Reversal of Feed Intolerance by Prokinetics Improves Survival in Critically Ill Cirrhosis Patients.

BACKGROUND AND AIMS: Feed intolerance (FI) is common in cirrhosis patients in intensive care units (ICU). Prokinetics are the first line treatment for FI but their efficacy and safety in critically ill patient with cirrhosis is unknown. We evaluated the role of prokinetics in reversal of FI and clinical outcomes. METHODS: Consecutive patients admitted in ICU developing new-onset FI, were randomized to receive either intravenous metoclopramide (Gr.A, n = 28), erythromycin (Gr.B, n = 27) or placebo (Gr.C, n = 28). FI was defined with the presence of 3 of 5 variables- absence of bowel sounds, gastric residual volume ≥ 500 ml, vomiting, diarrhoea and bowel distension. Primary end-point was complete resolution of FI (≥ 3 variables resolved) within 24-h and secondary end-points included resolution within 72-h and survival at 7-days. RESULTS: Of the 1030 ICU patients, 201 (19.5%) developed FI and 83 patients were randomized. Baseline parameters between the groups were comparable. Complete resolution at 24-h was higher in Gr.A (7.14%) and B (22.2%) than C (0%, p = 0.017). Overall, 58 (69.9%) patients achieved resolution within 72 h, more with metoclopramide (n = 24, 85.7%) and erythromycin (n = 25, 92.6%) than with placebo (n = 9, 32.1%, p < 0.001). The 7-day survival was better in patients who achieved resolution within 72-h (65.5 vs. 36%, p = 0.011) than non-responders. High lactate (OR-3.32, CI-1.45-7.70, p = 0.005), shock at baseline (OR-6.34, CI-1.67-24.1, p = 0.007) and resolution of FI within 72 h (OR-0.11, CI, 0.03-0.51, p = 0.04) predicted 7-day mortality. CONCLUSIONS: FI is common in critically-ill cirrhosis patients and non-resolution carries high mortality. Early recognition and treatment with prokinetics is recommended to improve short-term survival.

Gastrointestinal dysmotility is common in cirrhosis and higher incidence in critically ill patients. Promotility drugs are the first line of medication especially in ICU patients. In our study, we found that feed intolerance is present in nearly one in five critically ill cirrhosis and is associated with higher mortality. Patients who achieve resolution had an improved short-term survival. Prokinetic medications are safe in critically ill cirrhosis and help in early resolution of feed intolerance. Feed intolerance in critically ill cirrhosis should be recognized as an organ dysfunction and approaches for prevention and early diagnosis of feed intolerance could help in improving the outcomes in critical illness.

Role of horizontal transmission in hepatitis B virus spread among household contacts in north India.

OBJECTIVES: Familial clustering of HBV provides epidemiological evidence for the different modes of spread of the virus. Though the majority of the studies have addressed the issue of perinatal transmission in India, only a few reports have dealt with other modes of transmission. METHODS: The study was prospectively designed and data were collected from a total of 265 household contacts of 91 index patients with HBV-related chronic liver disease between January 2006 and July 2007. The prevalences of HBsAg and various antibodies; anti-HBs, anti-HBc and anti-HBe, were estimated in all household contacts using ELISA and VIDAS. RESULTS: Among the various household contacts, the highest prevalence of HBsAg was seen in the pediatric age group (kids 1-15 years: 37.0%) and especially in siblings (48.3%), with statistical significance (p < 0.001). Hepatitis B virus (HBV) serological markers were found more commonly in contacts of female (68.8%) index patients as compared to males (p > 0.05). The development of anti-HBV antibodies showed an increasing trend with age (p < 0.001), with the highest prevalence in parents. CONCLUSION: Horizontal transmission plays an important role in contributing to the high prevalence of HBsAg especially in young children. Hence, this age group needs to be targeted for primary prevention and effective vaccine.

Dietary survey and total dietary fiber intake in patients with irritable bowel syndrome attending a tertiary referral hospital.

