Retrospective Study

Nasogastric tube feeding in cats with suspected

acute pancreatitis: 55 cases (2001^2006)
Jennifer A. Klaus, DVM; Elke Rudloff, DVM, DACVECC and Rebecca Kirby, DVM, DACVIM,
DACVECC
Abstract
Objective To evaluate the complications and outcome associated with different nasogastric tube (NGT)
feeding techniques in cats with suspected acute pancreatitis.
Design Descriptive retrospective case series
Setting Small animal emergency and referral hospital
Animals The patient database (2001-2006) was searched for cats with suspected acute pancreatitis that
received NGT liquid enteral feeding within 72 hours of admission and 12 hours during hospitalization.
Measurements and Main Results Signalment, history, clinical signs, laboratory data and abdominal
ultrasonographic examinations were used for suspected diagnosis. Cats were grouped based upon whether
they received bolus feeding or continuous rate infusion (CRI) of a liquid diet via the NGT, and whether or not
administration of an intravenous amino acid and carbohydrate solution occurred prior to NGT feeding (AAS
and non-AAS group, respectively). Fifty-ve cats were included. For all cats, NGT feeding was initiated at
a mean of 33.5 15.0 hours and the target caloric intake (1.2 X {(30 X BW [kg]) +70}) was reached at
58.0 28.4 hours from presentation. There was a signicantly longer time from admission to the initiation of
NGT feeding in the 34/55 cats in the AAS group vs. the 21/55 cats in the non-AAS group (P = 0.009). The 8
bolus-fed cats took longer to reach target caloric intake vs. the 47 CRI-fed cats (P = 0.002). Complications
associated with NGT feeding for all cats included: mechanical problems (13%), diarrhea (25%), vomiting
following NGT placement (20%) and vomiting following NGT feeding (13%). Mean time to discharge for all
cats occurred after 78.6 29.5 hours with an overall weight gain of 0.08 0.52 kg. Fifty cats survived 28
days post-discharge.
Conclusions NGT feeding in this group of cats with suspected acute pancreatitis was well tolerated, and
associated with a low incidence of diarrhea, vomiting, and mechanical complications.
(J Vet Emerg Crit Care 2009; 19(4): 337346) doi: 10.1111/j.1476-4431.2009.00438.x
Keywords: enteral feeding, enteral nutrition, feline, partial parenteral nutrition, tube feeding
Introduction
The prevalence of feline pancreatitis documented in
postmortem evaluation of 6504 feline pancreata has
been reported by Hanichen and Minkus
1
to be acute
pancreatitis in 0.26% of cats and chronic pancreatitis in
0.52% of cats. It is difcult to make a diagnosis of acute
pancreatitis in the cat without a pancreatic biopsy,
therefore a presumptive diagnosis relies on compatible
historical, clinical, and ultrasonographic ndings.
2,3
Clinical signs are often vague and nonspecic, and
can include lethargy, anorexia, dehydration, vomiting,
and weight loss.
36
Laboratory abnormalities are often
variable, and may include neutrophilia, anemia, ele-
vations in alanine aminotransferase, alkaline phos-
phatase, total bilirubin, and cholesterol, as well as
hypocalcemia, hyperglycemia, glucosuria, and keto-
nuria.
36
Recently, feline pancreatic lipase immunore-
activity has been promisingly reported as a diagnostic
tool.
7
Current therapeutic recommendations for treating
cats with suspected or conrmed pancreatitis include
fasting for at least 23 days if vomiting is present.
810
However, withholding enteral feeding may prove
detrimental as the majority of cats with pancreatitis
are anorexic at the time of presentation
3,5
and concur-
rent weight loss has been correlated with an increase in
Address correspondence and reprint requests to
Dr. Jennifer A. Klaus, Southern Arizona Veterinary Specialty and
Emergency Center, 141 E Fort Lowell, Tucson, AZ 85705, USA.
Email: dr_jenklaus@yahoo.com
From the Animal Emergency Center, Glendale, WI 52309, USA.
Journal of Veterinary Emergency and Critical Care 19(4) 2009, pp 337346
doi:10.1111/j.1476-4431.2009.00438.x
& Veterinary Emergency and Critical Care Society 2009 337
mortality rate.
11
In human medicine, early nutritional
support is one of the mainstays of therapy.
12
Nutritional therapy for feline pancreatitis remains
controversial. Some reported nutritional strategies for
cats with pancreatitis incorporate partial parenteral nu-
trition (PPN; 8.5% amino acids, 20% lipids), or total
parenteral nutrition (TPN; 6% amino acids, 20% lipids,
50% dextrose), or both instead of enteral feeding.
