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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 |
| 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. |
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.
|
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