Enteral Nutritional Support in Gastrointestinal and Liver Diseases

Eun Ran Kim

doi:10.4166/kjg.2015.65.6.354

Journal List > Korean J Gastroenterol > v.65(6) > 1007384

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Kim: Enteral Nutritional Support in Gastrointestinal and Liver Diseases

Review Article

Korean J Gastroenterol 2015;65(6):354-360.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.65.6.354

Enteral Nutritional Support in Gastrointestinal and Liver Diseases

Eun Ran Kim

Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

Correspondence to: Eun Ran Kim, Division of Gastroenterology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea. Tel: +82-2-3410-3409, Fax: +82-2-3410-6983, E-mail: er.kim@samsung.com

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Nutritional support is important because malnutrition is a major contributor to increased morbidity and mortality, decreased quality of life, increased length of hospital stay, and higher healthcare costs. Patients with gastrointestinal disease are at an increased risk of nutritional deterioration due to therapeutic dietary restriction, fasting for the diagnostic tests, loss of appetite due to anorexia or altered nutritional requirement caused by the disease itself. Therefore, it is important that gastroenterologists are aware of the nutritional status of patients and plan a treatment strategy considering patient's nutritional status. Enteral nutrition is preferred to parenteral nutrition as it is more physiologic, has fewer complications, help to prevent mucosal atrophy and maintain gut barrier function, which decrease intestinal bacterial translocation. Hence, enteral nutrition has been considered to be the most effective route for nutritional support. In this article, we will review enteral nutrition (oral nutritional supplements, enteral tube feeding) as a treatment for the patients with gastrointestinal, liver and pancreatic disease at risk of malnutrition.

Keywords: Enteral nutrition, Inflammatory bowel diseases, Liver diseases, Nutritional support, Pancreatic diseases

References

1. Kyle UG, Genton L, Pichard C. Hospital length of stay and nutritional status. Curr Opin Clin Nutr Metab Care. 2005; 8:397–402.

2. Lim SL, Ong KC, Chan YH, Loke WC, Ferguson M, Daniels L. Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality. Clin Nutr. 2012; 31:345–350.

3. Jensen GL, Compher C, Sullivan DH, Mullin GE. Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach. JPEN J Parenter Enteral Nutr. 2013; 37:802–807.

4. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ. 1994; 308:945–948.

5. Chang DK. Hospital malnutrition. Intest Res. 2013; 11:238–242.

6. Baik HW. Nutritional therapy in gastrointestinal disease. Korean J Gastroenterol. 2004; 43:331–340.

7. Baik HW. Nutritional therapy in hospital. J Korean Med Assoc. 2014; 57:491–495.

8. Jeon WK. Complement and integrative approach in gut health and immunologic disease. Hanyang Med Rev. 2010; 30:109–114.

9. Bourlioux P, Koletzko B, Guarner F, Braesco V. The intestine and its microflora are partners for the protection of the host: report on the Danone Symposium "The Intelligent Intestine," held in Paris, June 14, 2002. Am J Clin Nutr. 2003; 78:675–683.

10. Gebbers JO, Laissue JA. Immunologic structures and functions of the gut. Schweiz Arch Tierheilkd. 1989; 131:221–238.

11. Gopalan S, Khanna S. Enteral nutrition delivery technique. Curr Opin Clin Nutr Metab Care. 2003; 6:313–317.

12. Lochs H, Allison SP, Meier R, et al. Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics. Clin Nutr. 2006; 25:180–186.

13. Anker SD, John M, Pedersen PU, et al. ESPEN guidelines on enteral nutrition: cardiology and pulmonology. Clin Nutr. 2006; 25:311–318.

14. Cano N, Fiaccadori E, Tesinsky P, et al. ESPEN guidelines on enteral nutrition: adult renal failure. Clin Nutr. 2006; 25:295–310.

15. Kreymann KG, Berger MM, Deutz NE, et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr. 2006; 25:210–223.

16. Plauth M, Cabré E, Riggio O, et al. ESPEN guidelines on enteral nutrition: liver disease. Clin Nutr. 2006; 25:285–294.