10,11
It
has been postulated that enteral feeding will exacerbate
pancreatic secretions and inammation.
13,14
Delivering nutrients distal to the duodenojejunal
exure has been described in dogs and humans with
acute pancreatitis to bypass cephalic, gastric, and du-
odenal stimulation of pancreatic enzyme secretion and
reduce inammation.
1417
However, a meta-analysis
concluded that early nasogastric (NG) tube nutrition
was a breakthrough therapy for human pancreatitis,
where no worsening in clinical outcome occurred com-
pared with TPN and nasojejunal tube feeding.
18
Anecdotal reports
19,20
describe the use of early gas-
trointestinal feeding, but there are no studies investi-
gating the feeding techniques, complications, and
survival rate in cats with suspected acute pancreatitis
given enteral nutrition via NG tubes. The purpose of
this study is to provide a descriptive retrospective
evaluation of feeding techniques, outcome, and inci-
dence of complications in cats with suspected acute
pancreatitis given enteral nutrition via NG tubes.
Materials and Methods
Criteria for selection of cases
The patient database of cats examined at the Animal
Emergency Center from July 1, 2001 to December 31,
2006 was searched. Cases selected for review received
NG tube feeding of a liquid enteral diet
a
within 72
hours of presentation and had historical (lethargy, an-
orexia, vomiting, or diarrhea), clinical (dehydration,
hypothermia, or abdominal discomfort), and ultrasono-
graphic ndings (an enlarged hypoechogenic pancreas
with or without hyperechogenicity of peripancreatic
mesenteric fat or a pancreas with mixed hyper- and
hypoechogenicity
2,6
), supportive of acute pancreatitis.
All ultrasound examinations were performed by 1 of 2
board-certied veterinary emergency and critical care
specialists having 45 years experience performing ul-
trasound examinations. Medical records had to have
detailed history and physical examination ndings and
an hourly intensive care unit treatment record.
The placement of NG tubes in cats is standardized in
this hospital and performed by: (1) premeasuring a 5-
or 8-Fr exible polyurethane feeding tube from the nose
to the last rib; (2) lubricating the tip with lidocaine gel
and inserting the tube through 1 nostril to the premea-
sured mark; and (3) suturing the tube to the nose when
either gastric contents are aspirated or abdominal ra-
diographs conrm placement in the stomach. To be in-
cluded in this study, feeding through the NG tube must
have been initiated within 72 hours of admission. NG
feeding had to have been provided for at least 12 hours
and the target caloric intake reached using a liquid
enteral diet.
Supplemental enteral electrolyte solution
b
containing
9% glycine and 69% glucose, and an IVamino acid and
carbohydrate solution
c,d
(AAS) were the only other
means of nutritional supplementation before NG tube
feeding acceptable for inclusion. The AAS could have
been administered through a peripheral or central ve-
nous catheter. The same catheter could also have been
used for concurrent IV uid administration.
Data evaluation
Signalment, history, presenting clinical signs, ultra-
sonographic ndings, and all types of nutritional sup-
port were recorded and evaluated. Data collected
pertaining to the administration of NG tube nutrition
consisted of: technique of enteral diet administration
through NG tube (either bolus or low volume con-
tinuous rate infusion [CRI]); time from presentation to
initiation of liquid diet feeding; and time from start of
NG tube feeding to provision of target caloric require-
ments. Complications were recorded and included as:
tube blockage, tube displacement, hypersalivation,
vomiting, and diarrhea. The use and type of adjunc-
tive therapy (promotility agents and antiemetics, insu-
lin, antibiotics, or analgesic agents) was recorded.
Patient parameters identied included weight change,
whether or not there was return of appetite, and length
of hospitalization. Outcome was recorded with survi-
vors alive at least 28 days after hospital discharge.
Cats that received IVAAS solution before and during
NG tube enteral feeding were designated as the AAS
group. This group was compared with the non-AAS
group for any signicant effect on time to target caloric
intake, complications, and outcome. The two different
techniques for the administration of enteral diet
through the NG tube, bolus and CRI infusion were
also evaluated for their impact on time to target caloric
intake, complications, and outcome.
Statistical analysis
Descriptive data were examined graphically and are pre-
sented as mean SD for normally distributed data, and
as median (range) for skewed data. To assess the effects
of providing AAS and bolus or CRI methods on various
feeding time points and major outcomes in the study,
continuous outcomes were examined using a 2-way
ANOVA; this tested whether there was a signicant
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 338
J.A. Klaus et al.
difference between bolus and CRI, and between AAS
and non-AAS for the outcomes of interest.
