Feeding tubes

Question: Which of the following cirrhotic patients can receive nasogastric feeding tube placement (instead of nasojejunal feeding, which is common practice)?

A. 61 M with severe hepatic encephalopathy

B. 48 F with insulin-dependent diabetes mellitus

C. 44 M in the ICU and intubated

D. 51 M with grade II esophageal varices, no recent band ligation


Answer: For patients requiring naso-enteral feeding tube placement, it is common practice to advance the tube into the jejunum, but why?  A meta-analysis found that there is a trend toward fewer aspiration events with NJ (vs NG) feeds, but the difference is negated once you remove one, particularly large study within the analysis.  After all, most aspiration is due to oropharyngeal secretions and not gastric secretions.

So, it is probably safe to feed into the stomach in most cases; that’s what the stomach is there for- to receive food.  However, there are certain circumstances that may be at higher risk for aspiration, and answer choices A through C are good examples.  For patients with severe encephalopathy or who are intubated, prolonged supine positi0ning could facilitate reflux, and aspiration.  Advanced diabetes mellitus, with the possibility of gastroparesis and retained feeds, would be another problematic setup. 

The presence of gastric varices, on the other hand, poses no intrinsic threat to aspiration of gastric contents.  Furthermore, as long as there is no recent variceal band ligation, it is not risky to place a feeding tube if varices are present.  So, I believe patient D should be fed into the stomach.

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