BACKGROUND: Based on their chemical extraction, dietary fibers are classified into crude fibers and total dietary fibers (TDF). TDF gives the best estimate of fiber content in the diet. Whereas data on intake of crude fibers are available, there is a lack of data on intake of TDF in patients with irritable bowel syndrome (IBS). AIM: We assessed the TDF and its source in the diet of patients with IBS and healthy controls (HC). METHODS: Based on their predominant symptoms, 81 patients with IBS (according to Rome II criteria) were categorized into constipation-predominant (IBS-C, n=48), diarrhea-predominant (IBS-D, n=16) and mixed type (IBS-M, n=17). Information was collected on fiber supplementation and preference for high-fiber food. A pretested, open-ended, semi-quantitative food frequency questionnaire was used to collect dietary information on food groups and TDF. Age- and sex-matched healthy individuals (n=89) were recruited as HC. The mean (SD) age of patients and HC was 36.5 (11.4) years (59 men), and 36 (12) years (62 men), respectively. RESULTS: Thirty-nine patients (48%) were taking medicinal fiber supplements, of which 28 patients were taking supplements daily (2.10 [0.84] teaspoon full). The mean daily TDF intake was 51.7 (23.1) g vs. 52.3 (21.6) g for patients and HC, respectively (p=0.8). The intake of TDF was similar in patients having less (n=41) or more (n=40) preference for fiber-rich foods (55 [23] g vs. 47 [22] g, p=0.16). The daily mean cereal intake in patients was significantly lower than that in HC (322 g vs. 404 g, p=0.001). However, consumption of fruits (150 g vs. 80 g, p=0.001) and vegetables (348 g vs. 219 g, p=0.006) was higher in patients in comparison with HC. There was a positive correlation between TDF with cereals (p=0.001), pulses (p=0.001), vegetables and fruits (p=0.033) in patients with IBS but only with cereals (p=0.001) in HC. CONCLUSION: The intake of TDF in patients with IBS and HC is much higher than the dietary recommendation for healthy Indians. Patients with IBS consumed more fruits and vegetables rather than cereals as compared with HC.

Correlation of serum HCV core concentration with blood level of lipid and antioxidants in various forms of liver diseases.

BACKGROUND/AIMS: The present study was designed to investigate the effect of hepatitis C virus (HCV) core protein expression on the blood level of lipids, lipoproteins and apolipoprotein in various forms of liver diseases. At the same time, effect of HCV core protein was also studied on the level of antioxidants in these patient groups. The aim behind this study was to explore the possibility of HCV core induced lipid changes and ensuing oxidative liver damage in these liver diseases. METHODOLOGY: We studied a total number of 130 patients including 50 patients with acute viral hepatitis (AVH), 30 with chronic hepatitis (CH), 30 with hepatic cirrhosis and 20 patients with fulminant hepatic failure (FHF). Sera from all these patients were analyzed for hepatitis viral markers and HCV core protein using EIA assays. Sera/plasma from them were simultaneously analyzed for total cholesterol, triglyceride, low density lipoprotein (LDL), high density lipoprotein (HDL), apolipoprotein A-1 and B, and also for antioxidants. RESULTS: Analysis of data demonstrated the presence of viral hepatitis B, C and E infections in these cases. Hepatitis A and D infections were absent in all the patients. When data on lipid and lipoprotein were analyzed in relation to HCV core expression, we could not observe a significant change in the serum level of total cholesterol, triglyceride, LDL, HDL, apolipoprotein A-1 and apoprotein B in core positive patients as compared to core negative cases. However, lipoprotein (a) [Lp(a)] level was significantly reduced in core positive patients as compared to core negative cases. Furthermore, analysis of Superoxide dismutase (SOD), Total antioxidant (TAO) and Uric Acid in these patients demonstrated only a minor change in SOD and TAO levels in relation to HCV core, though at the same time, Uric Acid was found raised in all the groups. CONCLUSIONS: These observations clearly indicate that core expression does not bring a significant change in serum level of lipids, lipoprotein and apoproteins. Similarly, HCV core expression also does not show a major change in SOD and TAO levels suggesting an insignificant impact of core on oxidative stress during liver diseases.

Transfusion transmitted virus: A review on its molecular characteristics and role in medicine.