For binary outcomes, logistic regression analysis was
used. Odds ratios were calculated and tested for sig-
nicance. Odds ratios of 0 occurred when there were no
events in a combination of the outcome and covariate
(eg, there were no cats that had diarrhea after bolus
feeding). Fishers exact test was used to measure asso-
ciation in those cases. In all analyses commercially
available software
e
was used and Po0.05 was consid-
ered signicant.
Results
Study population
From July 1, 2001 to December 31, 2006, 18,902 cats were
examined at the Animal Emergency Center. Seventy of
these cases were identied for possible inclusion into the
study, representing 0.37% of all cats seen. Fifteen of these
cases were excluded from the study. Eight of the 15 re-
cords were incomplete. Another 6 cats failed to reach
target NG tube feedings in hospital. Of these 6 cats,
2 were euthanized during surgery before reaching main-
tenance caloric feeding, and 4 cats were sent home or
transferred to another veterinarian before 12 hours of in-
hospital NG tube feeding. One case was excluded be-
cause the cat had received esophagostomy tube feedings
before reaching maintenance NG tube feeding.
Fifty-ve cats met the inclusion criteria for the study.
Forty-six were domestic short hair cats, 5 were domes-
tic long hair cats, 2 were domestic medium hair cats
and there was 1 Birman, and 1 Himalayan cat. The av-
erage age of the cats was 8.4 years (118 y) and 29 of
55 (53%) were male.
Clinical signs and ultrasound ndings
A history of lethargy was reported in all cases, de-
creased appetite in 53 of 55 cats (96%), and complete
anorexia ranging from 1 to 8 days in 38 of 55 (69%) cats.
Dehydration was present in 53 of 55 (96%), weight loss
in 11 of 55 (20%) and diarrhea in 9 of 55 (16%) cats.
Forty-two of 55 (76%) cats had a history of vomiting,
and 29 of these cats received AAS (29/34; 85%), which
was not signicant (P50.07).
Ultrasonographic examination of the abdomen doc-
umented a hypoechoic pancreas with a hyperechoic
mesentery in 29 of 55 (53%) cats, a mixed hypoechoic/
hyperechoic pancreas in 14 of 55 (25%), and a hypo-
echoic pancreas without mesenteric changes in 12 of
55 (22%) cats.
Concurrent diseases
In addition to acute pancreatitis, the following abnor-
malities were documented in the history, clinical ndings,
or through diagnostic testing or ultrasonographic exam-
ination of this population of cats: hepatic changes (33/55
[60%]), renal insufciency (19/55 [35%]), thickened in-
testines (11/55 [20%]), diabetes mellitus (7/55 [13%]), and
upper respiratory disease (4/55 [7%]). Inammatory
bowel disease was diagnosed in 3 of 9 cats based on
histopathologic ndings in a surgical biopsy (1 cat) or a
positive response to a hypoallergenic diet (2 cats).
Nutritional support
After NG tube placement, gastric suctioning was per-
formed every 46 hours in all cases for the duration of
NG tube placement. Supplemental electrolyte solution
b
was administered to all patients through the NG tube
before liquid enteral diet feeding by either CRI (0.55
2.2 mL/kg beginning 14.5 14.3 hours after admission)
for 47 of 55 (85%) cats or bolus infusion (2.24.4 mL/kg
every 4 hours beginning at 20.3 13.1 hours after ad-
mission) for 8 of 55 (15%) cats. There was no statistical
difference in enteral electrolyte solution volume or on-
set of administration between the AAS and non-AAS
groups (see Table 1, P50.17) or between bolus and CRI
groups (see Table 2, P50.19).
An 8.5% amino acid solution with 5% dextrose
c
was
administered to 14 cats and a 3% amino acid and 3.5%
glycerol solution
d
to 20 cats IV. At the administered rate
of 1.1 mL/kg/h, the rst solution provided 14.4kcal/kg/
d (2.3 g of protein/kg/d and 1.3g of dextrose/kg/d), and
the second solution administered at 2.2 mL/kg/h pro-
vided 13.2kcal/kg/d (1.6g of protein/kg/d and 1.6 g of
carbohydrate/kg/d). The average time from admission
to start of AAS was 13.7 20.8 hours.
NG tube feedings with a liquid enteral diet were ini-
tiated when there was low volume (o1 mL/kg/h of NG
tube suction volumes) of gastric uid residuals and as
long as no vomiting had occurred for at least 12 hours.
NGtube feedings with the liquid enteral diet were started
at 2550% of the target caloric intake (0.551.1 kcal/kg/h
CRI, or 2.24.4 kcal/kg bolus every 4 hours). Over 12
72 hours, feedings were gradually increased in volume
to reach the target caloric intake of 1.2 resting energy
requirement (RER) (2.2 kcal/kg/h CRI or 8.8 kcal/kg
bolus every 4 hours). The target caloric intake provided
30% of caloric density as protein, 45% of caloric density
as lipids, and 25% of caloric density as carbohydrates.
