Mistakes in ... Booklet 2020 - 30

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Mistakes in... 2020

patients at risk of refeeding syndrome it is vital
that feeding is commenced at the recommended
amount and rate, and that they receive
appropriate thiamine supplementation
and undergo close blood monitoring with
replenishment of electrolyte deficits in keeping
with local and national guidelines.13

Nasojejunal (NJ)

Mistake 7 Failing to manage symptoms
following a rate increase
Percutaneous
endoscopic
gastrojejunostomy
(PEG-J)

Percutaneous
endoscopic
jejunostomy
(PEJ)

Figure 1 | Jejunal feeding via a nasojejunal (NJ) feeding tube (blue), percutaneous endoscopic
gastrojejunostomy (PEG-J) tube (pink) or a percutaneous endoscopic jejunostomy (PEJ) tube (green).

be considered carefully before jejunal feeding
is adopted. Jejunal feeding is frequently poorly
tolerated in those who have centrally mediated
abdominal pain and narcotic bowel syndrome.
Conversely, those with gastroparesis and
malnutrition are likely to gain the most from
jejunal feeding.
Patients who have underlying but yet-to-bediagnosed eating disorders or atypical eating
behaviours are being referred initially more
frequently to gastroenterology services. Such
disorders will often present as an existing low BMI,
progressive weight loss and/or vomiting. If the
primary reason for jejunal feeding is actually an
eating disorder and this is not recognised by the
NST, then the likelihood that the therapeutic
goals will be achieved is remote and the
primary pathology may go untreated. Thus,
gastroenterologists and NSTs should engage the
appropriate psychology and psychiatric services
early if there is suspicion of an underlying mental
health disorder.

Mistake 5 Incorrect selection or insertion
of a permanent tube
If a patient has proven tolerance and improved
nutritional status with NJ tube feeding, together
with long-term dependence, then there are a
number of potential errors that can be made
relating to permanent tube selection.
First, the method of insertion of a transgastric
tube endoscopically (PEG-J tube) or radiologically
inserted percutaneous gastrojejunostomy (RIG-J
tube)-should be carefully considered. If there
is no cardiorespiratory or anatomical reason to
18

preclude endoscopic placement, then we would
recommend this as the first choice, as reported
outcomes can be worse for radiologically sited
tubes.12
Second, PEG-J tubes in general have
somewhat better stability and longevity than
RIG-J tubes and usually have better gastric venting ports. Of the commercially available PEG-J
tube options, however, some have more stable
jejunal extension attachments than others and
some have a greater risk of buried bumper than
others. It is important to be familiar with the
pros and cons of each option for optimal tube
selection.
A further mistake is insertion at an
insufficiently distal gastric site for the PEG-J
tube, which worsens the stability of the jejunal
extension, thus increasing chances of tube
dislodgement back into the stomach. If local
expertise permits, then a direct PEJ using
device-assisted enteroscopy is less invasive than
surgical jejunal feeding tube insertion, and may
be more stable than PEG-J, but does not allow for
gastric venting (which may require the additional
placement of a gastric tube).

Mistake 6 Starting with an initial feeding
rate that's too fast
Enteral feeding must be commenced slowly after
jejunal tube placement. An initial trial of 0.9% w/v
sodium chloride at 10mL/hour for the first
24 hours after insertion is recommended, with a
gradual introduction of enteral feed, increasing the
rate as tolerated and also in keeping with the
management of any refeeding risk.2 For those

Patients may be intolerant of larger rates and
volumes of feed, presenting with symptoms of
nausea, bloating, pain and diarrhoea. The use of
prokinetics and laxatives, where appropriate, may
be beneficial to facilitate increments in jejunal
feeding rates. Antiemetics may also be required.
In those patients who have diarrhoea,
alternative feeds can be trialled along with
antidiarrhoeal agents, as needed. Factors related
to enteral-tube-associated diarrhoea should be
considered, including the feed formulation used,
the manner of administration, or bacterial
contamination.14 Early and frequent access to
experienced dietitians to stagger increment rates
when needed and consider switching feed types
should be available. To ensure that nutritional
requirements are met, and the appropriate
treatment administered, all possible causes
of diarrhoea should be considered and
appropriate measures taken before discontinuing
feed.14
Occasionally, therapy for presumed small
intestinal overgrowth can also improve feed
tolerance, particularly in those who have
underlying intestinal dysmotility. In patients
who have pancreatitis requiring jejunal
feeding or those who have undergone Roux-en-Y
reconstruction, awareness of the possibility of
pancreatic enzyme insufficiency or poor enzyme
mixing should prompt the addition of pancreatic
enzyme supplementation to the feed to reduce
any malabsorption. Support from clinical
psychology services can help patients when
they are adapting to long-term feeding
requirements.

Mistake 8 Not reviewing and optimising
medications following jejunal tube
placement
Optimising medication to manage symptoms is a
crucial component of enhancing tolerance to
jejunal feeding. For example, the use of opioids
should be minimised, particularly in those who
have functional gastrointestinal disorders, owing
to their negative effects on gastrointestinal
motility. Consequently, early engagement of a
chronic pain team is important, with consideration
given to alternative pain therapies such as those
targeting neuropathic pain. Furthermore, careful
liaison with a pharmacist is essential because all
medications that are to be administered via the
Mistakes in ... Booklet 2020

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