17. Lee KM. Nutrition in inflammatory bowel disease. Korean J Gastroenterol. 2008; 52:1–8.

18. Kim KO. Management of anemia in patients with inflammatory bowel disease. Korean J Gastroenterol. 2015; 65:145–150.

19. Hartman C, Eliakim R, Shamir R. Nutritional status and nutritional therapy in inflammatory bowel diseases. World J Gastroenterol. 2009; 15:2570–2578.

20. Yoon SY, Jung SA. Nutritional support in patients with inflammatory bowel diseases. Intest Res. 2013; 11:243–249.

21. Lochs H, Dejong C, Hammarqvist F, et al. ESPEN guidelines on enteral nutrition: gastroenterology. Clin Nutr. 2006; 25:260–274.

22. Schütz T, Herbst B, Koller M. Methodology for the development of the ESPEN guidelines on enteral nutrition. Clin Nutr. 2006; 25:203–209.

23. Forbes A. Review article: Crohn's disease–the role of nutritional therapy. Aliment Pharmacol Ther. 2002; 16(Suppl 4):48–52.

24. Wright RA, Adler EC. Peripheral parenteral nutrition is no better than enteral nutrition in acute exacerbation of Crohn's disease: a prospective trial. J Clin Gastroenterol. 1990; 12:396–399.

25. Zachos M, Tondeur M, Griffiths AM. Enteral nutritional therapy for induction of remission in Crohn's disease. Cochrane Database Syst Rev. 2007; (1):CD000542.

26. Shanbhogue RL, Bistrian BR, Jenkins RL, Jones C, Benotti P, Blackburn GL. Resting energy expenditure in patients with end-stage liver disease and in normal population. JPEN J Parenter Enteral Nutr. 1987; 11:305–308.

27. Campillo B, Richardet JP, Scherman E, Bories PN. Evaluation of nutritional practice in hospitalized cirrhotic patients: results of a prospective study. Nutrition. 2003; 19:515–521.

28. Campillo B, Richardet JP, Bories PN. Enteral nutrition in severely malnourished and anorectic cirrhotic patients in clinical practice. Gastroenterol Clin Biol. 2005; 29:645–651.

29. Plank LD, Gane EJ, Peng S, et al. Nocturnal nutritional supplementation improves total body protein status of patients with liver cirrhosis: a randomized 12-month trial. Hepatology. 2008; 48:557–566.

30. Plauth M, Merli M, Kondrup J, Weimann A, Ferenci P, Müller MJ. ESPEN Consensus Group. ESPEN guidelines for nutrition in liver disease and transplantation. Clin Nutr. 1997; 16:43–55.

31. Yoshida T, Muto Y, Moriwaki H, Yamato M. Effect of long-term oral supplementation with branched-chain amino acid granules on the prognosis of liver cirrhosis. Gastroenterol Jpn. 1989; 24:692–698.

32. Charlton M. Branched-chain amino acid enriched supplements as therapy for liver disease. J Nutr. 2006; 136(1 Suppl):295S–298S.

33. Marchesini G, Bianchi G, Merli M, et al. Italian BCAA Study Group. Nutritional supplementation with branched-chain amino acids in advanced cirrhosis: a double-blind, randomized trial. Gastroenterology. 2003; 124:1792–1801.

34. de Lédinghen V, Beau P, Mannant PR, et al. Early feeding or enteral nutrition in patients with cirrhosis after bleeding from esophageal varices? A randomized controlled study. Dig Dis Sci. 1997; 42:536–541.

35. Grant JP. Nutritional support in acute and chronic pancreatitis. Surg Clin North Am. 2011; 91:805–820. viii.

36. Meier R, Ockenga J, Pertkiewicz M, et al. ESPEN guidelines on enteral nutrition: pancreas. Clin Nutr. 2006; 25:275–284.

37. Dickerson RN, Vehe KL, Mullen JL, Feurer ID. Resting energy expenditure in patients with pancreatitis. Crit Care Med. 1991; 19:484–490.

38. Hill GL. Jonathan E. Rhoads lecture. Body composition research: implications for the practice of clinical nutrition. JPEN J Parenter Enteral Nutr. 1992; 16:197–218.