Infusion rates were incrementally increased based on
patient response and residual gastric volumes. When it
was determined that trickle feeding was tolerated at
target caloric intake, a transition to bolus feeding would
occur in preparation for hospital discharge. The NG
tube was left in place when the cat was not voluntarily
consuming adequate oral nutrition or the pet owner
declined esophagostomy tube placement.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 339
NG tube feeding in cats with suspected acute pancreatitis
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& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 340
J.A. Klaus et al.
There was a signicantly longer time from admission
to initiation of NG tube feeding found in the AAS
group compared with the non-AAS group, 37.4 15.1
versus 27.1 13.5 hours, respectively (P50.009). The
time from initiation of NG tube feeding to target caloric
intake of NG feeding for the AAS group was 15.5 hours
and was 16 hours in the non-AAS group, which was not
signicantly different (P50.76).
These same data were evaluated for CRI and bolus
enteral feeding techniques (see Table 2). The time
from the start of NG tube feedings to target caloric
intake took 15 hours in the CRI-fed group compared
with 34 hours in the bolus-fed group, which was sig-
nicant (P50.002). There was no signicant differ-
ence between bolus-fed and CRI-fed groups for the
time from admission to initiation of NG tube feeding
(P50.28). Cats being CRI fed were converted to bolus
feedings at a mean of 32.4 19.1 hours after initiation
of feeding.
Outcome
Length of hospital stay, weight change, and survival
data are shown for AAS and non-AAS groups in Table 1
and for bolus and CRI-fed groups in Table 2. No sta-
tistical signicance was detected between groups for
these parameters. Of the cats that survived, 22 of 50
(44%) cats started eating voluntarily in the hospital, and
38 of 50 (76%) cats were discharged from hospital with
the NG tube in place to allow the owner to continue
bolus feeding. The NG tube was replaced with esoph-
agostomy tube feedings in 2 of 50 (4%) cats. Six of 50
(12%) cats were voluntarily eating adequately, not
requiring supplemental feeding. Four of 50 (8%) were
syringe fed at home without NG tube supplementation.
Five cats were euthanized, 4 due to the severe decline in
their clinical condition and 1 due to the owners in-
ability to perform home care, all having been CRI fed.
There was no statistical signicance between the ad-
ministration of AAS and the population of cats that
were euthanized (P50.49). No cats died.
Complications
The frequency of vomiting before and after NG tube
feeding, and the incidence of diarrhea and hypersali-
vation after NG tube placement were not signicantly
different between the AAS and non-AAS groups (see
Table 3). Bolus-fed cats had signicantly more vomiting
episodes after NG tube placement and before the ini-
tiation of feeding than did the CRI-fed cats (see Table 4,
P50.02). However, none of the bolus-fed patients
vomited after feeding began. No other variable was
signicantly associated with vomiting. Four of the 16
cats (25%) that vomited in hospital had vomiting re-
ported after discharge from the hospital, and 1 of these
patients was euthanized. An additional 5 cats that had
not vomited at all in the hospital vomited at home after
discharge. Fourteen cats, all in the CRI group, had di-
arrhea after NG tube feeding, and no statistical signi-
cance was found between the AAS and non-AAS
groups (P50.08).
One or more mechanical complications with the NG
tube were found in 7 of 55 (13%) cats, with tube dis-
lodgement occurring in 6 cats and tube obstruction in 1
cat (see Table 4). One of the cats removed the NG tube
following hospital discharge and required endoscopy
to remove a segment of the NG tube from the stomach.
A nasoesophageal tube was subsequently placed in that
cat for continued feeding. One cat had an obstruction of
the NG tube that cleared without requiring tube re-
placement. Three cats were hypersalivating following
NG tube placement (1 in the bolus-fed group) and
following initiation of NG tube feeding, 2 cats were
hypersalivating in the CRI-fed group.
Adjunctive therapy
Treatment other than IV uid replacement included
administration of promotility and antiemetic agents,
analgesic drugs (single agent opioid or combination
opioid and other analgesics), insulin, and antibiotics.
