Gastrostomy Tube Enteral Feeding
Enteral Nutrition (EN), tube feeding, is given via different types of tubes. One type of tube feeding can be given via a tube placed down through the nose into the stomach or bowel, known as Nasoenteric Feeding and includes naso gastric (NG), naso duodenal and naso jejunal (NJ) feeding.
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SPECIFICATIONS
Enteral Feeding: How It Works and When It’s Used
Indications
Types
Procedure
Vs. parenteral feeding
Complications
Contraindications
Outlook
What is enteral feeding?
Enteral feeding refers to intake of food via the gastrointestinal (GI) tract. The GI tract is composed of the mouth, esophagus, stomach, and intestines.
Enteral feeding may mean nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine. In the medical setting, the term enteral feeding is most often used to mean tube feeding.
A person on enteral feeds usually has a condition or injury that prevents eating a regular diet by mouth, but their GI tract is still able to function.
Being fed through a tube allows them to receive nutrition and keep their GI tract working. Enteral feeding may make up their entire caloric intake or may be used as a supplement.
When is enteral feeding used?
Tube feedings may become necessary when you can’t eat enough calories to meet your nutritional needs. This may occur if you physically can’t eat, can’t eat safely, or if your caloric requirements are increased beyond your ability to eat.
If you can’t eat enough, you’re at risk for malnourishment, weight loss, and very serious health issues. This may happen for a variety of reasons. Some of the more common underlying reasons for enteral feeding include:
a stroke, which may impair ability to swallow
cancer, which may cause fatigue, nausea, and vomiting that make it difficult to eat
critical illness or injury, which reduces energy or ability to eat
failure to thrive or inability to eat in young children or infants
serious illness, which places the body in a state of stress, making it difficult to take in enough nutrients
neurological or movement disorders that increase caloric requirements while making it more difficult to eat
GI dysfunction or disease, although this may require intravenous (IV) nutrition instead
Types of enteral feeding
According to the American College of Gastroenterology, there are six main types of feeding tubes. These tubes may have further subtypes depending on exactly where they end in the stomach or intestines.
The placement of the tube will be chosen by a doctor based on what size tube is needed, how long enteral feeds will be required, and your digestive abilities.
A medical professional will also choose an enteral formula to be used based on tube placement, digestive abilities, and nutritional needs.
The main types of enteral feeding tubes include:
Nasogastric tube (NGT) starts in the nose and ends in the stomach.
Orogastric tube (OGT) starts in the mouth and ends in the stomach.
Nasoenteric tube starts in the nose and ends in the intestines (subtypes include nasojejunal and nasoduodenal tubes).
Oroenteric tube starts in the mouth and ends in the intestines.
Gastrostomy tube is placed through the skin of the abdomen straight to the stomach (subtypes include PEG, PRG, and button tubes).
Jejunostomy tube is placed through the skin of the abdomen straight into the intestines (subtypes include PEJ and PRJ tubes).
Procedure for placing the tube
NGT or OGT
Placement of a nasogastric tube or orogastric tube, while uncomfortable, is fairly straightforward and painless. Anesthesia isn’t required.
Typically a nurse will measure the length of the tube, lubricate the tip, place the tube in your nose or mouth and advance until the tube is in the stomach. The tube is usually secured to your skin using soft tape.
The nurse or doctor will then pull some gastric juice out of the tube using a syringe. They’ll check the pH (acidity) of the liquid to confirm that the tube is in the stomach.
In some cases, a chest X-ray may be needed to confirm placement. Once placement is confirmed, the tube may be used immediately.
Nasoenteric or oroenteric
Tubes that end in the intestines often require endoscopic placement. This means using a thin tube called an endoscope, which has a tiny camera on the end, to place the feeding tube.
The person placing the tube will be able to see where they’re putting it via the camera on the endoscope. The endoscope is then removed, and placement of the feeding tube may be confirmed with aspiration of gastric contents and X-ray.
It’s common practice to wait 4 to 12 hours before using the new feeding tube. Some people will be awake during this procedure, while others may require conscious sedation. There’s no recovery from the tube placement itself, but it may take an hour or two for the sedation medications to wear off.
Gastrostomy or jejunostomy
Placement of gastrostomy or jejunostomy tubes is also a procedure that may require conscious sedation, or occasionally general anesthesia.
An endoscope is used to visualize where the tube needs to go, and then a tiny cut is made in the abdomen to feed the tube into the stomach or intestines. The tube is then secured to the skin.
Many endoscopists choose to wait 12 hours before using the new feeding tube. Recovery may take five to seven days. Some people experience discomfort at the tube insertion site, but the incision is so small that it typically heals very well. You may receive antibiotics to prevent infection.
Enteral vs. parenteral feeding
In some cases, enteral feeding may not be an option. If you’re at risk for malnutrition and don’t have a functional GI system, you may need an option called parenteral feeding.
Parenteral feeding refers to giving nutrition through a person’s veins. You’ll have a type of venous access device, such as a port or a peripherally inserted central catheter (PICC or PIC line), inserted so you can receive liquid nutrition.
If this is your supplementary nutrition, it’s called peripheral parenteral nutrition (PPN). When you’re getting all of your nutritional requirements through an IV, it’s often called total parenteral nutrition (TPN).
Parenteral feeding can be a life-saving option in many circumstances. However, it’s preferable to use enteral nutrition if at all possible. Enteral nutrition most closely mimics regular eating and can help with immune system function.
