Question

Patient presents with severe gastric ulcers and esophageal disorder. What type of feeding route should be used? What placement? Support your decisions.

Answer 1

The preferred route for feeding for patients with severe gastric ulcers and esophageal disorders is enteral feeding.

Enteral feeding refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into the stomach, duodenum or jejunum. Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake, chronic neurological or mechanical dysphagia or gut dysfunction and in patients who are critically ill.

Short-term access is usually achieved using nasogastric (NG) or nasojejunal (NJ) tubes at an initial continuous feeding rate of 30 mls per hour. Percutaneous endoscopic gastrotomy (PEG) or jejunostomy placement should be considered if feeding is planned for longer than one month:

• NG tubes: These are the most commonly used delivery routes but depend on adequate gastric emptying. They allow the use of hypertonic feeds, high feeding rates and bolus feeding into the stomach reservoir. Tubes are simple to insert but are easily displaced.
• NJ tubes: These reduce the incidence of gastro-oesophageal reflux and are useful in the presence of delayed gastric emptying. Post-pyloric placement can be difficult but may be aided by intravenous prokinetics or fibre-optic observation.
• PEG tubes: Indications for gastrostomy include stroke, motor neurone disease, Parkinson's disease and oesophageal cancer. Relative contra-indications include reflux, previous gastric surgery, gastric ulceration or malignancy and gastric outlet obstruction. They are inserted directly through the stomach wall endoscopically or surgically, under antibiotic cover.
• Percutaneous jejunostomy tubes: They permit early postoperative feeding and are useful in patients at risk of reflux. They are inserted through the stomach into the jejunum, using a surgical or endoscopic technique. This can be difficult and has more complications.