Promotility agents were used in 48 of 55 (87%) cats
(see Tables 5 and 6). There was no signicant difference
Table3: Complications associated with NGT placement in cats with pancreatitis receiving or not receiving AAS
Group n
Vomiting
admission
until NGT
feeding
Vomiting after
NGT feeding
(in hospital)
Diarrhea
following
NGT feeding
Hypersalivation
with NGT
placement
Hypersalivation
with NGT
feeding
Tube
dislodgement
Tube
obstruction
All 55 11 (20%) 7 (13%) 14 (25%) 3 (5%) 2 (4%) 6 (11%) 1 (2%)
AAS 34 8 (24%) 6 (18%) 12 (35%) 2 (6%) 1 (3%) 6 (18%) 0
Non-AAS 21 3 (14%) 1 (5%) 2 (10%) 1 (5%) 1 (5%) 0 1 (5%)
P value 0.18 0.26 0.08
OR 3.38 3.60 4.42
95% CI 0.5, 19.7 0.39, 32 0.85, 22
NGT, nasogastric tube; AAS, amino acid solution; OR, odds ratio; CI, condence interval.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 341
NG tube feeding in cats with suspected acute pancreatitis
between promotility agent usage in the AAS group and
non-AAS group (P = 0.15), or in the CRI group and
bolus-fed group (P = 0.88). Analgesics were used in 35
of 55 (64%) cats, and antibiotics in 51 of 55 (93%) cats.
Six of 7 cats presenting with a history of diabetes mel-
litus were treated with CRI or subcutaneous insulin
administration. Insulin therapy was not used in any
nondiabetic hyperglycemic cats.
Discussion
The retrospective data from these 55 cats with sus-
pected acute pancreatitis demonstrate that enteral feed-
ing of a liquid diet, by CRI or bolus methods of
administration, was associated with few clinically sig-
nicant complications and no deleterious effects on
morbidity and mortality. Feeding could occur early in
the course of the hospitalization and a survival rate of
91% was documented in this population of cats.
This is the rst retrospective review evaluating the
feeding techniques, complications and outcome of ent-
eral feeding by NG tube as a treatment strategy for
suspected acute pancreatitis in cats. The prevalence
of 0.37% suspected acute feline pancreatitis in all cats
examined is similar to the 0.26% prevalence of feline
acute pancreatitis reported elsewhere.
1
It is likely, how-
ever, that our referral hospitals true prevalence is
higher because abdominal ultrasonography, although
highly specic, has been reported to be 2035% sensi-
tive for the diagnosis of acute pancreatitis.
21,22
The cats were divided into groups according to feed-
ing technique in order to evaluate any potential impact
on complications and outcome. Clinician preference,
anticipation of delayed enteral feeding, time to target
caloric intake, and nancial limitations may have
played a role in the decision of whether or not to ini-
tiate nutritional support with AAS solution. In addi-
tion, bolus feedings may be elected when nancial
limitations restrict days in hospital.
In this population of cats with suspected acute pan-
creatitis, the proportion of males (53%) to females
(47%), domestic short hair breed predilection, and age
of cats is comparable with previously reported studies
of cats with acute pancreatitis.
36
There were a large
number of anorexic cats (69%), and 96% of cats had a
decreased appetite on presentation. This is similar to
another retrospective study with 40 cats with pancre-
atitis, where 84% were completely anorexic and 97%
Table4: Complications associated with NGT placement in cats with pancreatitis that were fed by bolus infusion compared with CRI
Group n
Vomiting
admission
until NGT
feeding
Vomiting after
NGT feeding
(in hospital)
Diarrhea
following
NGT feeding
Hypersalivation
with NGT
placement
Hypersalivation
with NGT
feeding
Tube
dislodgement
Tube
obstruction
All 55 11 (20%) 7 (13%) 14 (25%) 3 (5%) 2 (4%) 6 (11%) 1 (2%)
Bolus 8 4 (50%) 0 0 1 (13%) 0 1 (13%) 1 (13%)
CRI 47 7 (15%) 7 (15%) 14 (30%) 2 (4%) 2 (4%) 5 (11%) 0
P value 0.02
n
N/A N/A
OR 9.09 N/A N/A
95%CI 1.41, 58.4 N/A N/A
n
Po0.05.
NGT, nasogastric tube; CRI, continuous rate infusion; OR, odds ratio; CI, condence interval.
Table5: Promotility and antiemetic therapy in cats with pancreatitis that received nasogastric tube feedings in addition to or
without AAS
Group n
Promotility
agents used
Single agent
promotility:
Cisapride
Single agent
promotility:
Metoclopramide
Single agent
antiemetic
n
Combination
promotility
agents antiemetics
w
All 55 48 (87%) 23 (42%) 8 (15%) 1 (2%) 17 (31%)
AAS 34 31 (91%) 16 (47%) 4 (12%) 1 (3%) 11 (32%)
Non-AAS 21 17 (81%) 7 (33%) 4 (19%) 0 6 (29%)
P value 0.15
OR 3.87
n
Single antiemetic agent chlorpromazine.
w
Chlorpromazine or ondansetron as a combination agent in 3/55 and 1/55 cases, respectively.