The present review gives an updated overview of transfusion transmitted virus (TTV), a novel agent, in relation to its molecular characteristics, epidemiological features, modes of transmission, tissue tropism, pathogenesis, role in various diseases and its eradication from the body. TTV, a DNA virus, is a single stranded, non-enveloped, 3.8 kb long DNA virus with a small and covalently closed circular genome comprising 3852 bases. It was tentatively designated Circinoviridae virus. TTV genome sequence is heterogeneous and reveals the existence of six different genotypes and several subtypes. TTV has been reported to transmit not only via parenteral routes, but also via alternate routes. This virus has been detected in different non-human primates as well. At present, TTV is detected by polymerase chain reaction (PCR) with no other available diagnostic assays. It shows its presence globally and was detected in high percent populations of healthy persons as well as in various disease groups. Initially it was supposed to have strong association with liver disease; however, there is little evidence to show its liver tropism and contribution in causing liver diseases. It shows high prevalence in hemodialysis patients, pointing towards its significance in renal diseases. In addition, TTV is associated with several infectious and non-infectious diseases. Though, its exact pathogenesis is not yet clear, TTV virus possibly resides and multiplies in bone marrow cells and peripheral blood mononuclear cells (PBMCs). Recently, attempts have been made to eradicate this virus with interferon treatment. More information is still needed to extricate various mysteries related to TTV.

Transfusion-transmitted virus in association with hepatitis A-E viral infections in various forms of liver diseases in India.

AIM: To describe the prevalence of transfusion-transmitted virus (TTV) infection in association with hepatitis A-E viral infections in different forms of liver diseases in North India. METHODS: Sera from a total number of 137 patients, including 37 patients with acute viral hepatitis (AVH), 37 patients with chronic viral hepatitis (CVH), 31 patients with cirrhosis of liver and 32 patients with fulminant hepatic failure (FHF), were analyzed both for TTV-DNA and hepatitis A-E viral markers. Presence of hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis E virus (HEV) infections was detected in different proportions in different groups. Moreover, TTV-DNA was simultaneously tested in 100 healthy blood donors also. RESULTS: None of the patients had hepatitis A virus (HAV) and hepatitis D virus (HDV) infections. Overall prevalence of TTV-DNA was detected in 27.1% cases with AVH, 18.9% cases with CVH, 48.4% cases with cirrhosis and 9.4% cases with FHF. TTV-DNA simultaneously tested in 100 healthy blood donors showed 27% positivity. On establishing a relation between TTV infection with other hepatitis viral infections, TTV demonstrated co-infection with HBV, HCV and HEV in these disease groups. Correlation of TTV with ALT level in sera did not demonstrate high ALT level in TTV-infected patients, suggesting that TTV does not cause severe liver damage. CONCLUSION: TTV infection is prevalent both in patients and healthy individuals in India. However, it does not have any significant correlation with other hepatitis viral infections, nor does it produce an evidence of severe liver damage in patients with liver diseases.

Cholangicarcinoma Presenting as a Sister Mary Joseph Nodule.

Sister Mary Joseph nodules represent metastatic cancer of the umbilicus. More than half of these cases are attributable to gastrointestinal malignancies including gastric, colonic, and pancreatic cancer. In addition, gynecologic (ovarian, uterine cancer), unknown primary tumors, and, rarely, bladder or respiratory malignancies may cause umbilical metastasis. We report the case of a Sister Mary Joseph nodule originating from a hilar cholangiocarcinoma. Umbilical nodules should prompt clinical evaluation, as these tumors are usually associated with poor prognosis.

Lactose intolerance in North and South Indians.

A multicenter study was carried out in India to determine the incidence of lactose intolerance in healthy volunteers from different parts of the country. The incidence was found to be 66.6% in the subjects from two South Indian centers at Trivandrum and Pondicherry. In contrast, the incidence in the subjects from a North Indian center in New Delhi was much lower, i.e., 27.4% (p less than 0.001). The lower incidence in the North Indian subjects may perhaps be due to the fact that they are descendants of the Aryans who have been dairying for long and are known to be lactose tolerant.

An enzyme-linked immunosorbent assay (ELISA) for the detection of IgG and IgM anti-idiotypes directed against anti-HBs molecules.

A simple and specific enzyme-linked immunosorbent assay (ELISA) has been developed to detect circulating IgG and IgM anti-idiotypic antibodies directed against anti-HBs molecules using 96-well polyvinyl microtitre plates as the solid phase and HRPO-labelled goat anti-HBs as conjugate. Anti-idiotype reactions were observed in the supernatant portion after precipitation of immune complexes from sera with polyethylene glycol 6000 (PEG). Both IgG and IgM with anti-idiotype activity were detected concurrently in HBsAg-positive sera from HBV-infected patients and asymptomatic HBV carriers. Anti-idiotype activity was absent in HBsAg-negative sera from healthy persons, and in patients with non-A, non-B hepatitis and viral hepatitis A. However, such antibodies could be demonstrated in the sera of two out of eight HBsAg vaccine recipients negative for anti-HBs but in none of 11 recipients positive for anti-HBs after receiving a booster immunising dose of HBsAg vaccine. Those sera showing positive anti-idiotype reactions were free from rheumatoid factor and HBsAg/IgM or HBsAg/IgG complex activity. An analysis of anti-idiotype positive sera for anti-HBs, HBeAg and HBV-specific DNA-polymerase activity demonstrated these markers in 20%, 30% and 60% of cases, respectively. The presence of anti-idiotypic antibodies was presumed to permit a more active multiplication of hepatitis B virus.

