Mistakes in ... Booklet 2020 - 31

ueg education

enteral tube should be assessed for their risk of
causing tube blockage, as well as their suitability
for jejunal absorption. Water should be flushed
into the jejunal tube before and after medication
administration, and completely solubilised and
liquid medication options should be used,
wherever possible.

Mistake 9 Failing to pre-empt, recognise
and address complications
When considering specific tube-related
complications, the most commonly encountered
are leakage, obstruction, displacement, local
stoma complications and digestive intolerance.
A robust system of community-based care
and follow up must be in place to support
patients after hospital discharge and to
ensure complications are recognised and
managed in a timely manner (see also
Mistake 10).1
Displacement of NJ tubes is a frequent issue,
with the tip recoiling into the stomach or the
whole tube being removed nasally. Such
displacement may require repeated insertions
and the patient should be informed of this prior
to the initial insertion, in order to set their
expectations appropriately. Tube displacement
should be promptly recognised when following
management protocols in hospital or in the
community2 and/or if the patient is vomiting
enteral feed. Patients with repeated NJ tube
displacement should have their case discussed
with the NST to ensure ongoing replacement is
appropriate or to consider an alternative route
when needed.
Displacement is not limited to NJ tubes and
may be a frequent issue with PEG-J tubes as the
jejunal extension recoils into the stomach. Such
issues may be pre-empted by appropriate patient
selection (e.g. excluding those with significant
small bowel dysmotility), medication
optimisation (e.g. administering prokinetics
and avoiding opioids) and tube placement
(e.g. low antral site). However, even when all
of these aspects have been considered, tube
displacements may still occur. At this stage
consideration might be given to clipping of the
jejunal tube,15 changing to a weighted radiology
transgastric tube or switching to a PEJ or surgical
jejunostomy.
A lack of awareness of the risk of developing
buried bumper with some types of PEG-J tube
can lead to inadequate aftercare. The PEG-J tube
should be advanced and retracted daily to reduce
the risk of buried bumper, but it should not be
rotated since this would dislodge the jejunal
extension.
Peristomal leakage can be a particular problem
with poorly vented PEG-J tubes and with direct
jejunal placement. A mistake here is to increase
the tube size/diameter in the tract in an attempt
to reduce leakage; this will tend to lead to

Mistakes in... 2020

gradually increasing tract size/diameter and
potentially worsened leakage. Instead, venting the
stomach where possible and the use of peristomal
barrier creams, stoma bags and stoma cones can
help. Venting the stomach consists of actively
aspirating the gastric content. This can be
performed by the patient at set intervals or when
they have symptoms of nausea or pain. Re-siting
the tube may simply result in a recurrence of the
problem at another site and risk leaving a
permanent enterocutaneous fistula.

Mistake 10 Inadequate long-term follow-up
Unscheduled healthcare contact is a frequent
occurrence for patients receiving communitybased jejunal feeding. Therefore, a robust system
for community-based care and follow-up must
be in place.1 ESPEN also recommend defined
pathways and procedures to ensure efficacy of
feeding and the assessment of body weight,
body composition, hydration, muscle strength
and performance, together with nutritional
intake.2 The systems put in place should also
assess feed tolerance and manage tube-related
complications.2 Failure to ensure community
and hospital NST follow-up can lead to
poor therapeutic effect, increased
complications, patient morbidity and increased
hospitalisations.

4.

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6.

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8.

9.
10.

11.

12.

13.

References
1. National Collaborating Centre for Acute Care. NICE
Clinical Guideline 32. Nutrition support for adults:
oral nutrition support, enteral tube feeding and
parenteral nutrition. February 2006.
2. Bischoff SC, Austin P, Boeykens K, et al. ESPEN
guideline on home enteral nutrition. Clin Nutr 2020;
39: 5-22.
3. Hvas C, Farrer K, Blackett B, et al. Reduced 30-day
gastrostomy placement mortality following the

14.

15.

introduction of a multidisciplinary nutrition support
team : a cohort study. J Hum Nutr Diet 2017;
31: 413-421.
BAPEN. Organisation of food and nutritional
support in hospitals. Nutrition Support Team(s).
https://www.bapen.org.uk/ofnsh/
OrganizationOfNutritionalSupportWithinHospitals.
pdf (2019, accessed 25 August 2020).
Seres DS, Valcarcel M and Guillaume A. Advantages
of enteral nutrition over parenteral nutrition.
Ther Adv Gastroenterol 2013; 6: 157-167.
Alkhawaja S, Martin C, Butler R, et al. Post-pyloric
versus gastric tube feeding for preventing
pneumonia and improving nutritional outcomes in
critically ill adults. Cochrane Database Syst Rev
2015; 8: CD008875.
Pearce CB and Duncan HD. Enteral feeding. Nasogastric,
nasojejunal, percutaneous endoscopic gastrostomy, or
jejunostomy: its indications and limitations. Postgradute
Medical Journal 2002; 78: 198-204.
Lynch A, Tang CS, Jeganathan LS, et al. A systematic
review of the effectiveness and complications of
using nasal bridles to secure nasoenteral feeding
tubes. Aust J Otolaryngol 2018; 1: 8.
Weimann A, Braga M, Carli F, et al. ESPEN guideline:
clinical nutrition in surgery. Clin Nutr 2017;
36: 623-650.
Blakely A, Ajmal S, Sargent R, et al. Critical analysis of
feeding jejunostomy following resection of upper
gastrointestinal malignancies. World J Gastrointest
Surg 2017; 27: 53-60.
Lehmann S, Ferrie S and Carey S. Nutrition
management in patients with chronic gastrointestinal
motility disorders: a systematic literature review.
Nutr Clin Pract 2020; 35: 219-230.
Vidhya C, Phoebe D, Dhina C, et al. Percutaneous
endoscopic gastrostomy (PEG) versus radiologically
inserted gastrostomy (RIG): a comparison of
outcomes at an Australian teaching hospital.
Clin Nutr ESPEN 2018; 23: 136-140.
National Collaborating Centre for Acute Care. NICE
Clinical Guideline 32. Nutrition support for adults:
oral nutrition support, enteral tube feeding and
parenteral nutrition. February 2006 (updated
July 2017).
Eisenberg PG. Causes of diarrhea in tube-fed
patients: a comprehensive approach to diagnosis
and management. Nutr Clin Pract 1993;
8: 119-123.
Frizzel E and Darwin P. Endoscopic placement of
jejunal feeding tubes by using the Resolution clip:
report of 2 cases. Gastrointest Endosc 2006;
64: 454-456.

