Enteral nutrition gastrointestinal

Gastrointestinal fistulas if enteral nutrition cannot be provided above or below the fistula... 

Gastrointestinal complications are the most common complications of enteral nutrition (EN), limiting the amount of feeding that patients receive. 

Enteral nutrition (EN) is broadly defined as delivery of nutrients via the gastrointestinal (GI) tract. This could include normal oral feeding as well as delivery of nutrients in a liquid form by a tube. Sometimes when the term enteral nutrition is used, only tube feedings are included hence the terms enteral nutrition and tube feedings are often used synonymously. The bulk of this chapter will include information regarding delivery of feedings via tubes. Formulas for EN usually are delivered in the form of commercially prepared liquid preparations, although some products are produced as powders for reconstitution. 

Enteral nutrition Delivery of nutrients via the gastrointestinal tract, either by mouth or by feeding tube. 

Patients who cannot or will not eat, or who are unable to absorb nutrients taken by mouth, may be fed intravenously (parenteral nutrition) or through a tube inserted into the gastrointestinal (GI) tract (enteral nutrition). 

The gastrointestinal (Gl) tract is the optimal route for providing nutrients unless obstruction, severe pancreatitis, or other Gl complications are present (see Fig. 136-1). Other considerations that may have an impact on determination of an appropriate route for nutrition support include expected duration of nutrition therapy and risk of aspiration. Patients who have nonfunctional Gl tracts or are otherwise not candidates for enteral nutrition (EN) may benefit from PN. Use of the intravenous route for nutrition support is also commonly referred to as total parenteral nutrition (TPN) or hyperalimentation. Routine monitoring is necessary to ensure that the nutrition regimen is suitable for a given patient as his or her clinical condition changes and to minimize or treat complications early. 

Pseudo-obstruction PN is indicated in patients with prolonged dysmotility of the gastrointestinal tract distal to the pylorus, or in patients who cannot grow and gain weight with enteral nutrition alone. 

The gastrointestinal (Gl) tract defends the host from toxins and antigens by both immunologic and nonimmunologic mechanisms, collectively referred to as the gut barrier function. Whenever possible, enteral nutrition (EN) is preferred over parenteral nutrition (PN) because it is as effective, may reduce metabolic and infectious complications, and is less expensive. 

Most patients with ARF have a superimposed illness that requires nutritional support by the parenteral route. Enteral nutrition (EN) should be considered when patients with ARF have functional gastrointestinal tracts. The products used frequently during EN in ARF are the calorically dense, electrolyte-free or electrolyte-reduced formulas (Table 139-1). These formulas are useful in patients with fluid overload, hyperkalemia, and hyperphosphatemia. Unfortunately, EN is impossible for many patients with ARF because they are critically ill and have an ileus. 

Gastrointestinal The factors associated with diarrhea in patients receiving enteral nutrition have been studied in 160 patients, of whom 61% had diarrhea [44 ]. The enteral... 

Gastrointestinal system Nausea and vomiting Diarrhea Constipation Anorexia Stomatitis (waste buildup) Bleeding (waste buildup, impaired clotting) Parenteral nutrition (if indicated) Enteral nutrition (if indicated) Dietary restriction of potassium (40 mEq or as ordered), sodium, phosphate based on values of labwork Protein intake based on need (0.6-2 g/kg/day)... 

In a prospective cohort study including 24 infants, the incidence and risk factors of parenteral nutrition-associated liver disease (PNALD) was determined. Eight infants developed PNALD. The concluded that the duration of enteral starvation, gastrointestinal surgery, duration of enteral nutrition, maximum caloric and carbohydrate intakes were significant risks of PNALD in newborn infants [lob ll. In a retrospective review of the safety and efficacy of PN among 105 paediatric patients with bum injuries (>30% total-body sxuface area), no respiratory or blood infections were observed with the use of parenteral nutrition, and the overall mortality rate was 4% [107 ]. 

Daly JM, Weintraub FN, Shou J, et al. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg 1995 221 327-338. 

This study has several limitations. First, the manometric technique cannot verify whether an NGT is placed in the stomach or more distal gastrointestinal tract, a critical consideration for enteral nutrition. The desired depth of NGT insertion was determined to just reach the stomach in this study. Therefore, when a nasointestinal tube is placed for administering jejunal feedings, the manometric technique may not be useful to verify the correct placement. Second,... 

Crohn s disease of the small bowel classically affects the ileocaecal region, although any part of the gastrointestinal tract may be involved, from the mouth downwards. Patients with small bowel involvement are frequently malnourished and specialist dietetic input is essential enteral or parenteral nutrition may be required. Osteoporosis is common, particularly if corticosteroid consumption has been high. 

Parenteral nutrition is often necessary in seriously ill ARDS patients because blood flow to the gastrointestinal tract is limited. Enteral... 

Detsky AS, Baker JP, O Rourke K, et al. Predicting nutrition-associated complications for residents undergoing gastrointestinal surgery. JPEN J Parenter Enteral Nutr 1987 11 440 46. 

Phosphorus can be omitted from the nutritional formula of patients receiving PN until the phosphorus level approaches normal (<5 mg/dL). It is prudent to monitor phosphorus concentrations daily and to add phosphorus in small doses once the serum concentration is below 4 mg/dL. Failure to do so can lead to severe hypophosphatemia (see Chap. 49) despite continued renal failure, especially in the patient treated with CRRT. Patients with persistently high serum phosphorus concentrations who have a functional gastrointestinal tract (GIT) can be prescribed phosphate-binding therapy (see Chap. 44) and enteral feedings low in phosphorus to minimize the absorption of exogenous phosphorus. 

Xue, H., Sawyer, M.B., Wischmeyer, P.E., and Baracos, V.E. 2011. Nutrition modulation of gastrointestinal toxicity related to cancer chemotherapy from preclinical findings to clinical strategy. J Parenter Enteral Nutr 15(1) 74—90. 

The precise mechanism and the localization of the absorption for orally taken aluminum are not known so far. It is assumed, however, that the aluminum is absorbed in the stomach and the duodenum, possibly in the proximal jejunum as well. The absorbed amount depends on the solubility of the aluminum compound and the respective gastrointestinal pH level. In addition, iron and fluorine increase the enteral absorption. Furthermore, the aluminum intake might be influenced by the parathyroid hormone and vitamin D. The daily aluminum intake via nutrition depends on eating habits and is estimated at an average of 5-10 mg/day less than 1% of this amount is absorbed. 

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