Studies on HBsAg binding with polymerised human serum albumin by ELISA.

A simple and sensitive ELISA was developed to characterize the interaction between polymerised human serum albumin (pHSA) and HBsAg, using pHSA-coated polyvinylmicrotitre plates as solid phase and anti-HBs-coupled HRPO as the conjugate. The interaction was found to be specific and dependent on the size of albumin polymer. pHSA-binding activity (pHSA-BA) was studied in both HBsAg-negative and HBsAg-positive sera from various liver diseases including acute viral hepatitis, fulminant hepatitis, cirrhosis of liver, chronic active hepatitis, and healthy HBsAg carriers. pHSA-BA was detected only in HBsAg-positive sera. Analysis of HBsAg-positive sera indicated pHSA-BA in high proportions of patients sera as compared to sera from healthy HBsAg carriers. pHSA-BA was detected both in the presence and absence of HBe markers, though the mean BA was relatively high in presence of HBeAg. The effect of human serum immunoglobulins (IgG, IgA, and IgM) on the BA was investigated and a correlation between pHSA-BA and HBsAg-IgM complex positivity in sera was established. Finally, the probable role of human serum IgM in facilitating the binding process was discussed.

Superoxide dismutase and total anti-oxidant levels in various forms of liver diseases.

In order to understand the impact of viral hepatitis on anti-oxidant defence system of the body, blood levels of superoxide dismutase (SOD), an enzymatic anti-oxidant, and total anti-oxidant (TAO) were evaluated and co-related to etiological viral hepatitis in various forms of liver diseases. A total number of 110 patients including 50 patients with acute viral hepatitis (AVH), 30 patients with chronic active hepatitis (CAH) and 30 patients with cirrhosis of liver were analysed for different hepatitis viral markers and the anti-oxidant levels in their blood. For comparison, blood from 100 healthy persons were also simultaneously tested for anti-oxidant levels. Analysis of results indicated that none of the patients belonging to these three liver diseases had hepatitis A viral (HAV) and hepatitis D viral (HDV) infections. AVH group had mainly hepatitis B viral (HBV), hepatitis C viral (HCV) and hepatitis E viral (HEV) infections, CAH group had B and C infections and cirrhosis group had B, C and E infections. A sizeable number of patients in each group had no markers and were labelled as non-BCE group. On co-relating anti-oxidant levels to viral etiology in these patients, it was observed that in comparison to healthy control group, SOD level was significantly reduced in all the patients irrespective of the viral etiology (P<0.05-0.001). The impact of different viruses on reduction in SOD level was recorded to be the same with no significant difference in SOD level between any two viral infections. On the contrary, TAO level in the majority of patients was found to be comparable with that observed in healthy persons. An appreciable change in SOD level but little impact on TAO level during viral hepatitis may be explained by the possible adaptive rise of some other anti-oxidant level in the blood of these patients.

Prevalence of hepatitis C virus antibodies in the general population & in selected groups of patients in Delhi.

We report on the prevalence of anti-HCV antibodies in healthy individuals and patient groups with different liver diseases. The healthy population comprising 234 voluntary blood donors and 65 pregnant women with no history of liver diseases, had a per cent positivity of 1.5 anti-HCV in each group. The patients groups comprising 32 with acute viral hepatitis, 110 with fulminant hepatic failure, 65 with subacute hepatic failure, 33 with chronic active hepatitis, 45 with cirrhosis and 10 with hepatocellular carcinoma, had anti-HCV per cent positivity of 12.5, 43.6, 41.5, 48.5, 8.8 and 0 respectively. Anti-HCV was also tested in sera from 9 patients who had developed post-transfusion hepatitis and was recorded in 2 (22.2%) within one year of transfusion.

Role of enteral hyperalimentation in patients of carcinoma oesophagus.

