Tube feeding info.

 

Some important points regarding tube feeding (enteral nutrition) and gastroparesis:

 

Carol Rees Parrish RD, MS

Nutrition Support Specialist

University of Virginia Health System (UVAHS)

Digestive Health Center of Excellence

Charlottesville, VA

 

Carol recently presented to the GPDA initiative on: Gastroparesis, Consensus Guidelines for Treatment, September 12, 2004, Rochester, MN

 

Here is an excerpt from her presentation:

 

Gastroparesis presents a challenge to maintaining adequate nutrition. Dietary modification can help subdue the symptoms of gastroparesis. Learning some dietary modifications can be very helpful; yet for others, further steps will be needed to halt weight loss and malnourishment. First and foremost, my concern as a nutritionist is to create a hierarchy of whom we need to start nutritional support on immediately and who can wait, as attempts with various prokinetic/antiemetic agents are tried and exhausted.

 

Many of the diet restrictions quoted or advised by clinicians have not been studied. We really know very little about diet therapies for patients with gastroparesis. Gastroparetic patients are often advised to avoid fats and fibers. Yet in my clinical experience, fat, in the liquid form of ice cream or as part of beverages such as whole milk or Ensure, is often well-tolerated. To take fat out of the diet of a patient faced with malnourishment is to remove a tremendous calorie source. As far as I'm concerned as a nutritionist, any nutrient, any calorie, is a good calorie, especially for someone who is now unintentionally down 30 pounds, and we are talking about putting a tube in their abdomen to feed them.

 

What about fiber? Well, a lower fiber diet is definitely appropriate. There is worry regarding bezoar formation, though that is rare. A bezoar is a congealed, retained mass of food, which may block the lower stomach outlet or pylorus. They form as a result of the weakened propulsive action of the stomach, failing to clear all solids. Some foods implicated in bezoar formations are:

 

Apples Figs Brussels sprouts Potato peels

Berries Oranges Green beans Sauerkraut

Coconuts Persimmons Legumes

 

Fortunately, many patients do not consume the foods on this list. Fiber supplements, such as Metamucil, Perdiem, and Citrucel, should be avoided. They may aggravate gastric emptying as well as cause bezoar formation.

 

For the patient with diabetes mellitus, good glucose control is vital. This goes without saying but is difficult to achieve with the unpredictable emptying of the gastroparetic stomach. We know hyperglycemia aggravates and impedes stomach emptying, especially if blood sugar levels are over 200 mg%. In addition, wide fluctuations in blood glucose levels may actually aggravate gastroparesis more than would a steady state of slightly higher glucose levels. More research is needed in this area. Furthermore, there is some published evidence to suggest that high glucose levels decrease the effectiveness of the pro-motility drug, erythromycin.

 

Of course I always recommend that people chew their foods well, as we all should. This brings up the point about dentition. Individuals experiencing prolonged bouts of chronic vomiting may not have been to the dentist for some time (because they are too busy being sick!). Teeth continually exposed to stomach acid can result in dental enamel loss. Acid prescription medication may help to slow this process since these drugs reduce stomach acid. A dental check-up is vital since the first step of food breakdown begins in the mouth. Gastroparetic patients need to maximize their ability to utilize and digest their meals.

 

Food intolerances are also important to recognize. Depending on the underlying cause for the gastroparesis, many patients experience intolerance to milk and milk products.

 

 

For example, individuals with gastroparesis from post-vagotomy syndrome often report problems with milk products. There are other potential nutrient problems, such as with iron, B12, and bone health in this patient population, which need to be investigated.

 

As a nutritionist, I also like to review, with the gastroenterologists I work with, all medications that an individual may be taking. Many medications are constipating. Often, patients with gastroparesis also experience constipation as a part of their gastrointestinal motor disturbance. The treatment that is instituted for constipation may aggravate gastroparetic symptoms, further limiting oral intake.

 

A word about blood tests.

I obtain a Hemoglobin A1C level on all patients I see with diabetes mellitus. It is important to know if the patient has good glucose control over time.

 

With regards to specific nutrient deficiencies, if an individual has suffered a significant weight loss, I presume total nutrient deficiency. However, depending on the severity of the gastroparesis, the key things I check on all patients are: serum ferritin (Iron), B12, and a 25-hydroxy vitamin D.

 

Blood levels of calcium are not a reliable indicator of calcium status. If the vitamin D status is poor, then it is valuable to obtain a dual-energy x-ray absorptiometry (DXA) scan. If this is abnormal, then I need to pay attention not only to vitamin D issues, but I also need to pay attention to calcium, especially with patients who don't tolerate milk or milk products. Osteoporosis is a problem in this country, it is probably a bigger problem in patients with gastroparesis and there is a link between low bone density and diabetes.

