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The words "tube feeding" suggest to most people a transnasal tube into the stomach, with all the discomfort that entails. The review summarized here considers a welcome alternative to transnasal feeding for elderly patients with malnutrition.
Severe malnutrition demands intensive nutritional support. Although patients should be encouraged to take food by the natural route for as long as possible, artificial nutrition is needed if their requirements cannot be met this way. In particular, tube feeding is necessary in cases of neoplasia (cachexia, stenosing tumors of the oropharynx and upper GI tract), neurological diseases (stroke, brain tumor, Parkinson's disease), and psychiatric disorders (Alzheimer disease, depression, psychosis), and persistent vegetative state.
Enteral nutrition can be done in several ways -- transnasal tube, percutaneous endoscopic gastrostomy (PEG), and fine-needle-catheter jejunostomy (FCJ).
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Transnasal tube
This is the simplest method, which has been used for many decades. The tube is passed through the nose and then into the stomach, duodenum or jejunum. Direct placement should be verified by radiography. Nasal tubes induce a foreign-body sensation in the pharynx, and may cause reflux esophagitis and pressure ulcers. They also have a tendency to dislodge. Older, confused patients often tolerate them poorly, necessitating repeated insertion and even restraint. As the presence of the tube interferes with swallowing they are unsuitable for patients with potentially reversible dysphagia.
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Percutaneous endoscopic gastrostomy
A gastroscope is inserted into the stomach and air insufflated. Then, under local anesthesia, a puncture needle containing a guide thread is passed through the abdominal wall into the stomach. Using the gastroscopy forceps, the thread is withdrawn from the stomach, together with the gastroscope. The proximal end of the thread is attached to a catheter, which is pulled by gentle traction through the mouth, esophagus and stomach wall to the exterior, until it's retaining disk is against the inside of the stomach wall.
This procedure is simple, free of complications, and well tolerated by patients. The most serious complications are peristomal leakage with peritonitis, necrotizing fasciitis of the anterior abdominal wall and gastric bleeding; these are seen in <1% of patients. Mild peristomal wound infection is more common (<30% of patients), but can be minimized by regular skin and stomal care. A useful refinement is a catheter end that allows a replacement tube to be inserted without the need for repeat gastroscopy.
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Fine-needle-catheter jejunostomy
These catheters are usually inserted only in conjunction with abdominal surgery. They are technically easy to insert, and have the same advantages and disadvantages as PEG. The most frequent serious complication is dislodgement.
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Enteral feeding
Industrially manufactured balanced diets are normally used. They usually yield one kilocal/mL and are roughage-free. They may be classified as high molecular weight, nutrient-defined diets (NDD), or low molecular weight, chemically defined diets (CDD).
Standard NDDs contain 15-20% protein, 25-35% fat and 45-55% carbohydrate. Their main nutrients are high-quality native protein, polysaccharides, and plant oils. Their use presupposes intact digestive and absorptive functions.
Patients with impaired digestion and absorption require CDDs. They chiefly contain oligo-peptides (pre-digested protein hydrolysates), 60-70% oligo- and mono-saccharides, and 15-20% medium-chain triglycerides.
The best physiological way of artificial feeding is via a tube into the stomach, with nutrient given intermittently, often by gravity, so that the gastric contents pass to the small intestine in portions. However, intermittent feeding can cause regurgitation, aspiration and dumping. Putting the feed in the upper small intestine directly is indicated if there is stenosis of the pylorus or upper intestine, in unconscious patients because of the risk of aspiration, and in patients with diabetic gastroparesis; with this placement, a pump should administer nutrient continuously.
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Complications of tube feeding
The most common complications are gastro-intestinal in origin, but it should be remembered that sometimes they can be caused by the underlying condition, or the treatment being given. Symptoms must be assessed for their cause, which is then treated accordingly.
- Diarrhea - may be caused by too rapid increase in amount of daily food, too rapid administration, cold food, high osmolarity of food, lactose intolerance, fat malabsorption, long-term antibiotics, or chemotherapy/radiation.
- Nausea/vomiting - too rapid administration, contamination of food/apparatus.
- Cramps/bloating - too rapid administration, lactose intolerance, fat malabsorption.
- Regurgitation/aspiration - gastric retention. (Patient should be put in inclined position.)
- Constipation - inadequate fluid intake, too little roughage.
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Treatment at home
Artificial enteral feeding can be accomplished at home, provided the patient and caregiver are fully trained by an experienced hospital team. The benefit in the patient's quality of life is considerable.
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