The nutritional status of 24 patients of carcinoma oesophagus was assessed before and after central hyperalimentation with a liquid blenderized diet containing 3000-3500 cal and 100-120 g protein. The overall prevalence of malnutrition was found to be 70.8 per cent before the initiation of therapy. Of the various parameters used for assessment of nutritional status weight loss was the most common finding (91.6%) followed by alteration in midarm circumference, haemoglobin, triceps skin fold thickness, midarm muscle circumference and serum albumin. Enteral hyperalimentation for 10 days improved nutritional status by inducing significant gain in body weight (74.1%), triceps skin fold thickness (50%), midarm circumference (58%), midarm muscle circumference (62.5%) and serum albumin levels (91.6%). There was no significant change in haemoglobin levels.

A preliminary open trial on interferon stimulator (SNMC) derived from Glycyrrhiza glabra in the treatment of subacute hepatic failure.

The efficacy of the interferon stimulator named Stronger Neo Minophagen-C (SNMC) derived form the plant G. glabra was studied at a dose of 40 or 100 ml daily for 30 days followed by thrice weekly intravenously for 8 wk in 18 patients of subacute hepatic failure due to viral hepatitis. The survival rate amongst these patients was 72.2 per cent, as compared to the earlier reported rate of 31.1 per cent in 98 patients who received supportive therapy (P < 0.01). Death in four of the five patients was due to associated infections leading to hepatorenal failure and terminal coma. Further studies are necessary to standardize the dose and duration of therapy with SNMC in subacute hepatic failure.

Animal transmission of enteric non-A, non-B hepatitis infection to Macaca mulatta by faeco-oral route.

M. mulatta monkeys were inoculated faeco-orally by enteric non-A, non-B virus to study the development of clinical, biochemical, histopathological and serological changes in the blood and liver. Pooled stool samples positive for putative non-A, non-B viral antigen by micro-ELISA and aggregated viral particles by immune electron microscopy, were administered in two M. mulatta monkeys. Biochemical, histopathological and serological changes were seen in the blood and liver and excretion of 27 nm virus like particles around 27 days of inoculation in the experimental monkey but not in the control animal.

Role of immune serum globulin in post transfusion virus B infection.

Fifty four blood recipients were administered prophylactic immune serum globulin (31) or hepatitis B immune globulin (23) and followed up for six months. None of the patients developed either acute hepatitis B or HBsAg carrier state. However, 7 (14%) had anicteric self limiting non-B post-transfusion hepatitis. Twenty (40%) of the blood recipients developed anti-HBs during the follow up period suggesting either HBV exposure by subdetectable levels of HBsAg present either in blood or immunoglobulin preparation or due to passive transfer by administration of immunoglobulins.

Outcome of hepatitis E virus infection in Indian pregnant women admitted to a tertiary care hospital.

BACKGROUND AND OBJECTIVES: information on the incidence and prevalence of hepatitis E virus (HEV) infection in Indian pregnant women is scanty. Only a few studies have been done so far to document the vertical route of transmission of this virus. We therefore studied the prevalence of HEV infection in pregnant women with hepatitits and the outcome of their pregnancy. METHODS: fifty pregnant women with clinical hepatitits were included in the study. After informed consent, their blood samples were tested for potential causes of hepatitis including hepatitis A, B, hepatitis C, and hepatitis E infections. RESULTS: of the 50 cases, 20 (40%) patients were found to be positive for IgM anti -HEV (group A) and 30 (60%) were negative for IgM anti-HEV antibodies (group B). Overall 19 patients were in their second trimester while 30 were in third trimester. Of these 52.6 per cen (10/19) of those in second trimester and 50 per cent (15/30) in third trimester had fulminant hepatic failure (FHF). Only one patient presented in the first trimester who had acute viral hepatitis (AVH) and recovered completely. Of the HEV infected women, 70 per cent were in their third trimester and remaining 30 per cent in second trimester of pregnancy. A similar percentage of patients i.e., 14 of 20 (70%) manifested with FHF while 6 (30%) had acute hepatitis leading to recovery. The percentage of women with FHF and acute hepatitis was 36.6 and 63 per cent, respectively, in group B. Upon follow up all the 13 of the 14 HEV infected patients with FHF expired and only one delivered a male baby during the illness. The fatality rate in HEV infected patients was not different between the second and third trimesters (66.6% vs. 71.43%), respectively). INTERPRETATION AND CONCLUSIONS: this study suggests that HEV causes high mortality in pregnant women as compared to non-HEV infected pregnant women. This pilot study indicates that steps should be taken to prevent HEV infection during pregnancy.

