Question 20

Compare and contrast the advantages and disadvantages of enteral feeding via a nasogastric tube, a PEG and a percutaneous feeding jejunostomy.

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College Answer

Nasogastric tube: simple, commonly used, cheap, can assess and retrieve residual gastric contents (depends on tube size), advantages of gastric feeding (tolerant of bolus and continuous feeds, buffers gastric acids, bactericidal action of acid, gastric pepsin and lipase facilitate absorption of most feeds)

BUT aesthetic appearance, potential trauma of insertion, potential misplacement during insertion (especially critically ill), requires radiological confirmation of placement, easily dislodged, sinusitis, increase aspiration risk (less competence gastro-oesophageal sphincter), potential for gastric distension, tolerance of feeding susceptible to gastroparesis (emesis, regurgitation).

PEG: avoids nose/mouth issues, better tolerated than nasogastric, less likely to be displaced than nasaogastric, can assess and retrieve gastric contents (if large bore and in stomach), advantages of gastric feeding (see above), avoids interfering with gastro- oesophageal sphincter

BUT more complex to insert, less commonly performed, moreexpensive tube, requires endoscopy (with associated complications), percutaneous wound, often larger bore tube with potential for trauma and displacement, potential for gastric distension, tolerance of feeding susceptible to gastroparesis (emesis, regurgitation).

Percutaneous feeding jejunostomy: avoids nose/mouth issues, better tolerated than nasogastric, less likely to be displaced than others, avoids interfering with gastro- oesophageal sphincter, bypasses stomach and allows earlier feeding (avoids gastric distension and problems of gastroparesis), theoretically better for pancreatitis (less pancreatic exocrine secretion)

BUT more complex to insert, less commonly performed, more expensive tube, requires endoscopy &/or surgery (with associated complications), percutaneous wound, small bore tube with potential for displacement and blockage (eg. with enteral drugs), less tolerant of bolus or high volume infusions.

Discussion

Elsewhere, there is a brief summary of the routes of enteral nutrition, and it contains this table, which is essentially a tabulated form of the stream-of-consciousness answer offered by the college.

~Enteral Feeding Routes~
A Comparison of the Nasogastric Tube, Percutaneous Endogastic Tube and Feeding Jejunostomy
Tube type	Advantages	Disadvantages
Nasogastric	Easy to insert The tubes are cheap Gastric aspiration is possible Gastric food delivery buffers gastric acids and protects the gastric mucosa The gastric acid has a bactericidal action which helps prevent gastroenteritis Gastric secretions (gastric pepsin and lipase) facilitate absorption of feeds, which means one is not limited to any specialised feed mixtures	Uncomfortable in the awake patient It is easily dislodged by a delirious patient It may increase aspiration risk because the gastro-oesophageal sphincter is less competent when there is something constantly in it.
Nasojejunal tube	Decreased risk of aspiration. Decreased stimulus to pancreatic secretion.	Uncomfortable in the awake patient Difficult to place. Not exactly cheap One must wait for the tip to migrate into the jejunum Impossuble to administer large boluses. Gastric mucosa is unprotected from acid, and loses trophic stimulus The feeds do not benefir from the bactericidal eactivity of stomach acid Absorption may be impaired due to the loss of gastric pepsin and lipase; specialised mixtures may be required
PEG tube	Improved tolerance in the awake patient None of the facial pressure are complications No sinusitis or mucositis No risk of oesophageal stricture Better tolerance in the extremely long term (one can have a percutaneous tube for their entire life) Nice, large bore tube - less likely to block All the advantages of gastric feeding (eg. tolerance of bolus feeds, sterilising effects of stomach acid and usefulness of gastric digestive enzymes) All the advantages of NG sumps - can aspirate and sample gastric contents Less likely to result in aspiration, as it does not interfere with the gastrooesophageal sphincter. Alows earlier feeding, as poor gastric emptying is not an issue	Needs to be surgically placed Requires endoscopy to position Risk of early dislodgement and loss of the imamture fistula tract Tube can block unless it is wide-bore Skin erosion and ulceration may take place.
Feeding jejunostomy	Improved tolerance in the awake patient None of the facial pressure are complications No sinusitis or mucositis No risk of oesophageal stricture Least likely to be dislodged Alows earlier feeding, as poor gastric emptying is not an issue Decreased stimulus to pancreatic secretion.	Needs to be surgically placed Requires endoscopy, or more usually laparoscopy, to position It is a small bore tube which is blocked more easily One can neither aspirate it, nor bolus-feed through it

References

M Keymling Technical aspects of enteral nutrition Gut 1994; supplement 1: S77-S80

Hayden White1*, Kellie Sosnowski1, Khoa Tran1, Annelli Reeves2 and Mark Jones A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. Critical Care 2009, 13:R187 doi:10.1186/cc8181

Eatock FC, Chong P, Menezes N, Murray L, McKay CJ, Carter CR, Imrie CW. A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis. Am J Gastroenterol. 2005 Feb;100(2):432-9.

O. Odocha, R. C. Lowery, Jr, H. M. Mezghebe, S. M. Siram, and O. G. WarnerTracheopleuropulmonary injuries following enteral tube insertion J Natl Med Assoc. 1989 March; 81(3): 275–281. PMCID: PMC2571629 .

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