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A guide to enteral access procedures and enteral nutrition

Nature Reviews Gastroenterology & Hepatology volume 6, pages 207–215 (2009)Cite this article

Abstract

The advent of total parenteral nutrition in the late 1960s meant that no situation remained in which a patient could not be fed. Unfortunately, total parenteral nutrition was complicated by serious infective and metabolic side effects that undermined the beneficial effects of nutrient repletion. Consequently, creative ways of restoring upper gut function were designed, based on semielemental diets and novel feeding tube systems. The employment of specific protocols and acceptance of increased gastric residual volumes has allowed most patients in intensive care to be fed safely and early by nasogastric tube. However, nasogastric feeding is unsuitable for patients with severely compromised gastric emptying owing to partial obstruction or ileus. Such patients require postpyloric tube placement with simultaneous gastric decompression via double-lumen nasogastric decompression and jejunal feeding tubes. These tubes can be placed endoscopically 40–60 cm past the ligament of Treitz to enable feeding without pancreatic stimulation. In patients whose disorders last more than 4 weeks, tubes should be repositioned percutaneously, by endoscopic, open or laparoscopic surgery. Together, the advances in enteral access have improved patients' outcomes and led to a 70–90% reduction in the demand for total parenteral nutrition.

Key Points

  • Enteral feeding is more effective and is associated with fewer serious complications than total parenteral nutrition

  • Patients who would previously have been dependent on total parenteral nutrition can be fed enterally, which improves their outcomes

  • Patients with gastroesophageal reflux, subacute gastroduodenal obstruction, ileus, and diarrhea can be successfully fed by enteral access techniques

  • Patients who require enteral feeding for longer than 4 weeks should be considered for percutaneous feeding tube placement by endoscopy, radiology, laparoscopy or open surgery

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Figure 1: Endoscopic view of a nasogastric tube incorrectly placed in the right main bronchus.
Figure 2: A CT scan of a patient with a massive pseudocyst of the pancreas that compressed not only the stomach but also the duodenum.
Figure 3: An endoscopic view of a cystic mass in a patient with gastric compression caused by a large pancreatic pseudocyst.
Figure 4: Radiographic image of the patient in Figure 3 that shows the final placement of a double-lumen feeding tube, which allowed simultaneous decompression of the stomach and distal jejunal feeding.
Figure 5: Radiographic view of a double-lumen tube (the tube tip is indicated by an arrow) that was successfully placed by transnasal endoscopy in a patient with vomiting, abdominal pain, acute respiratory distress syndrome and ileus due to severe acute pancreatitis, which had also caused duodenal compression.

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Acknowledgements

I thank the NIH and NIDDK for their support through grants R01 DK56142 and R01 DK075803.Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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  1. SJD O'Keefe, Division of Gastroenterology, University of Pittsburgh Medical School, 200 Lothrop Street, Pittsburgh, PA 15213, USA sjokeefe@pitt.edu

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  1. Division of Gastroenterology, University of Pittsburgh School of Medicine, PA, USA

    Stephen J. D. O'Keefe

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O'Keefe, S. A guide to enteral access procedures and enteral nutrition. Nat Rev Gastroenterol Hepatol 6, 207–215 (2009). https://doi.org/10.1038/nrgastro.2009.20

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