Mistakes in ... Booklet 2020 - 29

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Mistakes in... 2020

Mistakes in jejunal feeding and how to avoid them
Ashley Bond and Simon Lal
Jejunal feeding is an important means to support nutrition and hydration in patients
who have impaired oesophagogastric access and function, but in whom the small
bowel remains both accessible and functioning. However, jejunal feeding is not always
a straightforward intervention and can be fraught with pitfalls. Awareness of these
pitfalls, together with advance consideration and planning to mitigate problems, can
improve outcomes. Although jejunal feeding is a well-established and common
modality for the administration of artificial nutrition support, the evidence base
supporting its use is limited. The majority of this discussion is, therefore, pragmatic
and based on the authors' experience in clinical nutrition, with reference to the
literature where available.
Mistake 1 Not involving a multidisciplinary
nutrition support team
When managing a patient who may require
long-term enteral feeding, involvement of a
nutrition support team (NST) is recommended
by both the UK National Institute for Health
and Care Excellence (NICE) and the European
Society of Parenteral and Enteral Nutrition
(ESPEN) guidance.1,2 Indeed, it is recommended
that all hospitals providing acute care should
have a multidisciplinary NST.1,2 Failure to adopt
this approach can result in a nonstandardised
approach to decision making and worse patient
outcomes. The optimal NST includes medical
clinical nutrition specialists, nutrition nurses,
dietitians, clinical psychologists (and on,
occasion, liaison with psychiatrists, particularly if
disordered eating is suspected) and pharmacists,
with access to radiologists, clinical biochemists
and surgeons as needed. The available literature
reports the potential for improved patient
outcomes when NSTs form the basis of an enteral
nutrition service.2-4 In particular, NSTs should
assess the suitability of different feeding routes
and advise on alternative treatment options
(see Mistake 2).

Mistake 2 Overlooking jejunal feeding as
the optimal feeding route
Jejunal feeding should not be overlooked when
considering the optimal route for nutritional
support. For individuals who have gastric
pathology and a functioning small bowel, jejunal
feeding may be preferable to avoid the
unnecessary use of parenteral nutrition, given
the inherent risk associated with central venous

© UEG 2020 Bond and Lal.
Cite this article as: Bond A and Lal S. Mistakes in jejunal feeding
and how to avoid them. UEG Education 2020; 20: 17-19.
Ashley Bond is a Consultant Gastroenterologist at Liverpool
University Hospitals Foundation Trust, UK.

catheters and parenteral nutrition in general.5
Similarly, clinicians should consider jejunal
feeding as the route of choice in some other
settings; for example, the postpyloric route may
be preferable in the critical-care setting to reduce
the risk of pneumonia.6

Mistake 3 Placing a permanent tube
without trialling nasojejunal feeding
In the majority of cases, the first choice for jejunal
feeding will be a nasojejunal (NJ) feeding tube
(figure 1). Proceeding straight to placement of a
long-term invasive tube (e.g. via direct puncture
percutaneous endoscopic jejunostomy [PEJ] or
percutaneous endoscopic gastrojejunostomy
[PEG-J], figure 1) is not advisable, since
tolerance and evidence of improvement in
nutritional status should be demonstrated in
order to risk stratify invasive tube placement. NJ
tubes can be placed radiologically, endoscopically
and in some instances are self-propelling.7 Given
that these tubes will often be required to maintain
a stable position for a number of weeks, we
recommend inserting a nasal bridle at the time
of NJ tube insertion and recording the position
of the feeding tube at the nose (using the tube
centimetre markings). The nasal bridle improves
stability and reduces accidental dislodgement,
and it can improve the patient's tolerance of the
tube by limiting pharyngeal movements.8
There are circumstances in which initial
insertion of an invasive jejunal feeding tube may
be appropriate; namely, following resection of
an upper gastrointestinal cancer.9 Even in the
latter case, however, postoperative dependence
on jejunal feeding can be highly variable and
surgically-placed tubes can be associated with

complications, including small bowel volvulus.10
ESPEN guidance recommends that placement
of an NJ tube or needle catheter jejunostomy be
considered for all tube feeding candidates who
are undergoing major upper gastrointestinal
and pancreatic surgery, with special regard to
malnourished patients.9 Assessment for risk of
pre- and postoperative malnutrition should take
place in order to guide the decision regarding
jejunostomy. In case of a major complication with
relaparotomy, the use of an NJ tube or needle
catheter jejunostomy may be considered.9

Mistake 4 Too early or inappropriate
jejunal feeding
Proceeding too readily to jejunal feeding in
patients who have no structural intestinal
pathology and predominantly functional
symptoms, such as nausea, vomiting and pain,
but who are not malnourished is a common pitfall.
In this patient group there is a range of possible
functional diagnoses to consider and address
and, in many of these patients, jejunal feeding can
unnecessarily add to the complexity of their care
with the potential for medical iatrogenesis. When
adopted in these circumstances, there is a risk of
losing the primary evidence-based indication for
jejunal feeding, which is to address malnutrition,
while instead focussing on trying to improve
foregut functional symptoms.
Nutritional approaches for patients with
gastrointestinal motility disorders should first trial
oral nutrition. For patients who progress to enteral
or parenteral feeds, the primary aim should be
to maintain or reinstate oral intake to reduce morbidity and mortality risk.11 The specific features
of certain functional foregut disorders need to

Simon Lal is a Consultant Gastroenterologist at Salford Royal

Correspondence to: Ashley.Bond@liverpoolft.nhs.uk

NHS Foundation Trust and a Professor at the University of
Manchester, UK.
Image: GerryP/Shutterstock.com
Illustration: J.Shadwell

Conflicts of interest: The authors declare there are no conflicts

of interest.
Published online: September 18, 2020.

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Mistakes in ... Booklet 2020

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