See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/352248643

Duration of Fasting During Acute Variceal Bleeding in Chronic Liver Disease:

Perceptions and Practices of Gastroenterologists

Article  in  Journal of Clinical and Experimental Hepatology · June 2021

DOI: 10.1016/j.jceh.2021.06.005

CITATIONS READS

0 52

5 authors, including:

Sanchit Sharma Jatin Yegurla

All India Institute of Medical Sciences All India Institute of Medical Sciences
53 PUBLICATIONS   142 CITATIONS    5 PUBLICATIONS   9 CITATIONS   

SEE PROFILE SEE PROFILE

Namrata Singh Deepak Gunjan

All India Institute of Medical Sciences All India Institute of Medical Sciences
75 PUBLICATIONS   1,130 CITATIONS    108 PUBLICATIONS   489 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Portal hypertension View project

Circulating miRNAs in Esophageal Cancer Patients and Healthy Subjects: Potential Blood Based Biomarkers for Diagnosis and Prognosis View project

All content following this page was uploaded by Sanchit Sharma on 21 July 2021.

The user has requested enhancement of the downloaded file.

Letter to the Editor
Duration of Fasting During Acute Variceal Bleeding in
Chronic Liver Disease: Perceptions and Practices
of Gastroenterologists
Dear Editor,
We read with great interest the guidelines on nutrition by
the Indian National Association of Study of Liver in pa-
tients with chronic liver disease.1 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 Associ-
ation of Study of Liver disease recommendation of sys-
temic fasting of 48–72 h during AVB.2 The concerns for
reservation of early feeding are increase in portal pressures
after meals and exacerbation of hyper ammonia with pro-
tein containing diet. However, the same has not been
demonstrated conclusively.3–5 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 con-
sisting of 16 questions evaluating these practices and per-
ceptions 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, Af-
rica, and the America. Most physicians (75%) were seeing
up to 10 cases of AVB at their center per week, while re-
maining 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 re-
sponders 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 re-
sponders, whereas 12.7% believed it to be harmful in these
patients. Approximately, 10.7% responders believed it to
https://doi.org/10.1016/j.jceh.2021.06.005
© 2021 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Sharma et al., Duration of Fasting During Acute Variceal Bleeding in Chronic Liver Disease: Perceptions and Practices of
Gastroenterologists, Journal of Clinical and Experimental Hepatology, https://doi.org/10.1016/j.jceh.2021.06.005
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
have no impact on management and remaining 28.2%
were not sure about their response (Figure 1d). Many re-
spondents 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 endo-
therapy at our center. The 6-week mortality rate and re-
bleeding rates in a prospective cohort of 523 patients
with AVB from our center are around 22% and 6%, respec-
tively,6 which is comparable with those of other cohorts.7
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.8 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 com-
mercial formula feed to initiate early oral nutrition in pa-
tients with AVB. Regarding the route of administration,
we suggest the use of polytetraflouroethylene (PTFE) mate-
rial-based feeding tubes with a size of 15G which can be in-
serted 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 recommen-
dations about timing of initiation of enteral feeding in pa-
tients with AVB, most respondents of the present survey
practiced early initiation of feeding and believed in its ben-
efits.
Journal of Clinical and Experimental Hepatology | - xxxx | Vol. xxx | No. xxx | xxx
 DURATION OF FASTING DURING ACUTE VARICEAL BLEEDING SHARMA ET AL

Figure 1 (a) Distribution of cases of acute variceal bleeding seen by respondents per week. (b) Timing of initiation of enteral feeding by responders of
the survey in patients with acute variceal bleeding after endoscopic hemostasis. (c) Time to resume solid diet advised by physicians to patients with
acute variceal bleeding after endoscopic hemostasis. (d) Perceived impact of early nutrition (within 12 h of endoscopic hemostasis) of normal feeding
(recommended calorie intake) after endoscopic hemostasis for acute variceal bleeding on their outcomes.