AAS, amino acid solution; OR, odds ratio.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 342
J.A. Klaus et al.
had a reduced appetite.
3
In that study, only 35% of cats
with severe pancreatitis were vomiting at presentation,
compared with 76% in this retrospective review.
Inammatory bowel disease, diabetes mellitus, en-
teritis, cholangiohepatitis, chronic interstitial nephritis,
acute tubular necrosis, and pyelonephritis are esti-
mated to occur in 92% of cats with acute pancreati-
tis.
5,9,23,24
Concurrent diseases have been reported to be
associated with a worse outcome in cats with acute
pancreatitis.
3,4,9
Forty-six of 55 (84%) cats in this study
had suspected concurrent diseases. Diabetes mellitus is
reported to occur in 315% of cats with pancreatitis
5
and was present in 7 of 55 (13%) of cats in this study.
Hepatopathy and renal insufciency were noted in 33
of 55 (60%) and 19 of 55 (35%) cats, respectively, in this
study. Hepatic lipidosis can occur within 72 hours of
fasting, and has been reported as an exacerbating ill-
ness in 59% of cats with pancreatitis,
3,24,25
increasing
mortality up to 80%.
4
Recommendations for nutritional support have in-
cluded using PPN with AAS and lipids of various com-
positions or TPN if severe vomiting or ileus is present.
26
Enteral nutrition is safer and less expensive than TPN
but effect on outcome in human clinical studies is still
debated.
12
One human clinical trial found that treating
severe acute pancreatitis patients with total enteral feed-
ing signicantly reduced infectious complications, mul-
tiorgan failure, and mortality compared with TPN.
27
However, enteral nutrition in human acute pancreatitis
patients did not result in signicant decreases in mortal-
ity and morbidity compared with TPN as reported by 2
meta-analyses.
28,29
Not surprisingly, nutritional therapy
for feline pancreatitis also remains controversial, and in a
study by Hill and Van Winkle
3
of 40 cats with the diag-
nosis of acute pancreatitis, rapid deterioration and death
occurred in 3 that were force fed while the other cats
were permitted to regain appetite on their own.
The use of NG tubes in this study permitted introduc-
tion of enteral feeding in the anorexic cat without the
restraint and stress associated with forced oral feeding.
NG tube placement is rapid and nonsurgical, with no
need for uoroscopic guidance, providing some benets
over jejunal and nasojejunal feeding methods.
Current published guidelines for treating suspected
acute feline pancreatitis recommend cautious introduc-
tion to food if the patient is anorexic, and withholding
enteral feeding for 23 days if the patient is vomiting.
810
These guidelines suggest that slow introduction to feed-
ing should be attempted with a low-fat, carbohydrate-
rich diet. Jejunostomy, nasojejunal, NG, esophagostomy,
or gastrostomy tubes have been given as options for
methods of feeding
8,11,19,30,31
and specic recommenda-
tions have been made to reach maintenance caloric re-
quirements over 34 days when jejunal tube feeding is
used in cats with pancreatitis.
32
Withholding enteral nutrition in the sick cat could
contribute to morbidity. Cats have a high dietary pro-
tein requirement, 23 times that of dogs, making them
susceptible to protein-energy malnutrition and severe
lean muscle loss when fasting.
3335
Negative nitrogen
balance can result in gastrointestinal ileus, villous at-
rophy with poor absorptive capabilities, and increased
risk of bacterial translocation.
19
Deleterious effects on
the renal, pulmonary, immune, cardiovascular, and
musculoskeletal systems have been reported as a con-
sequence of negative nitrogen balance,
19
and withhold-
ing enteral nutrition could exacerbate concurrent illness
in cats with pancreatitis. In addition, decreased argi-
nine and methionine may limit the synthesis of liver
proteins and phospholipids, contributing to the devel-
opment of hepatic lipidosis.
35
Currently, NG tube feeding in humans with pancre-
atitis is being reevaluated. In 26 humans with severe
acute pancreatitis, NG tube feeding was well tolerated
in 22 patients, with gastric stasis occurring in 3 patients;
all patients survived.
36
Other human studies have
shown no increase in patient perception of pain, acute
phase response, requirement of analgesics, length of
hospital stay, or mortality with NG tube feeding when
compared with NJ feeding.
