Clinical analysis of gastroesophageal reflux after PEG

Use of a Low-carbohydrate Enteral Nutrition Formula with Effective Inhibition of Hypoglycemia and Post-infusion Hyperglycemia in Non-diabetic Patients Fed via a Jejunostomy Tube

Objective As direct jejunal feeding often causes great fluctuation in glucose levels, continuous or slow infusion is recommended for jejunal tube-fed patients. However, continuous feeding results in prolonged immobility and the loss of activities of daily living. We investigated whether or not intermittent feeding of a low-carbohydrate high-monounsaturated fatty acid (LC/HM) nutrient formula reduces glucose fluctuation in patients who have undergone jejunotomy. Methods Ten bed-ridden non-diabetic patients receiving enteral feeding via a jejunostomy tube were enrolled in this study. LC/HM formula and standard control formula were infused in cross-over order for each patient at a speed of 160 kcal/h. Blood glucose levels were monitored by a continuous glucose monitoring system during the investigation period. Results The mean and standard deviation of the glucose concentrations and mean amplitude of glucose excursion (MAGE) were markedly lower while receiving LC/HM formula than while receiving control standard formula (104 vs. 136 mg/dL, 18.1 vs. 58.1 mg/dL, 50.8 vs. 160 mg/dL, respectively). The post-infusion hyperglycemia [area under the curve (AUC) >140 mg/dL] and peak value of the glucose level were also significantly lower in patients fed LC/HM than the control (25.7 vs. 880 mg・h/dL and 153 vs. 272 mg/dL, respectively). Reactive hypoglycemia (AUC <70 mg/dL) was also significantly lower (0.63 vs. 16.7 mg・h/dL) and the minimum value of the glucose level higher (78.4 vs. 61.8 mg/dL) in patients fed LC/HM than the control. Conclusion The LC/HM formula is considered to markedly inhibit glycemic spikes and prevent rebound hypoglycemia in patients who receive enteral feeding after jejunostomy.

Semisolid vs Liquid Nutrients and 30-Day Readmission in Gastrostomy Tube-Fed Patients: A Propensity-Matched Analysis

BACKGROUND

Semisolid nutrients have been widely used to prevent complications related to enteral nutrition (EN) in Japan. However, there are few data on the effect of feeding semisolid nutrient preparations. We compared 30-day readmission rates of gastrostomy tube-fed patients who had been prescribed semisolid vs liquid nutrients on discharge.

METHODS

This is a retrospective observational study using a Japanese nationwide inpatient database of data entered between June 2014 and March 2018. We identified patients aged ≥18 years who had received EN through gastrostomy during hospitalization. Patients were classified as having been prescribed semisolid vs liquid EN on discharge. After one-to-one propensity score matching, all-cause 30-day readmission rates were compared between the 2 groups.

RESULTS

In total, 5331 patients were identified, including a semisolid-nutrients group (n = 2089) and a liquid-nutrients group (n = 3242). Propensity score matching created 1912 pairs. The 30-day readmission rates were 15.6% and 13.9% in the semisolid-nutrients and liquid-nutrients groups, respectively. No significant difference was observed between the groups (risk difference, 1.7%; 95% CI, -0.6 to 4.0%; P = .14).

CONCLUSION

All-cause 30-day readmission of patients receiving gastrostomy tube feeding did not differ between those prescribed semisolid vs liquid nutrients on discharge. Randomized controlled trials are needed to accurately determine the effect of semisolid nutrients on clinical outcomes.

Interventions for Feeding and Swallowing Disorders in Adults with Intellectual Disability: A Systematic Review of the Evidence

Feeding and swallowing disorders are prevalent in adults with Intellectual Disability (ID) and can potentially lead to discomfort, malnutrition, dehydration, aspiration, and choking. Most common interventions include: diet modification, compensatory strategies, swallowing therapy, and non-oral feeding. Despite their common use, the research evidence for these interventions is lacking. The current study aimed to systematically review the evidence for the safety and the effectiveness of interventions for feeding and swallowing disorders in adults with ID. Seven electronic databases, conference proceedings, and reference lists of relevant studies were reviewed from online availability to March 2019, with no language restrictions. Eligibility criteria encompassed experimental or non-experimental study design, adults (> 18 years) with ID and feeding and/or swallowing disorders (any etiology and severity) and any intervention for feeding and/or swallowing disorders. Methodological quality was assessed by two independent reviewers using the Downs and Black checklist. Four articles met the inclusion criteria. All included studies considered enteral feeding as an intervention strategy and had a retrospective observational design. Overall, included studies reported positive change in nutritional status and a high incidence of adverse events following enteral feeding initiation. Risk of bias was high with variability in methodological quality. The safety and effectiveness of interventions for feeding and swallowing in adults with ID is unclear. This review highlights the lack of evidence-based practice in this area. Directions for further research are provided. Before enteral feeding initiation, risks and benefits should be appropriately balanced on an individual basis, and caregivers should be involved in the decision-making process.