 

Baseline B12 levels are also worthwhile to obtain. A B12 deficiency is cheap and easy to treat. I would much rather find out earlier, than later, that a patient's stomach problem also included pernicious anemia or B12 deficiency. Patients with post-vagotomy syndrome are at much higher risk for low B12 levels.

 

What about nutritional support?

When do we consider enteral support, (that is, liquid feedings delivered through a tube placed into the small intestine)? The answer is: with anyone who has sustained significant weight loss, defined by most as a 5 to 10% loss over 3 to 6 months respectively, or, those with repeated hospital admissions for fluids and medications. An “enteral” tube may make the difference to insure good medication delivery and to try and break the cycle of repeat hospitalizations.

 

Many patients come to us from outside facilities, on total parenteral nutrition (TPN) (intravenous feeding via a tube placed into a large blood vessel). We will quickly take them off of it and switch them over to enteral nutrition. We have not used TPN in over ten years in this patient population and in my 14 years at UVAHS I've never put a patient with gastroparesis on TPN. I just don't think it's necessary, but that's probably because we do so much enteral feeding, that we have a lot of tricks up our sleeve to get patients off the ground with enteral nutrition. Enteral nutrition is certainly safer. It is also less labor- intensive for patients and families.

 

However, some individuals may not be mentally ready for enteral nutrition support. In this situation, it is important to mutually agree upon a weight “goal”. For instance, a no-compromise weight is agreed upon, and if weight dips below this level or if weight cannot be gained over a certain period of time, then it's time to institute nutritional support. It is important to set concrete goals with individuals.

 

Confused about tubes?

~Well you should be there are many different types, materials, sizes, and ways to place them. It depends upon who is providing you the service (a gastroenterologist, radiologist, or surgeon). As well, it depends upon each center's expertise and success with various tubes in patients with dysmotilities. Motility patients may require these tubes for extended periods.

 

~To vent or not to vent? Regarding “venting” of the stomach, until better data is available, it is not known whether this approach is helpful or not. Venting ports (PEG-J) are a procedure offered at some centers as a means to control vomiting, but it does not halt vomiting. Yet other centers feel that it is better not to vent the stomach. (These individuals would just have a “J” tube.) Finally, some individuals end up with two different tubes in the abdomen, one for venting (“G” tube) and one for feeding (“J” tube). Finally, some centers may have very little experience with “motility” patients, and unfortunately may not think through these issues before tube placement. Currently, we do not have any research, as yet, to help settle these controversies.

 

~Tube placement should not be an emergency procedure, so you have time to learn more and ask questions before someone “puts a tube into you”.

 

~The all-popular PEG, PEG-J and PEJ are done by the gastroenterologist using endoscopy.

 

~What do the letters stand for? The “P” means percutaneous, how the opening from the abdomen is established. The “E” stands for endoscopy, this is an endoscopically-placed tube. Finally, the last letter stands for the area of the digestive tract which is the intended target, “G” for gastric or stomach; G-J meaning a “G” access for venting and an extension arm which must pass through the pylorus and gain access into the portion of the small intestine called the jejunum for feeding; or skip all of that and go strait for the jejunum (“J”) with no gastric access.

 

Tube talk:

For enteral nutrition, at the University of Virginia Health System, we primarily use a percutaneous endoscopic gastrostomy with a jejunal extension tube (PEG-J). This allows patients to vent off gastric secretions if needed and hopefully stop their vomiting. In patients with PEG-J tubes, migration of the “J” arm back into the stomach does occur maybe in 10 to12% of our patients. We are more successful with this type of tube nowadays because of care with positioning it and because of newer PEG/Js. These newer tubes have the feeding ports further down, not just past the pylorus. In the older tubes, feeding ports were situated just past the pylorus where duodenal contents would regurgitate back up into the stomach. This regurgitation would make symptoms worse.

 

Patients are at the mercy of their particular facility when it comes to which type of enteral access is used and which tube type.

 

Who puts the “tubes” into place?

~A radiologist can accomplish the same results, by using fluoroscopy (a “real-time” x-ray) or ultrasound, to guide his/her efforts with placement. A temporary naso-gastric tube must first be placed before heading to the radiology department. The radiologist does not always use sedation. This perhaps can make for a very uncomfortable procedure and may not be the best approach for a “motility” patient.