37,38
In addition, NG tubes
Table6: Promotility and antiemetic therapy in cats with pancreatitis that received nasogastric tube feedings by CRI or bolus infusion
Group n
Promotility
agents used
Single agent
promotility:
cisapride
Single agent
promotility:
metoclopramide
Single agent
antiemetic
n
Combination
promotility
agents antiemetics
w
All 55 48 (87%) 23 (42%) 8 (15%) 1 (2%) 17 (31%)
Bolus 8 7 (88%) 1 (13%) 4 (50%) 0 2 (25%)
CRI 47 41 (87%) 22 (47%) 4 (9%) 1 (2%) 15 (32%)
P value 0.88
OR 1.20
n
Single antiemetic agent chlorpromazine.
w
Chlorpromazine or ondansetron as a combination agent in 3/55 and 1/55 cases, respectively.
AAS, amino acid solution; OR, odds ratio.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 343
NG tube feeding in cats with suspected acute pancreatitis
were easier and less costly to place and maintain than
surgically placed jejunal or uoroscopically placed
nasojejunal tubes.
37,38
The AAS is administered to augment calories in pa-
tients not meeting their daily caloric needs through
enteral feeding. The AAS can provide close to 30%
daily caloric needs in the cat. In addition, these solu-
tions contain balanced electrolytes, arginine, and
branched-chain amino acids (leucine, isoleucine, and
valine). IVarginine supplementation has been shown to
enhance both cellular and humoral immunity,
39
and
parenteral branched-chain amino acids preserve intes-
tinal morphology and protein content.
40
The 13.7 20.8
hours from presentation to the onset of AAS adminis-
tration was earlier in this study than reported by Chan
et al,
41
where an 8.5% amino acid and 20% lipid solu-
tion was started at a mean of 43.2 hours after hospi-
talization. Similarly, in a large retrospective study
evaluating TPN, 35 of 75 (47%) of cats had a diagno-
sis of pancreatitis, and a median of 36 hours elapsed
before TPN was initiated.
11
The ultimate goal of NG tube enteral feeding is to
reach the necessary volumes to provide target caloric
intake as rapidly as possible without causing deleteri-
ous effects such as nausea, vomiting, or diarrhea. In this
study, target caloric intake with enteral feeding was
reached at a mean of 58.0 28.4 hours from admission
for all cats. This is more rapid than recommendations
made for jejunal feeding to reach maintenance caloric
needs over 34 days.
32
Also, the bolus-fed group took a
signicantly longer time to reach target caloric intake
than the CRI-fed group (P50.002). When the enteral
diet can be delivered as a CRI, the volume and con-
centration can be more carefully titrated.
The target nutrition used represented 1.2 RER for a
standard 5.5 kg cat. RER can be multiplied by an illness
factor (11.25 in cats) to calculate the metabolic energy
requirement.
19,42
This calculation is being used because
it was the caloric intake commonly recommended dur-
ing that treatment period. The recommendations have
since changed to strictly feed cats with pancreatitis the
RER without adding an illness factor.
43
Sixteen of 55 (29%) cats vomited while in the hospital.
The incidence of vomiting with enteral feeding
throughout the groups may have been reduced by a
combination of factors: periodic gastric aspiration of air
and uid by NG tube, testing tolerance of NG tube
feeding with an electrolyte solution before giving the
enteral diet, the addition of antiemetics, or promotility
agents, or both, and the selection of a specic feeding
technique for each individual cat. Factors that may have
contributed to increased vomiting incidence include the
adverse effects of adjunctive therapies used, such as
antibiotics and opioid analgesic agents. It cannot be
determined from the individual patient records what
criteria were used to determine the need for analgesic
or antibiotic agents.
Only 7 of 55 (13%) cats vomited after feeding,
and each had a history of vomiting before initiation
of feeding. This might have been coincidental, or a
factor related to their ongoing disease processes. In
these cases, enteral nutrition was discontinued tem-
porarily additional antiemetics or promotility agents
provided, and NG tube feeding was reinstated at a
slower pace.
Bolus-fed cats in this study had a statistically signi-
cant greater incidence of vomiting from time of NG
tube placement until start of feeding the enteral diet.
The explanation for this is not clear, but vomiting may
have occurred in association with the bolus adminis-
tration of the electrolyte solution after NG tube place-
ment compared with delivering the solution by a CRI.
No other variable was associated with vomiting. The
frequency of vomiting after initiation of NG tube feed-
ing with the enteral diet occurred with the same fre-
quency in AAS- or nonAAS-fed cats (P50.26), while
none of the cats in the bolus group vomited.
Mechanical complications associated with NG tube
feeding occurred in 7 of 55 (13%) of the cats in this
study, with manual removal of the NG tube occurring
in 6 cats and tube obstruction in 1 cat. This is similar to
a study by Abood and Bufngton,
44
where 2 of 26 (8%)
of critically ill cats removed their NG tube. No NG tube
obstructions occurred in the Abood study or a similar
study by Crowe et al.
