Gastroenteric tube feeding: Techniques, problems and solutions

Gastroenteric tube feeding plays a major role in the management of patients with poor voluntary intake,chronic neurological or mechanical dysphagia or gut dysfunction,and patients who are critically ill.However,despite the benefits and widespread use of enteral tube feeding,some patients experience complications.This review aims to discuss and compare current knowledge regarding the clinical application of enteral tube feeding,together with associated complications and special aspects.We conducted an extensive literature search on PubMed,Embase and Medline using index terms relating to enteral access,enteral feeding/nutrition,tube feeding,percutaneous endoscopic gastrostomy/jejunostomy,endoscopic nasoenteric tube,nasogastric tube,and refeeding syndrome.The literature showed common routes of enteral access to include nasoenteral tube,gastrostomy and jejunostomy,while complications fall into four major categories:mechanical,e.g.,tube blockage or removal;gastrointestinal,e.g.,diarrhea;infectious e.g.,aspiration pneumonia,tube site infection;and metabolic,e.g.,refeeding syndrome,hyperglycemia.Although the type and frequency of complications arising from tube feeding vary considerably according to the chosen access route,gastrointestinal complications are without doubt the most common.Complications associated with enteral tube feeding can be reduced by careful observance of guidelines,including those related to food composition,administration rate,portion size,food temperature and patient supervision.

Refeeding syndrome in Southeastern Taiwan:Our experience with 11 cases

AIM: To present our experience with refeeding syndrome in southeastern Taiwan.

Imaging changes of the pancreas and the occasion of refeeding in patients with acute pancreatitis

Objective: To explore the objective basis of the time and characterstics of refeeding of patients with acute pancreatitis (AP). Methods: AP patients were randomly divided into routine group (n=105) and special group (n=99). The refeeding time and characteristics of the routine group were based on their levels of blood and urine amylase, function of the gastrointestinal tract, and symptoms and signs, and those of the special group on their imaging changes of ultrasonography and CT of the pancreas. Clinical data from the groups were analyzed prospectively and statistically. Results: At the beginning of refeeding, patients of the two groups showed a high recurrence rate of ab- dominal pain (routine group, 9.1%; special group, 10.5%), but no AP relapse. Three days to 2 weeks after refeeding, the patients of the routine group had a higher recurrence rate of abdominal pain (11.1%) and a relapse rate of AP (14.1%) as compared with those of the special group (P<0. 05). Two weeks later, both rates decreased apparently. However, 3 days to 4 weeks after refeeding, the patients of the special group had no recurrence of abdominal pain and relapse of AP. Imaging changes of the pancreas and peripancreatic tissue were not consistent with the symptoms and signs of AP patients. The higher the Balthazar CT grading and APACHE-Ⅱ score, the higher the recurrence rate of abdominal pain and the relapse rate of AP after refeeding (P<0. 05). Conclusions: Symptoms and signs were usually dis- cordant to the imaging changes of the pancreas in AP patients. Imaging changes of the pancreas might serve as a basis for the best occasion of refeeding light semi-fluid or light food in AP patients.

Oral refeeding in mild acute pancreatitis:An old challenge

Although the idea that pancreas rest has long been considered as a very relevant topic in acute pancreatitis (AP)therapy,the right time and type of diet to be offered to patients recovering from an acute attack are a great challenge to clinicians who treat this condition.Fortunately,the last decade was noted for several trials looking for the best answer to the question:"when and how to start oral refeeding in AP?"It is well known that 80%of patients present with mild disease characterized by usually uncomplicated clinical course are managed with pancreatic rest through nil per oral;while the use of specific nutritional intervention is an exception.Therefore,mild AP has been the most investigated form of AP and researchers have tried different kind of meals to offer calories and reduce costs by shortening hospitalization time.Usually in mild AP,the oral refeeding is introduced between the first 3 d and 7 d after hospitalization but,the type of diet and patients’tolerance have been scrutinized in detail with mixed results.Although 20%to 25%have pain recurrence requiring nutritional support and greater time of hospitalization,most patients seem to tolerate oral refeeding well.We propose analyzing the most recent investigations of this matter and their conclusions to develop a better understanding of the management of AP.

MicroRNA signature in response to nutrient restriction and re-feeding in fast skeletal muscle of grass carp （Ctenopharyngodon idella）

The grass carp(Ctenopharyngodon idella) is one of the most important cultivated fish species in China.Mounting evidences suggests that microRNAs(miRNAs) may be key regulators of skeletal muscle among the grass carp,but the knowledge of the identity of myogenic miRNAs and role of miRNAs during skeletal muscle anabolic state remains limited.In the present study,we choose 8 miRNAs previously reported to act as muscle growth-related miRNAs for fasting-refeeding research.We investigated postprandial changes in the expression of 8 miRNAs following a single satiating meal in grass carp juveniles who had been fasting for one week and found that 7 miRNAs were sharply up-regulated within 1 or 3 h after refeeding,suggesting that they may be promising candidate miRNAs involved in a fast-response signaling system that regulates fish skeletal muscle growth.

Reverse or inverted apical ballooning in a case of refeeding syndrome

Takotsubo cardiomyopathy is characterized by the development of transient left ventricular regional wall motion abnormalities,in the absence of significant coronary artery obstruction. This syndrome usually occurs in women and is frequently associated with an intense emotional or physical stress. It usually involves apical segments,but in the recent years atypical forms have been described. Inverted or reverse Takotsubo is a variant in which the basal and midventricular segments are hypokinetic,sparing contractile function of the apex. In this report we describe the case of a 54-year-old woman,with chronic malnutrition,initially admitted because of hypoglycemia and severe electrolyte disturbance due to a refeeding syndrome. Within the next hours she experienced acute cardiac symptoms and developed heart failure with low cardiac output. Electrocardiogram(ECG),elevation of troponin and echocardiographic findings were consistent with inverted Takotsubo cardiomyopathy. To the best of our knowledge,this is the first incidence reported of inverted Takotsubo triggered by refeeding syndrome.

