Enteral Nutrition by Endoscopic Means; II. Complications and Management

N. Hoepffner; O. Schröder; J. Stein

doi:10.1055/s-2004-813807

Zeitschrift für Gastroenterologie, Table of Contents

Z Gastroenterol 2004; 42(12): 1393-1398
DOI: 10.1055/s-2004-813807

Übersicht

Enteral Nutrition by Endoscopic Means; II. Complications and Management

Enterale Sondenernährung - II. Komplikationen und ManagementN. Hoepffner¹ , O. Schröder¹ , J. Stein¹

¹Medizinische Klinik I, ZAFES, J. W. Goethe-Universität Frankfurt, Frankfurt/Main, Germany

The authors are grateful to Professor Jennifer Dressman for reviewing the manuscript. This work was supported by the Else Kröner-Fresenius-Stiftung, Bad Homburg.

Abstract

Zusammenfassung

In der Entstehung von Komplikationen einer enteralen oder Sondenernährung spielen gastrointestinale (z. B. Erbrechen, Diarrhö), mechanische (z. B. Sondendislokation oder -okklusion) oder metabolische (z. B. „Re-Feeding”-Syndrom, Hypoglykämie) Ursachen eine Rolle. Die Art und Häufigkeit dieser Komplikationen ist dabei abhängig von der Sondenplatzierung im Gastrointestinaltrakt (gastral vs. intestinal), der Zusammensetzung der Sondenkost und dem Schweregrad der Grunderkrankung. So wird beispielsweise das Auftreten sondenbedingter Komplikationen in der Literatur mit 0 - 20% angegeben, während 8 - 65% der Patienten postoperativ über gastrointestinale Symptome im Zuge einer Ernährungstherapie nach Anlage einer Feinnadelkatheterjejunostomie (offen chirurgisch oder laparaskopisch) klagen. Die Komplikationsrate lässt sich durch Beachtung der Richtlinien zur Sondenernährung, wie Zusammensetzung und Temperatur der Sondenkost, Zufuhrgeschwindigkeit und Portionsgröße sowie durch Anleitung des Patienten zur sachgemäßen Sondenpflege reduzieren. Mit Abstand am häufigsten werden gastrointestinale Nebenwirkungen beobachtet.

Abstract

Despite the benefits and the widespread use of enteral and tube feeding (ETF) some patients experience complications, which can be divided in three categories: mechanical, e. g., tube blockage or removal; gastrointestinal, e. g., vomiting, diarrhea; and metabolic, e. g., re-feeding syndrome, hyperglycemia. The type and frequency of complications related to tube feeding varies considerably in accordance with the access to the intestinal tract (e. g., nasoenteric vs. percutaneous gastric vs. small bowel), the composition of the formula diet used, and the severity of the underlying disease. For example, tube-related complications have been reported to occur in 0 - 20 % and gastrointestinal complications in 8 - 65 % of patients during early postoperative feeding via a needle catheter jejunostomy (NCJ) using comparable techniques. The complication rate can be reduced by careful observance of guidelines on tube feeding including those related to food composition, administration rate, portion size, food temperature, and supervision of the patient. Gastrointestinal side effects (including diarrhea) are without doubt the most frequent.

Schlüsselwörter

Perkutane endoskopische Gastrostomie - enterale Sondenernährung - Introducermethode - Pulltechnik - lokale Infektionen - Langzeiternährung - Button - Gastrostomie - jejunale Ernährung - nasoenterale Sonden - Refeeding-Syndrom

Key words

Percutaneous endoscopic gastrostomy - enteral tube feeding - introducer technique - pull method - local infections - long-term nutrition - skin-level gastrostomy - one-step button - jejunal nutrition - nasoenteral tube - re-feeding syndrome