39. Windsor AC, Kanwar S, Li AG, et al. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Gut. 1998; 42:431–435.

40. Al-Omran M, Albalawi ZH, Tashkandi MF, Al-Ansary LA. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Rev. 2010; (1):CD002837.

41. Eckerwall GE, Tingstedt BB, Bergenzaun PE, Andersson RG. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery–a randomized clinical study. Clin Nutr. 2007; 26:758–763.

42. Eatock FC, Brombacher GD, Steven A, Imrie CW, McKay CJ, Carter R. Nasogastric feeding in severe acute pancreatitis may be practical and safe. Int J Pancreatol. 2000; 28:23–29.

43. Jiang K, Chen XZ, Xia Q, Tang WF, Wang L. Early nasogastric enteral nutrition for severe acute pancreatitis: a systematic review. World J Gastroenterol. 2007; 13:5253–5260.

44. Chang YS, Fu HQ, Xiao YM, Liu JC. Nasogastric or nasojejunal feeding in predicted severe acute pancreatitis: a metaanalysis. Crit Care. 2013; 17:R118.

45. Tiengou LE, Gloro R, Pouzoulet J, et al. Semi-elemental formula or polymeric formula: is there a better choice for enteral nutrition in acute pancreatitis? Randomized comparative study. JPEN J Parenter Enteral Nutr. 2006; 30:1–5.

46. Ford EG, Hull SF, Jennings LM, Andrassy RJ. Clinical comparison of tolerance to elemental or polymeric enteral feedings in the postoperative patient. J Am Coll Nutr. 1992; 11:11–16.

47. Caliari S, Benini L, Sembenini C, Gregori B, Carnielli V, Vantini I. Medium-chain triglyceride absorption in patients with pancreatic insufficiency. Scand J Gastroenterol. 1996; 31:90–94.

Table 1.

Routes for Enteral Feeding

Site of delivery	Access	Feeding route	Placement method
Stomach	Transnasal	Nasogastric tube	Spontaneous passive placement
Duodenum		Nasoduodenal tube	Using endoscopy
Jejunum		Nasojejunal tube	Using fluoroscopy
	Percutaneous	Gastrostomy tube	Using endoscopy
	(gastro/enterostomy)	Gastroduodenal tube	Using fluoroscopy
		Gastrojejunal tube	Surgical access
		Jejunostomy

Table 2.

Recommendations for the Indication, Application and Type of Formula of Enteral Nutrition in Patients with Inflammatory Bowel Disease²¹ (Grade²²)^a

	Crohn's disease	Ulcerative colitis
Indication	Indications for enteral nutrition are: prevention and treatment of undernutrition, improvement of growth and development in children and adolescents, improvements in quality of life, acute phase therapy, perioperative nutrition, maintenance of remission in chronic active disease
Active disease	In adults use enteral nutrition as sole therapy for the acute phase mainly when treatment with corticosteroids is not feasible. (A) Use combined therapy (enteral nutrition and drugs) in undernourished patients as well as in patients with inflammatory stenosis of the intestine. (C) In children with CD enteral nutrition is considered as the first line therapy. (C)	An influence of nutritional measures (nutritional counselling, oral nutritional supplements, tube feeding or parenteral nutrition) on the inflammatory activity in acute or in chronically active ulcerative colitis has not been demonstrated. Therefore, enteral nutrition is not recommended as treatment of active ulcerative colitis. (C)
Maintenance of remission	In case of persistent intestinal inflammation (e.g., steroid dependent patients) use oral nutritional supplements. (B) In longstanding (>1 year) clinical remission and in the absence of nutritional deficits a benefit of enteral nutrition (oral nutritional supplements or tube feeding) or supplements (vitamins and trace elements) has not been demonstrated. (B)	Enteral nutrition is not recommended. (C)
Peri-operative nutrition	Use perioperative nutrition in CD patients with weight loss prior to surgery and low albumin. (C)
Undernutrition	Enteral nutrition may improve the quality of life in undernourished CD patients. (C)	Initiate nutritional support in patients with undernutrition or inadequate nutritional intake. (C)
Application	Use tube feeding and/or oral nutritional supplements in addition to normal food to improve nutritional status and to eliminate consequences of undernutrition such as growth retardation. (A) Correct specific deficits (trace elements, vitamins) by supplementation. (C) Use continuous tube feeding rather than bolus delivery because of the lower complication rate. (B)	Treat specific deficiencies with supplements. (C)
Route	Using oral nutritional supplements, a supplementary intake of up to 600 kcal/day can be achieved in addition to normal food. (A) Use tube feeding if a higher intake is necessary. (C) Tube feeding can be safely delivered by nasogastric tube or percutaneous endoscopic gastrostomy. (B)
Type of formula Active disease	There are no significant differences in the effect of free amino acid, peptide-based and whole protein formulae for tube feeding. (A) Free amino acid or peptide-based formulae are not generally recommended. (A) Modified enteral formulae (fat modified, omega-3 fatty acids, glutamine, TGF--enriched) are not recommended because no clear benefits have been shown. (A)	The value of specific substrates (omega-3 fatty acids, glutamine, butyrate) on disease activity is controversial and not proven.

