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Enteral (NG/PEG) Nutrition

In recent years, research has increased on the use of iso-osmolar tube feedings by either a small-bore nasogastric (NG) feeding tube, or a percutaneous endoscopic gastrostomy (PEG) tube as an alternative to parenteral (intravenous) nutrition. Sometimes, the tube will be advanced into the jejunum instead for added safety and tolerance.

One should not assume that the metabolic complications of parenteral nutrition will avoided by use of enteral nutrition, nor is it without risk. The most common risks include tube displacement, pulmonary aspiration and poor patient tolerance. Many women with HG have delayed gastric emptying, extremely sensitive gag reflexes, and frequent vomiting which make this therapy intolerable and somewhat risky. Some of these women report repeated dislodgements due to vomiting.

The benefits of avoiding gut atrophy and improved nutrient metabolism, may not outweigh the risks in this patient population, especially during the acute phase of illness. Further, many women benefit greatly from a period of gut rest, yet require nutritional support after weeks of vomiting and limited intake. Intravenous nutrition is preferred initially in these women.

Research & Risks

A few studies have demonstrated that enteral nutrition may be a safe and effective alternative to TPN in selected pregnant women with hyperemesis gravidarum (HG) who have failed conventional treatment. However, these studies have only a few patients of varying severity, and thus should be interpreted cautiously. It is not yet clear as to which women with HG are the best candidates. It should be noted that women with HG have several risk factors for aspiration, as well as Refeeding Syndrome, both potential complications of enteral nutrition. (See lists below.)

Careful monitoring is important when initiating this therapy. The best advice when initiating nutritional support is to "start low and go slow". In women who continue to vomit, more aggressive antiemetic therapy should be considered, and/or an alternative mode of nutritional support.

Risk Factors for Aspiration

  • Decreased level of consciousness (sedative medication)
  • Diminished gag reflex
  • Incompetent low esoph. sphincter
  • GI reflux
  • Supine position
  • Use of large-bore feeding tubes
  • Large gastric residuals
  • Delayed gastric emptying
  • Vomiting or retching

 

Patient's at Risk for Refeeding Syndrome

  • Chronic malnutrition
  • Prolonged fasting
  • Prolonged IV hydration
  • Significant stress and nutrient depletion

 

Potential Complications of Enteral Nutrition
Metabolic Complications
Electrolyte imbalances (K+, Na+) Due to fluid imbalance, renal impairment, diarrhea, Refeeding syndrome.
Hyperglycemia Too many calories or lack of adequate insulin.
Dehydration  
Tube clogging  
Tube malposition  
Aspiration  
Nausea and vomiting  
Diarrhea  
Constipation
 
Malabsorption/maldigestion  
Refeeding syndrome The metabolic cascade of events that takes place when a malnourished patient is refed. Hypophosphatemia, hypokalemia, hypomagnesemia, body-fluid disturbances, vitamin deficiencies such as thiamine, cardiac arrhythmias, and congestive heart failure may result.

Adapted from www.rxkinetics.com, www.medscape.com, and other sources.

 

Offsite Research:

Enteral nutrition by nasojejunal tube in hyperemesis gravidarum.
Pearce CB, Collett J, Goggin PM, Duncan HD.
Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK.
Clinical Nutrition 2001 Oct;20(5):461-4.

We describe two cases in which self-propelling, blind placed nasojejunal tubes were placed in severe hyperemesis gravidarum. This method provides an alternative to parenteral nutrition and to percutaneous endoscopic tubes, is well tolerated, cost effective and with a low rate of complication. Both mothers were given nutritional support at home, had normal subsequent pregnancies and normal babies.
 

Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases.
Serrano P, Velloso A, Garcia-Luna PP, Pereira JL, Fernadez Z, Ductor MJ, Castro D, Tejero J, Fraile J, Romero H.
Department of Clinical Nutrition, Hospital Universitario Virgen del Rocio, Sevilla, Spain.
Clinical Nutrition 1998 Jun;17(3):135-9.

We describe the first two cases in which percutaneous endoscopic gastrojejunostomy was used as a means to provide enteral nutrition in severe hypermesis gravidarum. The use of this method of enteral access provided an alternative to parenteral nutrition, was well tolerated, cost-effective and had no major complications. In both cases the nutritional goal for mothers as well as appropriate fetal growth and development were achieved.
 

Refeeding syndrome induced by cautious enteral alimentation of a moderately malnourished patient.
Vaszar LT, Culpepper-Morgan JA, Winter SM.
Section of Pulmonary and Critical Care Medicine, Norwalk Hospital/Yale University School of Medicine, CT 06856, USA.
Gastroenterologist 1998 Mar;6(1):79-81.

Updated on: Apr. 18, 2013

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