Semi-solid feeds may reduce the risk of aspiration pneumonia and shorten postoperative length of stay after percutaneous endoscopic gastrostomy (PEG)

Background and study aims: Feeding-related adverse events after percutaneous endoscopic gastrostomy (PEG) such as aspiration pneumonia may result in prolonged hospitalization and postoperative mortality. This study evaluated the efficacy of using semi-solid feeds to reduce feeding-related adverse events and improve clinical outcomes. Patients and methods: Patients who received PEG for enteral nutrition at our hospital between January 2014 and December 2015 were allocated to a postoperative feeding protocol that used either liquid feed or semi-solid feed. Baseline characteristics, postoperative feeding-related adverse events and clinical outcomes in the 2 groups were prospectively analysed and compared. Results: One hundred and seventeen PEG patients (age range: 59 - 97 years, male: 53) were enrolled with 72 patients given liquid feed and 45 patients receiving semi-solid feed. Baseline characteristics were similar in both groups. The semi-solid feed group experienced fewer incidence of feeding-related aspiration pneumonia (2.2 % vs. 22.2 %, P < 0.005) and shorter postoperative hospital length of stay (12.7 days vs. 18.8 days, P < 0.01). Significant differences were not observed in the frequency of peristomal infection (11.1 % vs. 12.5 %, P = 0.82), feeding-related diarrhea (2.2 % vs. 12.5 %, P = 0.09) and 30-day mortality rates (2.2 % vs. 8.3 %, P = 0.25). Conclusions: Semi-solid feeding may reduce the risk of aspiration pneumonia and shorten postoperative hospital length of stay after PEG. Semi-solid feeds are safe to use and can be employed either as a first line feeding protocol or an alternative when liquid feeding is unsuccessful.

Enteral tube feeding for individuals with cystic fibrosis: Cystic Fibrosis Foundation evidence-informed guidelines

Nutrition is integral to the care of individuals with cystic fibrosis (CF). Better nutritional status is associated with improved pulmonary function. In some individuals with CF, enteral tube feeding can be useful in achieving optimal nutritional status. Current nutrition guidelines do not include detailed recommendations for enteral tube feeding. The Cystic Fibrosis Foundation convened an expert panel to develop enteral tube feeding recommendations based on a systematic review of the evidence and expert opinion. These guidelines address when to consider enteral tube feeding, assessment of confounding causes of poor nutrition in CF, preparation of the patient for placement of the enteral feeding tube, management of the tube after placement and education about enteral feeding. These recommendations are intended to guide the CF care team, individuals with CF, and their families through the enteral tube feeding process.

Randomized Study of Radiologic vs Endoscopic Placement of Gastrojejunostomies in Patients at Risk of Aspiration Pneumonia

Objective: In patients at risk of aspiration pneumonia due to gastroesophageal reflux who require gastrojejunostomy feeding tubes, the tubes are placed either radiologically (RIGJ) or endoscopically (PEGJ). There is little published evidence of the superiority of one technique over the other. Methods: Patients referred for long-term jejunal feeding were randomly allocated to have a 14F RIGJ or 15F with 9F jejunal extension PEGJ inserted. A technetium-99m (^99mTc) colloid study was done to determine the presence of gastroesophageal reflux and jejunogastric reflux after feeding tube placement. We recorded enteral feed and tube-related complications, in addition to tube-related morbidity and mortality to 90 days following placement. Results: Baseline characteristics were similar between groups, with gastroesophageal reflux demonstrated in 52%. Following enteral tube placement, gastroesophageal reflux was not observed by ^99mTc studies or any difference in clinical outcome to 90 days after placement. No jejunal tubes were displaced in any of the 31 RIGJ tubes, while 9 tubes were displaced in the 34 PEGJ patients (P = .008). Reversible jejunal tube blockages occurred: 19 RIGJ (5 patients) and 61 PEGJ (11 patients) (P = .003, χ² = 9.1). Conclusion: There was little difference between the 2 tubes for clinical outcomes. RIGJ tubes were less prone than PEGJ tubes to reversible blockage and displacement. It is likely that the better outcome for RIGJ tubes relates to their larger tube diameter and stiffness.