Your jejunal feeding briefing
UEG week

* 'Therapeutic nutrition in IBD' session at
UEG Week 2019 [https://ueg.eu/library/
session/therapeutic-nutrition-in-ibd/
156/2150].

* 'Nutritional support' presentation in the 'From

guidelines to clinical practice: Oesophageal
malignant strictures' session at UEG Week 2019
[https://ueg.eu/library/session/
from-guidelines-to-clinical-practice-oesophagealmalignant-strictures/156/2225].

* 'Motility disorders: Nutritional treatment'

presentation in the 'Anorexia and unexplained
weight loss session at UEG Week 2019
[https://ueg.eu/library/session/
anorexia-and-unexplained-weight-loss/156/2136].

* 'Percutaneous gastrostomy and jejunostomy' session
at UEG Week 2016 [https://ueg.eu/library/session/
percutaneous-gastrostomy-and-jejunostomy/144/1654].

Standards and Guidelines

* Bischoff SC, Austin P, Boeykens K, et al. ESPEN

guideline on home enteral nutrition. Clin Nutr 2020;
39: 5-22 [https://www.clinicalnutritionjournal.com/
article/S0261-5614(19)30198-0/fulltext].

* Weimann A, Braga M, Carli F, et al. ESPEN guideline:

clinical nutrition in surgery. Clin Nutr 2017;
36: 623-650 [https://ueg.eu/library/
espen-guideline-clinical-nutrition-in-surgery/173891].

* National Collaborating Centre for Acute Care. NICE

Clinical Guideline 32. Nutrition support for adults: oral
nutrition support, enteral tube feeding and parenteral
nutrition. February 2006 (updated July 2017)
[https://www.nice.org.uk/guidance/cg32/evidence/
full-guideline-194889853].

* BAPEN. Organisation of food and nutritional

support in hospitals. Nutrition Support Team(s).
[https://www.bapen.org.uk/ofnsh/
OrganizationOfNutritionalSupportWithinHospitals.
pdf] ](2019, accessed 25 August 2020).

19


https://www.bapen.org.uk/ofnsh/ https://www.ueg.eu/library/session/therapeutic-nutrition-in-ibd/156/2150 https://www.ueg.eu/library/session/therapeutic-nutrition-in-ibd/156/2150 https://www.clinicalnutritionjournal.com/ https://www.ueg.eu/library/session/therapeutic-nutrition-in-ibd/156/2150 https://www.ueg.eu/library/espen-guideline-clinical-nutrition-in-surgery/173891 https://www.ueg.eu/library/session/from-guidelines-to-clinical-practice-oesophageal-malignant-strictures/156/2225 https://www.ueg.eu/library/espen-guideline-clinical-nutrition-in-surgery/173891 https://www.ueg.eu/library/session/from-guidelines-to-clinical-practice-oesophageal-malignant-strictures/156/2225 https://www.ueg.eu/library/session/from-guidelines-to-clinical-practice-oesophageal-malignant-strictures/156/2225 https://www.nice.org.uk/guidance/cg32/evidence/full-guideline-194889853 https://www.ueg.eu/library/session/anorexia-and-unexplained-weight-loss/156/2136 https://www.nice.org.uk/guidance/cg32/evidence/full-guideline-194889853 https://www.ueg.eu/library/session/anorexia-and-unexplained-weight-loss/156/2136 https://www.ueg.eu/library/session/percutaneous-gastrostomy-and-jejunostomy/144/1654 https://www.bapen.org.uk/ofnsh/OrganizationOfNutritionalSupportWithinHospitals.pdf https://www.ueg.eu/library/session/percutaneous-gastrostomy-and-jejunostomy/144/1654 https://www.bapen.org.uk/ofnsh/OrganizationOfNutritionalSupportWithinHospitals.pdf https://www.ueg.eu/library/session/percutaneous-gastrostomy-and-jejunostomy/144/1654 https://www.bapen.org.uk/ofnsh/OrganizationOfNutritionalSupportWithinHospitals.pdf

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