A prospective study on the incidence of hepatitis B & C infections amongst patients with lymphoproliferative disorders.

Fifty one patients with acute lymphoblastic leukaemia (ALL) and non-Hodgkins lymphoma (NHL) undergoing chemotherapy were studied prospectively to determine the incidence, aetiology and natural course of hepatitis. Of 51 patients (31 NHL and 20 ALL), 22 developed hepatitis. Hepatitis B (IgM anti HBc positive) was the cause in 11 patients (50%), hepatitis C in 4 patients, and septicaemia and cytotoxic drugs in 3 patients each. Malignant infiltration of the liver was the cause in the remaining 1 patient. Hepatitis was predominantly (75%) anicteric. Mean duration of hepatitis was 21 days. Of 51 patients, 21 acquired hepatitis B and/or C virus infection. They had received 6.4 (+/- 3.4) units of packed red cells and 5.3 (+/- 11) units of platelet concentrate as compared to 3.4 (+/- 4.8) units of red cells and 5.3 (+/- 12.1) units of platelet concentrate received by those who did not acquire virus infection (P < 0.05 for packed red cells). Only transient stoppage of chemotherapy was necessary following development of hepatitis and most of the patients who developed hepatitis could complete their chemotherapy schedule. None of the patients who developed viral B or C infection cleared the infection. We conclude that there was a high incidence of hepatitis B and C infection amongst patients with lymphoproliferative disorders with an increased carrier rate. Transfusion was a major risk factor for such infections.

Prevalence of hepatitis B virus infection in healthy persons in North India.

BACKGROUND: There is scant information on the main methods through which hepatitis B virus infection is transmitted in India. We, therefore, studied the prevalence of hepatitis B surface antigen and antibody to hepatitis B surface antigen in voluntary blood donors as well as in those healthy groups who have a high risk of contracting this infection. METHODS: The groups at risk studied included commercial sex workers (635), eunuchs (28), truck drivers (217), professional blood donors (1117) and health care workers (1313). In addition, 20,435 voluntary blood donors were also studied. RESULTS: Hepatitis B surface antigen (and its antibody) was positive in 2.6% (14%) of voluntary blood donors, 3.6% (19%) of commercial sex workers, 5% (16%) of truck drivers, 12% (9%) of professional donors, 1.4% (19%) of health care workers and none (18%) of the eunuchs. Except professional donors and truck drivers, none of these groups had a higher positivity than the normal population (2.6%). CONCLUSIONS: Our results indicate that in India the so-called high risk groups, other than truck drivers and professional blood donors, are unlikely to represent major sources of infection.

A randomized trial of oral refeeding compared with jejunal tube refeeding in acute pancreatitis.

BACKGROUND: Relapse of pain during refeeding in acute pancreatitis may have a relation to the route of refeeding. AIM: To compare the efficacy of oral refeeding with jejunal tube refeeding in patients with acute pancreatitis, and determine the frequency of refeeding pain and factors associated with it. METHODS: Consecutive patients with acute pancreatitis, severe enough to stop oral feeding for 48 hours, were randomized to receive either oral or jejunal tube refeeding. The feeds were similar in calorie, lipid and protein content (400 Kcal on day 1, 1000 Kcal on day 2, 1400 Kcal on day 3, 1500 Kcal on day 4, and 1700 Kcal on day 5). Clinical and biological factors (serum amylase, lipase, C-reactive protein) and Balthazar CT severity index were recorded. Frequency of pain relapse and factors associated with it were analyzed. RESULTS: 28 patients with acute pancreatitis (biliary 14, alcohol 9, idiopathic 3, post-ERCP 2) were included. Fifteen patients received oral and 13 received enteral tube refeeding. Four patients in the oral group and none in the enteral tube group had relapse of pain (p=0.06). The factors associated with refeeding pain were longer duration of initial pain (p<0.02) and higher CT severity index (p<0.02). Pain relapse increased the total hospital stay (p<0.004) and hospital stay after the first attempt at feeding (p<0.001). CONCLUSIONS: Jejunal tube refeeding may reduce the frequency of pain relapse as compared to oral refeeding although the difference was not significant in this study. Longer duration of pain and higher CT severity index score were associated with occurrence of refeeding pain.