45
Also, 5 of 55 (9%) of cats in our
study were hypersalivating following NG tube place-
ment or feeding. The hypersalivation could be attrib-
uted to the tube placement, pain, or nausea associated
with the suspected acute pancreatic disease. The inci-
dence of hypersalivation was not reported in other
studies reporting on suspected pancreatitis or NG tube
feedings.
Previous studies implicated enteral feeding with a
liquid diet as the cause of diarrhea in 11.537.5% of
canine and feline patients.
30,44,45
Humans experience a
14.5% occurrence of diarrhea with liquid enteral diet
feeding.
46
Fourteen of 55 (25%) cats in this study de-
veloped diarrhea that had not previously been docu-
mented before feeding. The antibiotics that were
administered may have contributed to the diarrhea.
The administration of AAS was not associated with the
development of diarrhea (P50.08) and none of the bo-
lus-fed cats developed diarrhea.
Length of hospitalization, weight gain, and outcome
were not signicantly different between AAS and non-
AAS groups or between CRI-fed and bolus-fed groups.
During the treatment period, the cats experienced a
mean weight gain of 0.08 0.52 kg, or 1.5%, which is in
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00438.x 344
J.A. Klaus et al.
contrast to another study, in which cats fed a liquid
polymeric diet over 7 days experienced an average
weight loss of 3.8%.
45
It is likely that the weight gain was
a combination of correction of dehydration through uid
administration and from providing nutritional support.
No records reported signs of uid overload or intoler-
ance in any of the 55 cats.
Mean hospitalization time was 78.6 29.6 hours.
This length of hospitalization is relatively short in com-
parison with a gastrojenuostomy and a jejunostomy
tube study where patients with pancreatitis or other
diseases were hospitalized for 168504 hours for ther-
apy.
30,32
It is unknown, however, if the cats in these past
studies were voluntarily eating their caloric require-
ment at discharge. In addition, comparison of the se-
verity of disease with this study is not possible.
The mortality rate of cats with suspected pancreatitis
fed by jejunostomy tubes, PPN and TPN has previously
been reported. Swann et al
30
reported that of 8 cats fed
by jejunostomy tube (6 of 8 having pancreatitis), 4 of the
8 cats (50%) were euthanized. The study did not clarify
whether 2, 3, or all of the euthanized cats had pan-
creatitis. Chan et al
41
evaluated the use of PPN in cats
with pancreatitis among other diseases, and reported
that 19% died or were euthanized. In that study, more
cats survived when PPN was augmented with enteral
nutrition. A retrospective study by Pyle et al
11
found a
46% mortality rate in 35 cats with pancreatitis fed by
TPN. In the few small studies using NG tubes in human
pancreatitis, all patients survived.
36,37
Larger human
studies using various feeding methods report a 85
99.3% survival rate in patients with acute pancreati-
tis.
47,48
This retrospective study of 55 cats with sus-
pected acute pancreatitis that were enterally fed with
an NG tube-delivered liquid diet showed a 91% sur-
vival (50/55). All cats that were euthanized had been
fed their liquid enteral diet by CRI. This feeding tech-
nique had most likely been chosen for these cats to al-
low a gradual adjustment in volume and concentration
of liquid diet in this critical population.
Because this was a retrospective study, the patient
populations were not randomized into standardized
feeding groups making it more difcult to evaluate re-
sults from each subgroup without bias. In addition, as
the method of diagnosis and severity of illness is vari-
able, it is not possible to accurately compare this study
with previously reported studies looking at nutrition
and feline pancreatitis. Combining the feline pancreatic
lipase immunoreactivity test with the ultrasonographic
ndings would have increased the sensitivity for a
stronger antemortem diagnosis of acute pancreatitis,
7
and should be considered as part of any future studies
looking into the benets of NG tube feedings in cats
with pancreatitis.
Conclusion
Early NG tube feeding (o72 hours after admission) of a
liquid enteral diet by bolus or CRI feeding was toler-
ated well and resulted in few clinically signicant com-
plications. Enteral nutrition by NG tube should be
considered as a means of nutritional management for
suspected acute feline pancreatitis.
Footnotes
a
CliniCare Feline liquid diet, Abbott Laboratories, Animal Health, North
Chicago, IL.
b
Resorb, Pzer Animal Health, Exton, PA.
c
FreAmine III 8.5%, McGaw, Irvine, CA and 5% dextrose, Baxter
Healthcare, Deereld, IL.
d
ProcalAmine, B. Braun Medical Inc., Irvine, CA.
e
SAS 9.1, SAS Institute Inc., Cary, NC.
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