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The primary aim of enteral tube feeding is to:

avoid further loss of bodyweight

correct significant nutritional deficiencies

rehydrate the patient

stop the related deterioration of quality of life of the patient due to inadequate oral nutritional intake (Loser et al. 2005).

Indications

Indications for enteral tube feeding are as follows:

patient is unable to meet nutritional needs through oral intake alone

the gastrointestinal tract is accessible and functioning

it is anticipated that intestinal absorptive function will meet all nutritional needs.

(NCCAC 2006)

Preprocedural considerations

Equipment: types of enteral feed tubes

Nasogastric/nasoduodenal/nasojejunal

Nasogastric feeding is the most commonly used enteral tube feed and is suitable for short-term feeding, that is, 2–4 weeks (NCCAC 2006). Fine-bore feeding tubes should be used whenever possible as these are more comfortable for the patient than wide-bore tubes. They are less likely to cause complications such as rhinitis, oesophageal irritation and gastritis (Payne-James et al. 2001). Polyurethane or silicone tubes are preferable to polyvinylchloride (PVC) as they withstand gastric acid and can stay in position longer than the 10–14-day lifespan of the PVC tube (Payne-James et al. 2001).

Gastrostomy

A gastrostomy may be more appropriate than a nasogastric tube where medium- or long-term feeding is anticipated. It avoids delays in feeding and discomfort associated with tube displacement (NCCAC 2006). It is suitable for patients who are undergoing radical or hyperfractionated radiotherapy to the neck or children with solid tumours. They will require long-term enteral feeding because the treatment is intensive and prolonged.

A gastrostomy tube may be placed endoscopically (percutaneous endoscopically placed gastrostomy; PEG) or radiologically (radiologically inserted gastrostomy; RIG). They are made from polyurethane or silicone and are therefore suitable for short- or long-term feeding. A flange, flexible dome, inflated balloon or pigtail sits within the stomach and holds the tube in position.

For long-term feeding (i.e. longer than 1 month), a gastrostomy tube may be replaced with a button which is made from silicone. The entry site for feeding is flush with the skin, making it neat and less obvious than a gastrostomy tube. This is more cosmetically acceptable, especially for teenagers or patients who are physically active, but does require a certain amount of manual dexterity from the patient (Thomas and Bishop 2007). The button is held in place by a balloon or dome inside the stomach (Griffiths 1996).

Percutaneous endoscopically placed gastrostomy tubes may be placed while the patient is sedated, thereby avoiding the risks associated with general anaesthesia. However, patients who have compromised airways may require general anaesthesia and appropriate consideration for maintenance of the airway (see Chapter 10).

Certain groups of patients are not suitable for endoscopy; in these cases a RIG can be used. They are indicated for oesophageal patients with bulky tumours where it would be difficult to pass an endoscope and also for head and neck patients whose airway would be obstructed by an endoscope. There is also documented risk of the endoscope seeding the tumour to the gastrostomy site when it pulls the tube past a bulky tumour although this is a rare complication (Pickhardt et al. 2002).

Jejunostomy

A jejunostomy is preferable to a gastrostomy if a patient has undergone upper GI surgery or has severe delayed gastric emptying; in some cases it can be used to feed a patient with pyloric obstruction (Thomas and Bishop 2007). Fine-bore feeding jejunostomy tubes may be inserted with the use of a jejunostomy kit, which consists of a needle-fine catheter. The use of needles and an introducer wire allows a fine-bore polyurethane catheter to be inserted into a loop of jejunum. Alternatively, some gastrostomy tubes allow the passage of a fine-bore tube through the pylorus and into the jejunum. A double-lumen