Full Text

References

1 Brandt C P, Mittendorf E A. Endoscopic placement of nasojejunal feeding tubes in ICU patients. Surg Endosc. 1999; 13 1211-1214
2 Levy H. Nasogastric and nasoenteric feeding tubes. Gastrointest Endosc Clin N Am. 1998; 8 529-549
3 Damore L J, Andrus C H, Herrmann V M. et al . Prospective evaluation of a new through-the-scope nasoduodenal enteral feeding tube. Surg Endosc. 1997; 11 460-463
4 Patrick P G, Marulendra S, Kirby D F. et al . Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients. Gastrointest Endosc. 1997; 45 72-76
5 Kulling D, Bauerfeind P, Fried M. Transnasal versus transoral endoscopy for the placement of nasoenteral feeding tubes in critically ill patients. Gastrointest Endosc. 2000; 52 506-510
6 Bosco J J, Gordon F, Zelig M P. et al . A reliable method for the endoscopic placement of a nasoenteric feeding tube. Gastrointest Endosc. 1994; 40 740-743
7 Powell K S, Marcuard S P, Farrior E S. et al . Aspirating gastric residuals causes occlusion of small-bore feeding tubes. JPEN J Parenter Enteral Nutr. 1993; 17 243-246
8 Marcuard S P, Stegall K L, Trogdon S. Clearing obstructed feeding tubes. JPEN J Parenter Enteral Nutr. 1989; 13 81-83
9 Grant M D, Rudberg M A, Brody J A. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA. 1998; 279 1973-1976
10 Hull M A, Rawlings J, Murray F E. et al . Audit of outcome of long-term enteral nutrition by percutaneous endoscopic gastrostomy. Lancet. 1993; 341 869-872
11 Larson D E, Burton D D, Schroeder K W. et al . Percutaneous endoscopic gastrostomy. Indications, success, complications, and mortality in 314 consecutive patients. Gastroenterology. 1987; 93 48-52
12 Mathus-Vliegen L M, Koning H. Percutaneous endoscopic gastrostomy and gastrojejunostomy: a critical reappraisal of patient selection, tube function and the feasibility of nutritional support during extended follow-up. Gastrointest Endosc. 1999; 50 746-754
13 Gossner L, Keymling J, Hahn E G. et al . Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial. Endoscopy. 1999; 31 119-124
14 Jain N K, Larson D E, Schroeder K W. et al . Antibiotic prophylaxis for percutaneous endoscopic gastrostomy. A prospective, randomized, double-blind clinical trial. Ann Intern Med. 1987; 107 824-828
15 Jonas S K, Neimark S, Panwalker A P. Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy. Am J Gastroenterol. 1985; 80 438-441
16 Chung R S, Schertzer M. Pathogenesis of complications of percutaneous endoscopic gastrostomy. A lesson in surgical principles. Am Surg. 1990; 56 134-137
17 Akkersdijk W L, van Bergeijk J D, van Egmond T. et al . Percutaneous endoscopic gastrostomy (PEG): comparison of push and pull methods and evaluation of antibiotic prophylaxis. Endoscopy. 1995; 27 313-316
18 Preclik G, Grune S, Leser H G. et al . Prospective, randomised, double blind trial of prophylaxis with single dose of co-amoxiclav before percutaneous endoscopic gastrostomy. BMJ. 1999; 319 881-884
19 Amann W, Mischinger H J, Berger A. et al . Percutaneous endoscopic gastrostomy (PEG). 8 years of clinical experience in 232 patients. Surg Endosc. 1997; 11 741-744
20 Roozrokh H C. Gastrocolocutaneous fistula as a complication of PEG tube placement. Surg Endosc. 2002; 16 538-539
21 Yamazaki T, Sakai Y, Hatakeyama K. et al . Colocutaneous fistula after percutaneous endoscopic gastrostomy in a remnant stomach. Surg Endosc. 1999; 13 280-282
22 McClave S A, Chang W K. Complications of enteral access. Gastrointest Endosc. 2003; 58 739-751
23 Klein S, Heare B R, Soloway R D. The “buried bumper syndrome”: a complication of percutaneous endoscopic gastrostomy. Am J Gastroenterol. 1990; 85 448-451
24 Sasaki T, Fukumori D, Sato M. et al . Percutaneous endoscopic gastrostomy complicated by buried bumper syndrome. Int Surg. 2003; 88 64-67
25 Sauer B, Staritz M. [Buried bumper - a new method of non-surgical removal]. Z Gastroenterol. 2004; 42 227-232
26 Boyd J W, DeLegge M H, Shamburek R D. et al . The buried bumper syndrome: a new technique for safe, endoscopic PEG removal. Gastrointest Endosc. 1995; 41 508-511