Possible complications of enteral feeding
There are some complications that can occur as a result of enteral feeding. Some of the most common include:
aspiration, which is food going into the lungs
refeeding syndrome, dangerous electrolyte imbalances that may occur in people who are very malnourished and start receiving enteral feeds
infection of the tube or insertion site
nausea and vomiting that may result from feeds that are too large or fast, or from slowed emptying of the stomach
skin irritation at the tube insertion site
diarrhea due to a liquid diet or possibly medications
tube dislodgement
tube blockage, which may occur if not flushed properly
There are not typically long-term complications of enteral feeding.
When you resume normal eating, you may have some digestive discomfort as your body readjusts to solid foods.
Who shouldn’t have enteral feeding?
The main reason a person wouldn’t be able to have enteral feeds is if their stomach or intestines aren’t working properly.
Someone with a bowel obstruction, decreased blood flow to their intestines (ischemic bowel), or severe intestinal disease such as Crohn’s disease would likely not benefit from enteral feedings.
The outlook
Enteral feeding is often used as a short-term solution while someone recovers from an illness, injury, or surgery. Most people receiving enteral feeds return to regular eating.
There are some situations where enteral feeding is used as a long-term solution, such as for people with movement disorders or children with physical disabilities.
In some cases, enteral nutrition can be used to prolong life in someone who is critically ill or an older person who can’t maintain their nutritional needs. The ethics of using enteral feeding to prolong life have to be evaluated in each individual case.
Enteral feeding can seem like a challenging adjustment for you or a loved one. Your doctor, nurses, a nutritionist, and home health care providers can help make this adjustment a successful one.
USER MANUAL
FREQUENTLY ASKED QUESTIONS
Helpful Hints
Medication Administration Through Enteral Feeding Tubes
Nancy Toedter Williams, Pharm.D., BCPS, BCNSP
Am J Health Syst Pharm. 2008;65(24):2347-2357.
Enternal Access Sites and Delivery Methods
Various enteral feeding tubes are available for delivering medications and nutrients to the patient. The tubes are typically classified by site of insertion (e.g., nasal, oral, percutaneous) and location of the distal tip of the feeding tube (e.g., stomach, duodenum, jejunum) (Figure 1). The choice of an enteral access route depends on several factors, including the patient’s concurrent diseases or injuries, the presence or risk of impaired gastric motility or aspiration, and the anticipated duration of nutrition support. The stomach is traditionally used for delivery of EN because use of this site is generally more convenient, less costly, and less labor intensive than others. The stomach is also able to tolerate various medications and enteral formulas, including hypertonic preparations. However, small bowel access may be preferred in patients with pancreatitis, gastro-paresis, or severe gastroesophageal reflux disease, as well as in patients who have consistently high gastric residual volumes or who are at greater risk for aspiration. Jejunal feedings have not consistently been proven to reduce aspiration, and they may cause abdominal cramping and diarrhea.[6,7,8,9,10]
Figure 1.
For patients who require short-term EN, nasoenteric feeding tubes are commonly used because they are easier to place and less costly than other enteral access routes. These feeding tubes may be inserted nasally, with the distal end of the tube in the stomach (nasogastric [NG]) or in the small intestine (nasoduodenal [ND] or nasojejunal [NJ]). A tube inserted through the mouth into the stomach (orogastric [OG]) is another option for short-term feeding, particularly when a tube cannot be placed nasally because of head injury or sinusitis. The OG route may also be reserved for premature or small infants who can only breathe through their nose.[6,7,8,10] For patients who require long-term EN (i.e., more than four to six weeks), percutaneous feeding tubes may be inserted in the stomach, duodenum, or jejunum via laparotomy, laparoscopy, endoscopy, or fluoroscopy. Percutaneous endoscopic gastrostomy (PEG) is the most popular technique used for obtaining long-term enteral access because it can be performed under conscious sedation in an endoscopy center or even at the bedside. Using this method can help reduce costs, avoid general anesthesia, and shorten the recovery period.[6,7,8]
Enteral feeding may be administered by various methods, including continuous, cyclic, bolus, and intermittent. The delivery method is determined by the tip location of the feeding tube (e.g., gastric, jejunal), the patient’s clinical condition and tolerance to EN, and the overall convenience.[6] Continuous feedings are administered at a slow, continuous rate over a 24-hour period with sporadic interruptions for drug delivery or medical procedures. This is the preferred method when initiating EN in hospitalized patients, when infusing EN directly into the small bowel, and when patients are critically ill.[6] However, this method is also the most problematic for drug–nutrient interactions and frequently requires interrupting tube feedings when administering medications. Repeatedly interrupting continuous feedings for drug delivery is also challenging for health care workers because they have to stop and restart the feedings in a timely manner before and after medication administration. Additionally, the tube feeding rate may need to be increased to provide appropriate nutrition during the shortened infusion period.
Cyclic EN administration involves continuous feeding over a specified period (i.e., 8–20 hours per day). It is generally infused at night, thus allowing independence from the feeding equipment during the day and also encouraging oral intake in the daytime. Like continuous administration, this delivery method may be used when feeding into the stomach or small intestine.[6,11]
Bolus feedings closely mimic usual eating patterns and involve the infusion of EN over a short time period at specified intervals—usually four to six times per day. This rapid delivery method is commonly used when feeding into the stomach, and it is generally not well tolerated in patients with small bowel access; however, it offers the advantage of allowing medication administration to be separated from the feedings.[6,11]
Intermittent administration of EN uses a similar technique to that of bolus feeding, but it is used over a longer duration, which may help improve tolerance. This delivery method is also not recommended when feeding into the small bowel.[6,11]