Nutritional Support: Site of Enteral Support (Gastric versus Jejunal)

Published 2003
Citation: J Trauma. 57(3):660-679, September 2004.

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I. Statement of the Problem

Enteral nutrition is preferable to parenteral nutrition, and feeding into the stomach is convenient. Delayed gastric emptying may reduce the effectiveness and safety of gastric feedings compared with feeding into the small intestine.

II. Process

A. Identification of References

References were identified from a computerized search of the National Library of Medicine for English language citations between 1973 and 2000. Keywords included enteral nutrition, trauma, gastrostomy, and jejunostomy. The bibliographies of the selected references were reviewed for relevant articles not found in the computerized search. Literature reviews, case reports, and editorials were excluded. Twenty articles were identified.

B. Quality of the References

The quality assessment instrument applied to the references was that developed by the Brain Trauma Foundation and subsequently adopted by the EAST Practice Management Guidelines Committee. Articles were classified as Class I, II, or III according to the following definitions:

Class I: A prospective, randomized clinical trial. One article was chosen and analyzed.

Class II: A prospective, non-comparative clinical study or a retrospective analysis based on reliable data. Five articles were chosen and analyzed.

Class III: A retrospective case series or database review. Fourteen articles were chosen and analyzed.

III. Recommendations

A. Level I

No recommendations.

B. Level II

In critically injured patients, early gastric feeding, is feasible, and clinical outcome is equivalent to patients fed into the duodenum. For this reason and because access to the stomach can be obtained more quickly and easily than the duodenum, an initial attempt at gastric feedings appears warranted.

C. Level III

Patients at high risk for pulmonary aspiration due to gastric retention or gastroesophageal reflux should receive enteral feedings into the jejunum.

IV. Scientific Foundation

Since Moore and Jones[1] and Adams and colleagues[2] reported simultaneously that enteral nutritional support was feasible and possibly associated with fewer complications than parenteral nutrition in the metabolic support of the trauma patient, feeding into the gut has become the preferred technique for nutrition following major injury. Access to the gut can be obtained by a variety of devices: surgically-placed gastrostomy or jejunostomy tubes if the patient has to undergo a laparotomy for abdominal injuries; nasogastric or nasoenteric tubes; and endoscopically- or radiologically-placed gastric or gastrojejunal tubes.

Patients with brain injuries often require early and prolonged nutritional support. Early experience with such patients suggested that parenteral nutrition was preferable to enteral feeding in patients with moderate-to-severe brain injury.[3-5] Support for this conclusion was obtained from studies in brain-injured patients which identified physiologic derangements such as delayed gastric emptying[6] [7] and lower esophageal sphincter dysfunction.[8] Even when gastric feedings were given, they did not meet the increased metabolic requirements of the neurotrauma patient.[9] Feeding into the jejunum has been proposed to avoid some of the problems with gastric feeding and has been shown to provide adequate calorie and nitrogen intake.[10] One recent study, however, demonstrated that gastric feeding can be accomplished relatively soon (3.6 days in this series) following head injury without incurring significant complications.[11] Evidence regarding the optimal site of enteral nutrition in trauma patients is woefully inadequate. Although several studies have examined complication rates of gastric versus jejunal feeding in non-trauma patients, these studies tend to be retrospective,[12-16] have small numbers of subjects in each group,[12] [15] [17] [18] or compare nonequivalent procedures such as percutaneous gastrojejunostomy with surgical gastrostomy.[13] Percutaneous endoscopic gastrostomy (PEG) has recently been compared with percutaneous endoscopic gastrojejunostomy (PEGJ) in a consecutive group of severely injured patients, finding more rapid attainment of feeding goals in the PEGJ group but no differences in outcomes.[14] A recently published randomized trial comparing gastric with duodenal feeding demonstrated equivalent outcomes but slightly earlier achievement of protein and calorie goals with duodenal feedings.[15] On balance, there seems to be no superiority of jejunal feeding over gastric feeding, but more prospective, randomized studies with larger numbers of patients are needed to make a scientifically-supported decision.