DISCLOSURES 2. Merli M, Berzigotti A, Zelber-Sagi S, et al. EASL clinical practice guide-

---

lines on nutrition in chronic liver disease. J Hepatol. 2019;70:172–

None.
DATA AVAILABILITY STATEMENT
Data will be available after publication upon reasonable
request.
CONFLICTS OF INTEREST
The authors have none to declare.
CREDIT AUTHORSHIP CONTRIBUTION
STATEMENT
Sanchit Sharma: Preparation of questionnaire, data
collection, Writing - original draft. Jatin Yegurla: Prepara-
tion of questionnaire, Writing - original draft. Namrata
Singh: Preparation of questionnaire, data collection.
Deepak Gunjan: Preparation of questionnaire, Writing -
review & editing. Anoop Saraya: Preparation of question-
naire, Writing - original draft, Writing - review & editing.
193. https://doi.org/10.1016/j.jhep.2018.06.024.
3. Hebuterne X, Vanbiervliet G. Feeding the patients with upper gastro-
intestinal bleeding. Curr Opin Clin Nutr Metab Care. 2011;14:197–
201. https://doi.org/10.1097/MCO.0b013e3283436dc5.
4. Lo GH, Lin CW, Hsu YC. A controlled trial of early versus delayed
feeding following ligation in the control of acute esophageal variceal
bleeding. J Chin Med Assoc. 2015;78:642–647. https://doi.org/
10.1016/j.jcma.2015.07.004.
5. Sidhu SS, Goyal O, Singh S, Kishore H, Chhina RS, Sidhu SS. Early
feeding after esophageal variceal band ligation in cirrhotics is safe:
randomized controlled trial. Dig Endosc. 2019;31:646–652.
https://doi.org/10.1111/den.13423.
6. Rout G, Sharma S, Gunjan D, et al. Development and validation of a
novel model for outcomes in patients with cirrhosis and acute vari-
ceal bleeding. Dig Dis Sci. 2019;64:2327–2337. https://doi.org/
10.1007/s10620-019-05557-y.
7. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hyperten-
sive bleeding in cirrhosis: risk stratification, diagnosis, and manage-
ment: 2016 practice guidance by the American Association for the
Study of Liver Diseases. Hepatology. 2017;65:310–335. https://
doi.org/10.1002/hep.28906.
8. de Ledinghen V, Beau P, Mannant PR, 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–
541. https://doi.org/10.1023/a:1018838808396.

REFERENCES Sanchit Sharma*, Jatin Yegurla*, Namrata Singh,

1. Puri P, Dhiman RK, 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;11:97–143. https://doi.org/10.
1016/j.jceh.2020.09.003.
Deepak Gunjan, Anoop Saraya
Department of Gastroenterology and Human Nutrition
Unit, All India Institute of Medical Sciences, New Delhi,
110029, India

2 © 2021 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.
Please cite this article as: Sharma et al., Duration of Fasting During Acute Variceal Bleeding in Chronic Liver Disease: Perceptions and Practices of
Gastroenterologists, Journal of Clinical and Experimental Hepatology, https://doi.org/10.1016/j.jceh.2021.06.005
 JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY

Address for correspondence: Anoop Saraya, Professor and Sciences, New Delhi, 110029, India.
Head of Department, Department of Gastroenterology E-mail: ansaraya@yahoo.com (A. Saraya)
and Human Nutrition, All India Institute of Medical
14 April 2021.

---

equal contribution.

Journal of Clinical and Experimental Hepatology | - xxxx | Vol. xxx | No. xxx | xxx 3
Please cite this article as: Sharma et al., Duration of Fasting During Acute Variceal Bleeding in Chronic Liver Disease: Perceptions and Practices of
Gastroenterologists,
View publication stats Journal of Clinical and Experimental Hepatology, https://doi.org/10.1016/j.jceh.2021.06.005