 

~Surgical placement of tubes is rarely done unless surgery is needed for some other reason and tube placement is also undertaken, or endoscopy is not possible (example: a tumor obstructing the esophagus).

 

~The size of the tube matters! A larger diameter is better, creating fewer maintenance problems of clogging. Diameter size uses the terminology, size “__French”. A smaller number is a smaller diameter. Tube sizes from 8 to12 French should not be used for permanent placement due to clogging problems. Size 14 French up to 24 French is the more optimal range. Because of how they are placed, radiologically-placed tubes tend to be of a smaller size and can therefore run into maintenance problems (tube connections, clogging, etc.). Bigger is better.

 

~PEG-J tubes are gastric tubes with an internal extension arm that is manipulated to pass through the pyloric valve (lower valve of the stomach) to rest in the jejunum for feedings. Watch out some centers use very small-diameter (9 French) extension arms, you will plug up faster, and may also run into problems of vomiting the “J” arm back up into the stomach (a condition which can occur in up to 40% of these tubes).

 

~Many motility specialists do prefer a simple “J” tube. A large-size tube can be used with minimal risk of it being displaced back up into the stomach due to vomiting. Also, there are different ends on the tubes; a cone-shaped end is preferred over an inflatable balloon. Balloons, if over-inflated, can lead to a blockage. Radiologically-placed tubes tend to have a “curled” end and are smaller-diameter tubes. Finally an external “bumper” on the tube helps to keep it from sliding up and down and traveling where it should not!

 

Formulas:

We use the least expensive formula to get the job done. We have lots of resources for our patients, where to get products if the insurance doesn't cover, which is becoming more the norm. If they are fed gastrically, (yes, we have had patients that come to us with a gastrostomy tube in place before it was appreciated that they had gastroparesis), and before we go ahead and place a J arm, we will actually try low volume gastric feedings. This has not been studied. The assumption is we have to get past the stomach.

Elemental diets are rarely, if ever needed. There are some that assume that if one feeds past the pylorus, then the formula needs to be “pre-digested.” This is not correct.

 

Diabetic formulas have not been shown to be efficacious to date. We do not use them at our facility.

 

Products containing fiber are a good choice for most patients once jejunal access is achieved. The caveat to fiber formulas is that if a patient has bacterial overgrowth, we may aggravate symptoms by using a fiber-containing formula. If we have somebody on a fiber-containing product that experiences worsening of their symptoms, I think of two things. I think either that they've got bacterial overgrowth and we need to treat that with antibiotics, or we're eliciting the ileal break. This may require a change in formula to a non-fiber-containing product.

 

Most of our patients are fed during the night so they can go about their business during the day. We run flow rates up to “whatever their GI tract will bear”. We instruct patients at discharge to continue to increase the feeding rate by 10 mL every two or three days as tolerated until they reach a rate and number of hours of infusion they are happy with. We will then follow these people through our GI nutrition support clinic. For patients who feel “tethered to a pole” we will offer enteral backpacks. An enteral backpack holds up to 500 mL; patients can “infuse and cruise” so to speak during the day, and continue to get their hydration, nutrition support, and medications. An enteral backpack looks like a little fanny pack so no one needs to know that it is actually an infusion pump.

 

For patients who are fed via the jejunum, we use pump feeding; sometimes because of insurance issues, we are forced to use gravity drip feedings. Don't forget water! Water and medication flushing is very, very important, not only for hydration, but to ensure the medications do not clog the tube. Adequate water is especially important for those patients with diabetes.

 

I have talked a little bit about the ileal break and small bowel bacterial overgrowth the types of things that might crop up, which may make a clinician say, “The patient is not tolerating tube feeding; we need to move on to TPN”. We really work through these kinds of problems one step at a time. Most, if not all, can be solved. How do we feed these people? However we can!

 

What is the Ileal break?

~Gut motility is modulated by the composition of the nutrients we eat. High fat foods may slow or delay the delivery of food from the stomach to the small intestine. This may not be a problem for fats in liquid form.

 

~Once in the small intestine, high fat content, which makes its way down the last section of the small bowel (a region called the ileum) may trigger a response to slow down the delivery of stomach contents. The body is reacting to too much fat in the ileum. This “physiological” slowing of motility (breaking) helps improve absorption from above (that is, if nutrients reach the ileum, then “someone up above in the GI tract is not doing his job” so to speak). If this “breaking” occurs, it can produce symptoms such as bloating, abdominal distention, and increased symptoms (such as nausea and vomiting) in the upper digestive tract.

 

~Small bowel bacterial overgrowth may play a role in the “ileal-breaking” mechanism..