V. Summary

The need for nutrition following severe injury is intuitively apparent, especially in patients who cannot resume oral intake within a few days following injury. Enteral feeding is more physiologic and less expensive than parenteral feeding. Whether it is preferable to feed into the stomach or into the jejunum is not clear, but care must be taken in all patients to ensure that feedings are tolerated, and that aspiration is avoided. Patients with moderate to severe brain injury demonstrate delayed gastric emptying and dysfunction of the lower esophageal sphincter. These abnormalities may limit nutritional delivery of calories and protein for the first 2 weeks following injury. Nasojejunal feedings provide earlier success attaining nutritional goals compared with intragastric feedings, which are limited by high gastric residuals.

VI. Future Investigation

A multicenter, randomized, prospective trial is needed to evaluate the safety, efficacy, and cost of gastric feeding compared with postpyloric enteral feeding in trauma patients. Patients with brain injury should be evaluated as a separate subgroup to avoid confounding issues.

References

  1. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma: A prospective, randomized study. J Trauma. 1986;26;874-881.
  2. Adams S, Dellinger EP, Wertz MJ, Oreskovich MR, Simonowitz D, Johansen K. Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial. J Trauma. 1986;26:882-891.
  3. Rapp RP, Young B, Twyman D, et al. The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg. 1983;58:906-912.
  4. Young B, Ott L, Twyman D, et al. The effect of nutritional support on outcome from severe head injury. J Neurosurg. 1987;67:668-676.
  5. Norton JA, Ott LG, McClain C, et al. Intolerance to enteral feeding in the brain-injured patient. J Neurosurg. 1988;68:62-66.
  6. Ott L, Young B, Phillips R, et al. Altered gastric emptying in the head-injured patient: relationship to feeding intolerance. J Neurosurg. 1991;74:738-742.
  7. Kao CH, ChangLai SP, Chieng PU, Yen TC. Gastric emptying in head-injured patients. Am J Gastroenterol. 1998;93:1108-1112.
  8. Saxe JM, Ledgerwood AM, Lucas CE, Lucas WF. Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury. J Trauma. 1994;37:581-586.
  9. Clifton GL, Robertson CS, Constant CF. Enteral hyperalimentation in head injury. J Neurosurg.1985;62:186-193.
  10. Borzotta AP, Pennings J, Papasadero B, et al. Enteral versus parenteral nutrition after severe closed head injury. J Trauma. 1994;37:459-468.
  11. Klodell CT, Carroll M, Carrillo EH, Spain DA. Routine intragastric feeding following traumatic brain injury is safe and well tolerated. Am J Surg. 2000;179:168-71.
  12. Burtch GD, Shatney CH. Feeding jejunostomy (versus gastrostomy) passes the test of time.Am Surgeon. 1987;53:54-57.
  13. Ho CS, Yee AC, McPherson R. Complications of surgical and percutaneous nonendoscopic gastrostomy: review of 233 patients. Gastroenterology. 1988;95:1206-1210.
  14. Adams GF, Guest DP, Ciraulo DL, Lewis PL, Hill RC, Barker DE. Maximizing tolerance of enteral nutrition in severely injured trauma patients: a comparison of enteral feedings by means of percutaneous endoscopic gastrostomy versus percutaneous endoscopic gastrojejunostomy.J Trauma. 2000;48:459-65.
  15. Kortbeek JB, Haigh PI, Doig C. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. J Trauma. 1999;46:992-998.
  16. Mullan H, Roubenoff RA, Roubenoff R. Risk of pulmonary aspiration among patients receiving enteral nutrition support. J Parenter Enteral Nutr. 1992;16:160-164.
  17. Kadakia SC, Sullivan HO, Starnes E. Percutaneous endoscopic gastrostomy or jejunostomy and the incidence of aspiration in 79 patients. Am J Surg. 1992;164:114-118.
  18. Spain DA, DeWeese RC, Reynolds MA, Richardson JD. Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications. J Trauma. 1995;39:1100-1102.
  19. Strong RM, Condon SC, Solinger MR, Namihas BN, Ito-Wong LA, Leuty JE. Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized, prospective study. J Parenter Enteral Nutr. 1992;16:59-63.
  20. Montecalvo MA, Steger KA, Farber HW, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. Crit Care Med. 1992;20:1377-1387.
  21. Hadley MN, Grahm TW, Harrington T, Schiller WR, McDermott MK, Posillico DB. Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients. Neurosurgery. 1986;19:367-373.
  22. Fox KA, Mularski RA, Sarfati MR, et al. Aspiration pneumonia following surgically-placed feeding tubes. Am J Surg. 1995;170:564-567.