27 Ma M M, Semlacher E A, Fedorak R N. et al . The buried gastrostomy bumper syndrome: prevention and endoscopic approaches to removal. Gastrointest Endosc. 1995; 41 505-508
28 Boreham B, Ammori B J. Laparoscopic percutaneous endoscopic gastrostomy removal in a patient with buried-bumper syndrome: a new approach. Surg Laparosc Endosc Percutan Tech. 2002; 12 356-358
29 Schroder O, Hoepffner N, Stein J. Enteral Nutrition by Endoscopic Means; I. Techniques, indications, types of enteral feed. Z Gastroenterol. 2004; 42 1385-1392
30 Duncan H D, Silk D B. Problems of treatment-enteral nutrition. Nightingale J Intestinal failure London; Greenwich Medical Media Ltd 2001: 477-496
31 Stroud M, Duncan H, Nightingale J. Guidelines for enteral feeding in adult hospital patients. Gut. 2003; 52 (Suppl. VII) 1-12
32 Benya R, Layden T J, Mobarhan S. Diarrhea associated with tube feeding: the importance of using objective criteria. J Clin Gastroenterol. 1991; 13 167-172
33 Bliss D Z, Johnson S, Savik K. et al . Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding. Ann Intern Med. 1998; 129 1012-1019
34 Edes T E, Walk B E, Austin J L. Diarrhea in tube-fed patients: feeding formula not necessarily the cause. Am J Med. 1990; 88 91-93
35 Mylonakis E, Ryan E T, Calderwood S B. Clostridium difficile-associated diarrhea: A review. Arch Intern Med. 2001; 161 525-533
36 Stuck K, Faul K, Hylla S. et al . The application of a semi-continuous colon simulation technique (Cositec) for studying the effects of clindamycin on microbial hindgut metabolism. Z Gastroenterol. 1995; 33 241-246
37 Whelan K, Gibson G R, Judd P A. et al . The role of probiotics and prebiotics in the management of diarrhoea associated with enteral tube feeding. J Hum Nutr Diet. 2001; 14 423-433
38 Bleichner G, Blehaut H, Mentec H. et al . Saccharomyces boulardii prevents diarrhea in critically ill tube-fed patients. A multicenter, randomized, double-blind placebo-controlled trial. Intensive Care Med. 1997; 23 517-523
39 Studd C. Probiotic containing fermented milk supplements may improve the institution of early enteral nutrition. Crit Care Med. 2000; 28 1255-1256
40 McClave S A, DeMeo M T, DeLegge M H. et al . North American Summit on Aspiration in the Critically Ill Patient: consensus statement. JPEN J Parenter Enteral Nutr. 2002; 26 S80-S85
41 Nagler R, Spiro H M. Persistent gastrooesophageal reflux induced during prolonged gastric intubation. N Engl J Med. 1963; 269 495-500
42 Gomes G F, Pisani J C, Macedo E D. et al . The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Curr Opin Clin Nutr Metab Care. 2003; 6 327-333
43 Jacobs S, Chang R W, Lee B. et al . Continuous enteral feeding: a major cause of pneumonia among ventilated intensive care unit patients. JPEN J Parenter Enteral Nutr. 1990; 14 353-356
44 Olivares L, Segovia A, Revuelta R. Tube feeding and lethal aspiration in neurological patients: a review of 720 autopsy cases. Stroke. 1974; 5 654-657
45 Marik P E, Zaloga G P. Early enteral nutrition in actually ill patients: a systematic review. Critical Care. 2003; 7 46-51
46 Crook M A, Hally V, Panteli J V. The importance of the refeeding syndrome. Nutrition. 2001; 17 632-637
47 Marinella M A. The refeeding syndrome and hypophosphatemia. Nutr Rev. 2003; 61 320-323
48 Solomon S M, Kirby D F. The refeeding syndrome: a review. JPEN J Parenter Enteral Nutr. 1990; 14 90-97
49 Alpers D H, Klein S. Refeeding the malnourished patient. Curr Opin Gastroenterol. 1999; 15 151-153
50 O’Connor L R, Wheeler W S, Bethune J E. Effect of hypophosphatemia on myocardial performance in man. N Engl J Med. 1977; 297 901-903
51 Havala T, Shronts E. Managing the complications associated with refeeding. Nutr Clin Pract. 1990; 5 23-29

Prof. Dr. Dr. Jürgen Stein

Medizinische Klinik, ZAFES, J. W. Goethe-Universität Frankfurt

Theodor-Stern-Kai 7

60590 Frankfurt/Main, Germany

Phone: ++ 49/69/63 01-59 17

Fax: ++ 49/69/63 01-64 48

Email: J.Stein@em.uni-frankfurt.de