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Prevention of gastro-esophageal reflux by an application of half-solid nutrients in patients with percutaneous endoscopic gastrostomy feeding  Jiro Kanie *, Yusuke Suzuki*, Hiroyasu Akatsu**, Hiroshi Shimokata***, Takayuki Yamamoto**, Akihisa Iguchi* 　 * Department of Geriatrics, Medicine in Growth and Aging, 　Program in Health and Community Medicine, 　Nagoya University Graduate School of　Medicine, ** Department of Internal Medicine　Fukushimura Hospital, *** Department of Epidemiology　National Institute for Longevity Sciences Journal of the American Geriatrics Society 2004; 52(3): 466-467  　To the Editor: Although percutaneous endoscopic gastrostomy (PEG) feeding is widely used as a convenient method for long-term nutritional support1, administration of liquid nutrients is often accompanied by complications such as vomiting or diarrhea. Vomiting, which may result in critical condition by aspiration, is presumably caused by gastro-esophageal reflux (GER). Therefore, we used half-solid nutrients for PEG feeding and examined whether this approach can reduce GER. 　Seventeen patients (mean age±SD; 79.9±10.5), who were on PEG feeding participated in this study. Written informed consent was obtained from all patients. Either liquid or half-solid nutrients were administered via PEG tubing in a randomized order. Half-solid nutrients were prepared by mixing 5g of agarose with 500ml of liquid nutrients diluted with the same volume of water. Incidence of GER was assessed by computed tomography scan (CT) of the esophagus. Liquid nutrients were administered over 15 minutes in portions of 400ml containing 20ml of the water-soluble contrast material, Gastrografin (methylglucamine diatrizonate). The half-solid nutrients were administered by bolus injections of the same volume of nutrients, which were contained separately in 50ml syringes. Thirty minutes after the administration, CT scan was performed in 1cm thick slices of the esophageal portion. GER was confirmed if the Hounsfield number exceeded 100 in each slice examined. A Hounsfield number of 100 was employed because it can unequivocally distinguish the mixture of the nutrients containing contrast material from the esophageal and other surrounding tissues. The CT images were assessed by a radiologist, who was not informed of the type of nutrients used. Statistical comparison of the incidence of GER between the two types of nutrients was made using Mc Nemar’s test. 　GER was confirmed in 10 out of the 17 subjects (58.8%) when they received liquid nutrients. By contrast, when they received half-solid nutrients, only 4 of 17 subjects (23.5%) showed the evidence of GER from their CT findings. (χ2 = 6.0, df = 1, p = 0.014, by Mc Nemar’s test) (Table 1). 　The advantages of PEG feeding over nasogastric feeding has been discussed elsewhere albeit there have been some complications reported.2 Among the complications, vomiting can be a cause of fatal aspiration due to a reflux of the administered nutrients.3 The tubing used for PEG feeding has made it possible to apply half-solidified nutrients, which we hypothesized would cause less reflux from the stomach.4 As expected, we observed less evidence of GER when using half-solid nutrients than when using liquid nutrients. We also confirmed that solidifying nutrients using agarose did not clog the tube as compared to liquid nutrients. Continuous infusion and careful observation of the patient’s symptoms are considered necessary to reduce the risk of GER in PEG feeding. Also the patients are advised to remain in a sitting position during administration, which may increase the risk of developing or exacerbating decubitus ulcers. Thus, this pilot study suggests that the use of rapid administration of half-solid nutrients in PEG feeding can reduce the risk of GER substantially, and may eventually contribute to a reduction of complications as well as to the improvement in the quality of life for patients and their cargivers. 　 Table 1. Occurrence of gastro-esophageal reflux by liquid and half-solid nutrients Age Sex Clinical profile gastro-esophageal reflux Range of reflux Distance from the EC junction Liquid Half-solid Liquid Half-solid Liquid Half-solid 82 F Dementia ( - ) ( - ) 　 　 　 　 81 F Dementia ( - ) ( - ) 　 　 　 　 90 F Dementia ( + ) ( + ) 7 6 13 13 53 F Cerebral infarction ( - ) ( - ) 　 　 　 　 87 F Dementia ( + ) ( - ) 4 　 13 　 80 F Dementia ( + ) ( + ) 9 4 9 10 82 M Dementia ( + ) ( + ) 4 4 13 13 87 F Cerebral infarction ( + ) ( - ) 1 　 4 　 84 M Cerebral infarction ( + ) ( - ) 12 　 15 　 68 F Cerebral infarction ( + ) ( - ) 13 　 13 　 82 F Dementia ( - ) ( - ) 　 　 　 　 89 F Cerebral infarction ( - ) ( - ) 　 　 　 　 91 F Cerebral infarction ( + ) ( - ) 1 　 2 　 84 F Cerebral infarction ( + ) ( + ) 15 10 15 10 97 F Dementia ( - ) ( - ) 　 　 　 　 68 M Cerebral infarction ( - ) ( - ) 　 　 　 　 64 M Cerebral hemorrhage ( + ) ( - ) 5 　 8 　 　 　 　 10 (58.8%) 4 (23.5%) * 　 　 　 　 Range of reflux: Number of slices where contrast materials were confirmed in the esophagus Distance from the EC junction: Distance from the esophageal-cardiac junction to the upper limit of the slices　where contrast materials were confirmed (cm) 　 * Statistical significance by Mc Nemar’s test (χ2 = 6.0, df = 1, p = 0.014) 　 　 REFERENCES 1. Gauderer MW, Stellato TA. Gastrostomie: Evolution, techniques, indications and complications, Curr Prob Surg 1986; 23: 657-719. 2. Dwolatzky T, Berezovski S, Friedmann R et al. A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people. Clin Nutr 2001; 20: 535-540. 3. Coben RM, Weintraub A, DiMarino AJ Jr et al. Gastroesophageal reflux during gastrostomy feeding. Gastroenterology 1994; 106: 13-18. 4. Kanie J, Kagami C, Yamamoto T et al. Case report: Half-solid enteral nutrient prevents chronic complications of precautious endoscopic gastrostomy tube feeding. Nippon Ronen Igakkai Zasshi. 2002; 39: 448-451.

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