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Prevention of late complications by half-solid
enteral nutrients
in percutaneous endoscopic gastrostomy tube
feeding
Jiro Kanie 1 Yusuke Suzuki 1 Hiroyasu Akatsu 2
Masafumi Kuzuya 1 and Akihisa Iguchi 1 |
1 Department of Geriatrics, Medicine in Growth and Aging, Program in Health
and Community Medicine, Nagoya University Graduate School of Medicine,
2 Department of Internal
Medicine Fukushimura
Hospital |
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| Gerontology. 2004 Nov-Dec;50(6):417-9. |
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Abstract |
Background: Percutaneous endoscopic gastrostomy feeding
is accompanied by unique complications, which
are not easily controlled.
Objective: In an attempt to decrease complications,
we used half-solid nutrients for percutaneous
endoscopic gastrostomy feeding in an 85-year-old
woman. The patient had been receiving enteral
nutrients via percutaneous endoscopic gastrostomy
and examined whether this approach can reduce
complications. She presented with regurtigation
of enteral nutriments and recurrent respiratory
infections.
Methods: Half-solid enteral nutrients, prepared by
mixing liquid enteral nutrients with agar
powder, were administered via percutaneous
endoscopic gastrostomy.
Results: Symptoms due to gastro-esophageal reflux
disappeared immediately after the start of
half-solid enteral nutrients feeding.
Conclusion: Gastro-esophageal reflux and leakage, two
intractable late complications of percutaneous
endoscopic gastrostomy tube feeding, can
be alleviated by the solidification of enteral
nutrients. Since this method allows quick
administration of nutrients, it is also expected
to help prevent the occurrence of decubitus
ulcers and reduce the burden to caregiver. |
Introduction |
| Feeding via percutaneous endoscopic gastrostomy
(PEG) tube is a safe and efficient method
for patients who cannot maintain adequate
oral intake. PEG feeding is accompanied,
however, by unique complications, which are
not easily controlled. The administration
of liquid nutrients is often accompanied
by complications such as vomiting and diarrhea,
although these complications may be minimized
if the patient is sitting up during the administration
or if the nutrients are administered at a
slower rate. Nevertheless, these methods
do not completely succeed in eliminating
these common complications, and may require
the patients and their caregivers to have
great patience . In addition, maintaining
the same position for many hours may worsen
the conditions of patients who have pressure
ulcers. Here we report a case in which simply
solidifying nutrients alleviated the symptoms
due to gastro-esophageal reflux (GER) after
PEG tube placement, and alleviated the leakage
of nutrients from the PEG tube insertion
site. |
Methods |
An 85-year-old woman presented with regurtigation
of enteral nutriments and recurrent respiratory
infections after PEG placement. The patient
suffered a cerebral infarction, and underwent
PEG insertion on the 4 th May 2001 in a local
hospital. After commencing PEG tube feeding,
the following symptoms repeatedly occurred:
regurtigation of the enteral feed; leakage
of nutrients from the PEG tube insertion
site; vomiting followed by pyrexia; dyspnea
during the administration of nutrients; and
pneumonia confirmed by chest X-ray. The patient
often showed signs of discomfort on her face
during the feed administration. Liquid enteral
nutrients were given in a sitting position
at all times.
As the complications gradually became more
frequent in occurrence, we commenced giving
her on half-solid enteral nutrients on the
21 st October 2001, which were prepared by
mixing market-available enteral nutrients
and agar powder. Half-solid nutrients were
prepared by mixing 5g of agar powder with
500ml of liquid nutrients diluted with the
same volume of water (1000ml total volume).
The mixture was distributed into 50ml syringes
and kept in a refrigerator until it was administered
via the PEG tubing. The mixture was not liquified
in the stomach due to body temperature. The
Administration of half-solid nutrients was
made by injecting them into the stomach en
bloc (injection time: less than 5 minutes).
The patient was not forced to remain in a
sitting position during and after the administration. |
Results |
| The symptoms other than pyrexia disappeared
immediately after the administration of half-solid
nutrients, and the pyrexia vanished two weeks
thereafter. Also, the signs of discomfort
during the feed administration were no longer
noted. We followed the patient for up to
6 months after the start of the half-solid
enteral nutrients, and observed no recurrence
of the symptoms (Figure 1). At present (February,
2004), the patient still remains in a stable
condition and no longer suffers from complications
observed before the commencement of the half-solid
nutrients. |
Figure 1. Reduction of symptons after half-solid enteral
nutrition via PEG.
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Discussion |
PEG feeding is accompanied by unique complications,
which occur over a long-term clinical course [1-3]. An increase in vomiting is one of the most
common complications [4]. GER is clinically manifested by recurrent
vomiting or aspiration. The mechanism by
which GER increases in frequency has not
yet been clarified .
Ogawa et al. [5, 6] suggested that since the stomach cannot move
independently of the abdominal wall after
the formation of a gastric fistula, enteral
nutrients remain longer in the stomach, thereby
increasing the chance of GER. Gastrin, a
potent facilitator of peristaltic movement,
may not be sufficiently induced by the distension
of the stomach seen with slow infusion rates
of liquid nutrients. Thus enhanced GER may
eventually result. Since the nutrients can
be administered in a short time by our method
(less than 5 minutes), the stomach wall is
expected to be distended to a greater degree
and thus stimulate peristaltic movement.
Another disadvantage of slow
feed infusion
is that patients are forced to
remain in
a sitting position for long periods
while
the nutrients are administered,
which is
unfavourable in terms of the
prevention of
decubitus ulcers, which are commonly
found
in patients with PEG feeding.
One of the late complications after PEG
tube placement is the leakage from the PEG
tube insertion site. This is a difficult
problem to cope with. There are two causes
of the leakage: Inappropriate fixation of
the bumper (including the so-called buried
bumper syndrome [7]), and a decrease in the elasticity of the
fistular opening, which develops over a long
period after the PEG placement [8]. The leakage resulting from a decrease in
elasticity is intractable. Simply increasing
the tube diameter cannot solve this problem
[7, 9]. We found, however, that solidification
of the enteral nutrients alleviated the leakage
in the present case. This may simply be explained
by the fact that the solidified nutrients
could not be leaked out by the intragastric
pressure through the narrow gap between the
fistular pore and the tube.
In conclusion, our experience indicates
that the use of half-solid nutrients in PEG
feeding and their rapid administration can
reduce the risk of GER substantially and
may eventually contribute to a reduction
of complications as well as to improvement
in the quality of life of patients and their
caregivers. |
References |
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