CD, Crohn's disease.

^a (A) is assigned to recommendations which are based on at least one randomized controlled trial whereas the lowest recommendation (C) is based on expert opinion, including the view of the working groups.

Table 3.

Recommendations for the Application and Type of Formula of Enteral Nutrition in Patients with Liver Cirrhosis¹⁶ (Grade²²) ^a

General	Recommended energy intake: 35–40 kcal/kg/day (147–168 kJ/kg/day) (C) Recommended protein intake: 1.2–1.5 g/kg/day (C)
Application	Use supplemental enteral nutrition when patients cannot meet their caloric requirements through oral food despite adequate individualised nutritional advise. (A)
Route	If patients are not able to maintain adequate oral intake from normal food, use -Oral nutritional supplements or (C) -Tube feeding (even in the presence of oesophageal varices) (A) PEG placement is associated with a higher risk of complications and is not recommended. (C)
Type of formula	Whole protein formulae are generally recommended. (C) Consider using more concentrated high-energy formulae in patients with ascites. (C) Use BCAA-enriched formulae in patients with hepatic encephalopathy arising during enteral nutrition. (A) The use of oral BCAA supplementation can improve clinical outcome in advanced cirrhosis. (B)
Outcome	Enteral nutrition improves nutritional status and liver function, reduces complications and prolongs survival in cirrhotics and is therefore recommended. (A)

PEG, percutaneous endoscopic gastrostomy; BCAA, branched chain amino acid.

^a (A) is assigned to recommendations which are based on at least one randomized controlled trial whereas the lowest recommendation (C) s based on expert opinion, including the view of the working groups.

Table 4.

Recommendations for the Application and Type of Formula of Enteral Nutrition in Patients with Acute Pancreatitis³⁶ (Grade²²) ^a

Indication
Mild acute pancrease	Enteral nutrition is unnecessary, if the patient can consume normal food after 5–7 days. (B)
	Enteral nutrition within 5–7 days has no positive impact on the course of disease and is therefore not recommended. (A)
	Give tube feeding, if oral nutrition is not possible due to consistent pain for more than 5 days. (C)
Severe pancreatitis	Use continuous enteral nutrition in all patients who tolerate it. (C)
Severe necrotizing pancreatitis	Enteral nutrition is indicated if possible. (A)
	Enteral nutrition should be supplemented by parenteral nutrition if needed. (C)
	In severe acute pancreatitis with complications (fistulas, ascites, pseudocysts) tube feeding can be performed successfully.
Application	Tube feeding is possible in the majority of patients but may need to be supplemented by the parenteral route. (A)
	Oral feeding (normal food and/or oral nutritional supplements) can be progressively attempted once gastric outlet obstruction has resolved, provided it does not result in pain, and complications are under control. Tube feeding can be gradually withdrawn as intake improves. (C)
Route	Try the jejunal route if gastric feeding is not tolerated. (C)
	In case of surgery for pancreatitis an intraoperative jejunostomy for postoperative tube feeding is feasible. (C)
	In gastric outlet obstruction the tube tip should be placed distal to the obstruction. If this is impossible, parenteral nutrition should be given. (C)
Type of formula	Peptide-based formulae can be used safely. (A)
	Standard formulae can be tried if they are tolerated. (C)

TOOLS

Similar articles