/MCO.0b013e3283436dc5Crossref PubMed Scopus (19) Google Scholar, 4Lo G.H. Lin C.W. Hsu Y.C. A controlled trial of early versus delayed feeding following ligation in the control of acute esophageal variceal bleeding.J Chin Med Assoc. 2015; 78: 642-647https://doi.org/10.1016/j.jcma.2015.07.004Crossref PubMed Scopus (7) Google Scholar, 5Sidhu S.S. Goyal O. Singh S. Kishore H. Chhina R.S. Sidhu S.S. Early feeding after esophageal variceal band ligation in cirrhotics is safe: randomized controlled trial.Dig Endosc. 2019; 31: 646-652https://doi.org/10.1111/den.13423Crossref PubMed Scopus (2) Google Scholar Patients hospitalized with AVB are often malnourished and are usually fasting 6–12 h before presentation, and implementation of an additional 48 h of fasting can exacerbate accelerated starvation in them. Importantly, the practices and perceptions of gastroenterologists regarding timing of initiation of enteral feeding in the real-world scenario are not known. We therefore conducted an online survey consisting of 16 questions evaluating these practices and perceptions of physicians managing AVB around the world. The questionnaire was sent via social media and emails to faculties and trainees. All the responses were stored in Google Forms (Google Pvt limited) and analyzed using SPSS version-26 (University of Stanford). Sixteen hundred practitioners were approached during the period of 7 August 2020 to 1 November 2020. Of these, 252 physicians responded. Of these responders, 69.3% were practicing as a faculty and 30.7% were trainees in the field of gastroenterology and hepatology. Most of them were practicing in the Indian subcontinent (71.4%), while 38.6% belonged to various other countries such as Asia, Africa, and the America. Most physicians (75%) were seeing up to 10 cases of AVB at their center per week, while remaining physicians were seeing more than this number (Figure 1a). The recommendation of systemic fasting of 48 h after variceal bleeding was not followed by 99% of responders in their practice (Figure 1b). Forty-one percent of these responders preferred to restart oral nutrition as early as 6 h after endoscopic therapy. Early initiation (within 12 h) of oral feeding was perceived as beneficial by 48.4% of the responders, whereas 12.7% believed it to be harmful in these patients. Approximately, 10.7% responders believed it to have no impact on management and remaining 28.2% were not sure about their response (Figure 1d). Many respondents believed in multiple effects of early initiation. Seventy-seven percent of them felt that early feeding would prevent accelerated starvation, 69.3% felt that it would reduce the risk of post-bleeding infections, and 53.8% felt it would reduce the hospital stay and thus healthcare costs. Objective assessment of outcomes in AVB remains a key while evaluating this practice of shortened fasting during AVB in the real-world scenario. As a protocol, patients with AVB are initiated on oral feeding after 6 h of endotherapy at our center. The 6-week mortality rate and rebleeding rates in a prospective cohort of 523 patients with AVB from our center are around 22% and 6%, respectively,6Rout G. Sharma S. Gunjan D. et al.Development and validation of a novel model for outcomes in patients with cirrhosis and acute variceal bleeding.Dig Dis Sci. 2019; 64: 2327-2337https://doi.org/10.1007/s10620-019-05557-yCrossref PubMed Scopus (6) Google Scholar which is comparable with those of other cohorts.7Garcia-Tsao G. Abraldes J.G. Berzigotti A. Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases.Hepatology. 2017; 65: 310-335https://doi.org/10.1002/hep.28906Crossref PubMed Scopus (696) Google Scholar In addition to the timing of initiation of oral nutrition, another pertinent question is regarding the type of feed and route of administration (via a feeding tube or via mouth) in these patients. A randomized trial showed similar rebleeding risks among patients who were fed using a nasogastric tube and those who were not.8de Lédinghen V. Beau P. Mannant P.R. et al.Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study.Dig Dis Sci. 1997; 42: 536-541https://doi.org/10.1023/a:1018838808396Crossref PubMed Scopus (0) Google Scholar However, evidence is limited in this regard to make a formal recommendation. There remains a need for well-designed trials examining the nutritional benefits and rebleeding risks with a particular reference to the type and route of administration of oral nutrition (via feeding tube vs via my mouth) in patients with AVB. In the absence of recommendations, we suggest the use of a home-based blenderized mixture or polymeric commercial formula feed to initiate early oral nutrition in patients with AVB. Regarding the route of administration, we suggest the use of polytetraflouroethylene (PTFE) material-based feeding tubes with a size of 15G which can be inserted directly under endoscopic vision during the session of endotherapy. The use of PTFE tubes may be beneficial over standard nasogastric aspiration tubes which are made of polyvinyl chloride and consequently are less stiff. However, these recommendations require more evidence from future studies. In conclusion, despite heterogeneity in the recommendations about timing of initiation of enteral feeding in patients with AVB, most respondents of the present survey practiced early initiation of feeding and believed in its benefits. None. Data will be available after publication upon reasonable request. Sanchit Sharma: Preparation of questionnaire, data collection, Writing - original draft. Jatin Yegurla: Preparation of questionnaire, Writing - original draft. Namrata Singh: Preparation of questionnaire, data collection. Deepak Gunjan: Preparation of questionnaire, Writing - review & editing. Anoop Saraya: Preparation of questionnaire, Writing - original draft, Writing - review & editing. The authors have none to declare. 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