Enteral Feeding

Question 1

Enteral Feeding - Key Points

Answer 1

Enteral feeding

Key points
Identify patients as malnourished or at risk (see below)
Identify unsafe or inadequate oral intake with functional GI tract
Consider for enteral feeding
Gastric feeding unless upper GI dysfunction (then for duodenal or jejunal tube)
Check NG placement using aspiration and pH (check post pyloric tubes with AXR)
Gastric feeding > 4 weeks consider long-term gastrostomy
Consider bolus or continuous feeding into the stomach
ITU patients should have continuous feeding for 16-24h (24h if on insulin)
Consider motility agent in ITU or acute patients for delayed gastric emptying. If this doesn’t work then try post pyloric feeding or parenteral feeding.
PEG can be used 4 hours after insertion, but should not be removed until >2 weeks after insertion.

Surgical patients due to have major abdominal surgery: if malnourished, unsafe swallow/inadequate oral intake and functional GI tract then consider pre operative enteral feeding.

Question 2

Patients at risk of being malnourished

Answer 2

Patients identified as being malnourished
BMI < 18.5 kg/m2
unintentional weight loss of > 10% over 3-6/12
BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12

AT RISK of malnutrition
Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
Poor absorptive capacity
High nutrient losses
High metabolism

Reference

Stroud M et al. Guidelines for enteral feeding in adult hospital patients. Gut 2003; 52(Suppl VII):vii1 - vii12.

Question 3

Gastrotomy Tube - Example Question

Answer 3

A 72-year-old male under palliative care for metastatic antral gastric carcinoma presented to the Emergency Department on a Friday night. He was worried as the gastrostomy tube withdrew accidentally while he was taking a shower. This tube was used as a feeding route. On examination the patient was fully conscious, blood pressure 123/75 mmHg and pulse rate 94/min. His abdomen was soft and non-tender. Blood investigations showed:

Hb 114 g/l
Platelets 220 * 109/l
WBC 7.7 * 109/l

You are the core trainee doctor responsible for the patient care. What is the most appropriate action you should take?

Discharge with advice to come on Monday for senior review
Insertion of nasogastric tube as an alternative feeding pathway and discharge
> Insertion of Foley's catheter in the previous gastrostomy opening
Admission and monitor
Trial to re insert the gastrostomy tube

A gastrostomy tube is mainly used in cases of proximal gastrointestinal tract obstruction to facilitate feeding. If it withdrew accidentally, reinsertion of the tube as soon as possible would be the preferred action. However, it needs a good level of expertise to do this. Therefore, in this case, insertion of a Foley’s catheter is the best practice as it is easy to do and this should preserve the opening of the skin and anterior abdominal wall muscles until a someone experience enough is available to re-insert the gastrostomy tube. Waiting until Monday would result in a higher chance of spontaneous closure of the opening.

A nasogastric tube is not the correct option because it would not bypass the antral tumour.

Question 4

Gastrostomy Tube

Answer 4

A gastrostomy tube is mainly used in cases of proximal gastrointestinal tract obstruction to facilitate feeding.

If it withdrew accidentally, reinsertion of the tube as soon as possible would be the preferred action.

However, it needs a good level of expertise to do this. Therefore, if there is no specialist available, insertion of a Foley’s catheter is the best practice as it is easy to do and this should preserve the opening of the skin and anterior abdominal wall muscles until a someone experience enough is available to re-insert the gastrostomy tube. Waiting for specialist insertion would result in a higher chance of spontaneous closure of the opening.

A nasogastric tube cannot replace the function of a gastrostomy because it would not bypass the proximal GI tract obstruction/tumour.