Percutaneous Endoscopic Gastrostomy Prevents Gastroesophageal Reflux in Patients with Nasogastric Tube Feeding: A Prospective Study with 24-Hour pH Monitoring

Background/Aims

Percutaneous endoscopic gastrostomy (PEG) has been widely used for patients with swallowing dysfunction. However, its beneficial effects in the treatment of gastroesophageal reflux (GER) are controversial. The aim of this study was to evaluate the effect of PEG on the prevention of GER in patients with nasogastric tube (NGT) feeding.

Methods

Continuous 24-hour pH monitoring was performed prospectively in 21 patients receiving NGT feeding before and 7.3±2.2 days after PEG placement to compare the severity of GER.

Results

We studied 21 patients with a mean age of 59.8±14.1 years. The mean duration of NGT placement was 5.8±5.4 months. The causes of swallowing dysfunction included cerebral infarction, cerebral hemorrhage and other central nervous system (CNS) lesions. When all of the patients were considered, there were no significant differences in reflux parameters after PEG placement compared to before PEG placement. However, all seven patients who had preexisting GER showed significant improvement (p<0.05) of the reflux parameters, including the frequency of acid reflux, duration of acid reflux, total time with a pH below 4.0 and the fraction of time with a pH below 4.0, after PEG placement.

Conclusions

PEG might prevent GER in patients receiving NGT feeding, especially in those patients with GER.

Clinical investigation of upper gastrointestinal hemorrhage after percutaneous endoscopic gastrostomy

BACKGROUND

Upper gastrointestinal (GI) hemorrhage after percutaneous endoscopic gastrostomy (PEG) is sometimes reported as one of the serious complications. Our purpose was to clarify the cause of upper GI hemorrhage after PEG.

PATIENTS AND METHODS

We retrospectively investigated the causes of upper GI hemorrhage among a total of 416 patients out of 426 consecutive patients who underwent PEG in our institution, excluding 10 patients who showed upper GI tumors on PEG placement.

RESULTS

Among 17 patients who developed upper GI hemorrhage after PEG, three and four patients showed PEG tube placement and replacement-related hemorrhage, respectively; these lesions were vascular or mucosal tears around the gastrostomy site. Ten patients experienced 12 episodes of upper GI hemorrhage during PEG tube feeding. The lesions showing bleeding were caused by reflux esophagitis (five patients), gastric ulcer (two patients), gastric erosion due to mucosal inclusion in the side hole of the internal bolster (two patients), and duodenal diverticular hemorrhage (one patient). Anticoagulants were administered in six patients, including four patients with replacement-related hemorrhage and one patient each with reflux esophagitis and gastric ulcer.

CONCLUSIONS

Reflux esophagitis was the most frequent reason for upper GI hemorrhage after PEG. The interruption of anticoagulants should be considered for the prevention of hemorrhage on the placement as well as replacement of a gastrostomy tube.

Inhibition of gastroesophageal reflux by semi-solid nutrients in patients with percutaneous endoscopic gastrostomy

BACKGROUND

Aspiration is one of the major complications after percutaneous endoscopic gastrostomy (PEG). The administration of semi-solid nutrients by means of gastrostomy tube has recently been reported to be effective in preventing aspiration pneumonia. The effects of semi-solid nutrients on gastroesophageal reflux, intragastric distribution, and gastric emptying were evaluated.

METHODS

Semi-solid nutrients were prepared by liquid nutrients mixed with agar at the concentration of 0.5%. The distribution of the administered radiolabeled liquid and semi-solid nutrients was monitored by a scintillation camera for 15 post-PEG patients. The percentage of esophageal reflux, the distribution of the proximal and distal stomach, and the gastric emptying time were evaluated.

RESULTS

The percentage of gastroesophageal reflux was significantly decreased in semi-solid nutrients (0.82 +/- 1.27%) compared with liquid nutrients (3.75 +/- 4.25%), whereas the gastric emptying time was not different. The distribution of semi-solid nutrients was not different from liquid nutrients in the early phase, whereas higher retention of liquid nutrients in the proximal stomach was observed in the late phase.

CONCLUSIONS

Gastroesophageal reflux was significantly inhibited by semi-solid nutrients. One of the mechanisms of the inhibition is considered to be an improvement in the transition from the proximal to distal stomach in semi-solid nutrients.