Tables

Table 1. Site of Enteral Support: Gastric versus Jejunal: The Brain-Injured Patient

First AuthorYearData ClassInjury TypeConclusions

Rapp [3]

1983

II

CNS injury

20 brain-injured patients randomized to early TPN, 18 randomized to delayed gastric feedings. GCS scores were similar in the two groups, but eight enterally-fed patients died within 18 days of injury, while none of the TPN patients died in the same time span. TPN patients had more positive nitrogen balance, higher serum albumin levels, and higher total lymphocyte counts than enterally-fed patients.

Young [4]

1987

II

CNS injury

51 brain-injured patients with GCS score 4-10 were randomized to TPN or enteral nutrition. TPN patients had higher mean intake of nitrogen and calories, but there were no differences in rates of pneumonia, urinary infections, septic shock, or all infections. Anergy screens, lymphocyte counts, and serum albumin levels were not different between the two groups. TPN patients had greater initial improvement in GCS scores and more favorable outcomes at 3 months, but outcome differences at 6 months and 1 year were not significant.

Borzotta [10]

1994

II

CNS injury

48 patients with severe brain injury were randomized to early TPN (n=21) or jejunal feeding (n=27). Measured energy expenditure and nitrogen excretion were similar in the two groups. Both routes of nutrition were equally effective in meeting nutritional goals, and infections were equal in frequency in the two groups.

Clifton [9]

1985

III

CNS injury

20 brain-injured patients were randomized to enteral feeding with either 14% or 22% of calories as protein. Those fed with higher protein formula had improved nitrogen retention, but nitrogen equilibrium was rarely achieved in either group.

Hadley [21]

1986

III

CNS injury

45 brain-injured patients randomized to TPN or gastric feedings. TPN patients had greater daily nitrogen intake and greater daily nitrogen losses than gastric-fed patients. There were no differences in maintenance of serum albumin levels, weight loss, infection rates, nitrogen balance, or mortality.

Norton [5]

 

1988

 

III

 

CNS injury

 

23 patients with acute brain injury and GCS scores 4-10 were fed enterally. Tolerance of feeding was inversely related to increased intracranial pressure and to severity of brain injury (low GCS scores).

Ott [6]

1991

III

CNS injury

12 patients with brain injury and GCS scores 4-10 were evaluated with liquid gastric-emptying scans. These showed delayed gastric emptying in the first week after injury and rapid emptying by the third week. All patients tolerated full-rate feedings by post-injury day 16 except two patients with persistent delayed gastric emptying.

Saxe [8]

1994

III

CNS injury

16 patients with acute brain injury and GCS score <12 underwent esophageal manometry within 72 hours of admission, and five patients had repeat studies 1 week after injury. All had minimal or no gastric-to­esophageal pressure differential initially, and 4/5 had normal differential at 1 week. Aspiration rate was not studied.

Spain [18]

1995

III

CNS trauma

Retrospective review of 74 patients with brain injury who received nasogastric tubes. They remained intragastric in 42 and were transpyloric in 32 patients. There were no differences in days to full feeding, ventilator days, ICU-LOS, incidence of pneumonia, or incidence of aspiration.

Kao [7]

1998

III

CNS injury

Gastric emptying of liquids was prolonged in 35 patients with moderate-to­severe brain injury, especially in females, older patients, and patients with lower GCS scores.

Klodell [11]

2000

III

CNS injury

118 head-injured patients were started on gastric feedings at an average of 3.6 days post-injury. 80% were fed via a PEG tube, while 20% via small-bore nasogastric tube. All patients received prokinetic agents initially. Overall, 97% of patients tolerated gastric feedings, and only two of 118 patients required conversion to jejunostomy feedings. The incidence of aspiration was 4%.

 

Table 2. Site of Enteral Support: Gastric versus Jejunal Evidentiary Tables: Non-CNS Injury

First AuthorYearData ClassInjury TypeConclusions

Korbeek [15]

1999

I

ISS >16

Prospective, randomized (not blinded) study of 80 patients. Forty-three received gastric feedings, and 37 received duodenal feedings via a fluoroscopically-placed nasoduodenal tube. Patient groups were similar with respect to injury severity, age, gender, APACHE II scores, narcotic/paralytic use, and energy requirements. There was no difference in ICU or hospital LOS, ventilator days, overall morbidity, or mortality. The incidence of pneumonia was 42% in the gastric group and 27% in the duodenal group, not statistically significant; however, this may represent a type II statistical error. Patients in the duodenal group tolerated full-strength feedings an average 10 hours earlier than the gastric group.

Montecalvo [20]

1992

II

Non-trauma

38 selected medical and surgical ICU patients randomized to gastric (n=19) or jejunal (n=19) feeding. Patients fed in the jejunum received a higher proportion of their daily goal caloric intake and had a greater increase in serum prealbumin. Although the pneumonia incidence was lower in the jejunal (n=0) than in gastric-fed patients (n=2), this difference was not significant.

Strong [19]

1992

II

Non-trauma

33 patients randomized to gastric (n=17) or postpyloric (n=16) feedings. Pulmonary aspiration occurred in 31% of the gastric-fed patients compared with 40% of the postpyloric-fed patients.

Burtch [12]

1987

III

Non-trauma

Retrospective comparison of complications in 56 patients with surgical gastrostomy and surgical jejunostomy. Nine of 26 (35%) patients with gastrostomy had pulmonary aspiration, which was fatal in two patients. Only 2/30 (7%) patients with jejunostomy had aspiration (both nonfatal). Overall survival at 1 year was 4% and 10%, respectively.

Ho [13]

 

1988

 

III

 

Non-trauma

 

Retrospective review of 133 patients who underwent radiologically-placed percutaneous gastrojejunal catheters, compared with 100 patients who underwent surgical gastrostomy. Complication rate was 5.2% in the gastrojejunal catheter group, with no pulmonary aspiration, and a 7.5% 30-day mortality. Complications occurred in 33% of the gastrostomy patients, including eight episodes of postoperative aspiration. Mortality in the gastrostomy group was 12%.

Kadakia [17]

1992

III

Non-trauma

Retrospective review of 79 patients who underwent PEG or PEGJ (the latter procedure was chosen in six patients because of prior aspiration). Aspiration occurred in nine patients, including six of seven patients treated with jejunostomy.

Mullan [16]

1992

III

Medical-surgical (10% trauma)

Retrospective review of 276 patients receiving enteral nutrition. Only 12 (4.3%) episodes of aspiration occurred, and there was no difference in the risk of aspiration between nasoenteric, gastrostomy, or jejunostomy tubes.

Fox [22]

1995

III

Non-trauma

Retrospective study of 155 medical/surgical patients. Four of 69 (5.8%) gastrostomy patients had aspiration pneumonia (respiratory symptoms, leukocytosis, and an infiltrate on chest radiograph), compared with two of 86 (2.3%; not significant) jejunostomy patients.

Adams [14]

2000

III

Trauma

Prospective, non-randomized study of 89 trauma patients fed by either PEG or PEGJ. Although the latter group reached feeding goals earlier (80% at goal rate by day 3 versus 65% of PEG patients; 93% versus 79% by day 15, respectively), there were no differences in complications between the groups. The only complications tracked were pneumonia, ileus, and sepsis. There were no differences in ventilator days or hospital LOS.

ICU, intensive care unit; LOS, length of stay; PEG, percutaneous endoscopic gastrostomy; PEGJ, percutaneous endoscopic gastro-jejunostomy.

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