A Calcified Artery of Drummond, Could It Be a Sentinel Sign of Further Complications?

Objective: To understand the role of the artery of Drummond in the elderly population. The artery plays a crucial role in the anastamosis between the inferior mesenteric artery and superior mesenteric artery. Its maintenance is particularly important for the survivability of the bowel in events of stenosis of either one of the native arteries;SMA or IMA. Method: A 94 year old lady presents with post-prandial abdominal pain and significant emaciation. The patient undergoes clinical and radiological investigations to find out the cause of her ailments. Results: Abdominal X-ray revealed a serpentine structure that was later defined as the artery of Drummond, CT scan revealed a calcified and enlarged artery of Drummond in addition to an occluded origin of SMA and celiac artery as well as a severe stenosis origin of IMA. Conclusion: The artery of Drummond was immensely hypertrophied and was supplying the entire bowel through the native IMA;subsequent occlusion of the IMA was the main cause that caused the demise of the patient.

Responses of the Adult Rat Glucose Metabolism to Early Life Feeding, Caloric Restriction and Refeeding

Early life overfeeding in the rat can be experimentally induced by reducing litter size. This investigation assessed the consequences of this manipulation on glucose metabolism in vivo and in isolated hepatocytes in 150-day old rats. Additionally, after body growth, the effects of caloric restriction and refeeding were tested. Adult rats from control （G9） and reduced litters （G3L） did not differ in body and fat weights, glucose tolerance or insulin resistance （insulin-induced hypoglycemia）, or hepatocyte glucose release under basal or gluconeogenic conditions. Caloric restriction （G3R） reduced body and fat weights, decreased glucose decay after insulin injection and decreased hepatocyte gluconeogenic glucose release. Refeeding after caloric restriction reversed these parameters to those of the freely-fed groups （G9 and G3L）. Taken together, these results suggest that the liver glucose metabolism is not programmed by lactational overfeeding, but rather is responsive to the current nutritional condition of the animal.

Enteral refeeding syndrome after long-term total parenteral nutrition

Background Early enteral feeding （EF） may result in fever, elevated white blood cell count, increased serum levels of liver enzymes, and diarrhea. We name the complications ＂enteral refeeding syndrome＂, as a subtype of refeeding syndrome, because they are likely to result from long-term lack of lumen nutrition. The aim of this study was to investigate the characteristics of enteral refeeding syndrome after long-term total parenteral nutrition （TPN）, and the solution for the disease. Methods We collected the clinical data of 100 patients with gastrointestinal fistula, who were cured from Apirl 2001 to July 2002. Their fasting time, daily stool frequency, body temperature, heart rate, respiratory rate, levels of transaminases, alkaline phosphatase （AKP）, and γ-glutamylcyclotransferase （γ-GT）, white blood cell count, and systemic inflammatory reaction syndrome （SIRS） score were recorded before and 1, 3, 5, 10, and 15 days after EF. Student＇s t test and analysis of variance were used to analyze the data. Results Of the 100 patients, 56 were cured after selective resection of intestinal fistula, 15 were cured by emergency operation, and 29 recovered spontaneously. The levels of AKP and y-GT increased significantly on the 3rd day after EF [On the 3rd day after EF, （243.0±121.6） U/L and （177.2±109.9） U/L vs. before EF （181.5±127.5） U/L and （118.4±94.2） U/L, P〈0.05], and decreased gradually afterwards. The SIRS scores on the 1st day （1.05±1.08） and 3rd day （0.96±1.11） after EF were significantly higher than that before EF （0.72＋0.84）, then decreased to 0.83±0.91, 0.49±0.73 and 0.32±0.60 on the 5th, 10th and 15th days after EE The number of patients with diarrhea at 1, 3, 5, 10 and 15 days post-EF were 31, 26, 12, 13, and 7, respectively. Conclusions The longer the TPN lasts, the more severe the enteral refeeding syndrome becomes. Continuous EF is effective for the syndrome. Early enteral nutrition is useful in preventing it.

Gluconeogenesis during starvation and refeeding phase is affected by previous dietary carbohydrates levels and a glucose stimuli during early life in Siberian sturgeon(Acipenser baerii)

Gluconeogenesis responses was assessed during a short starvation period and subsequent refeeding in Siberian sturgeon(Acipenser baerii) previously fed different dietary carbohydrates levels and experienced to a glucose stimuli during early life. The sturgeon larvae were previously fed either a high glucose diet(G) or a low glucose diet(F) from the first feeding to yolk absorption(8 to 12 d post-hatching [dph]). Each group of fish was sub-divided into 2 treatments at 13 dph and was fed either a high-carbohydrate diet(H) or a low carbohydrate diet(L) until 20 wk. In the current study, the fish in 4 groups(GL, FL, GH and FH) were experienced to starvation for 21 d following by re-feeding of their corresponding diets for 21 d.Fish were sampled at postprandial 6 and 24 h before starvation(P6 h and P24 h), starvation 7,14 and 21 d(S7, S14 and S21) and 1, 7,14 and 21 d during refeeding(R1, R7, R14 and R21). Plasma samples during refeeding were taken at P6 h at each time point. Glycaemia levels, liver and muscle glycogen contents,activities and mRNA levels of hepatic gluconeogenic enzymes were examined. We found that both dietary carbohydrate levels and early glucose stimuli significantly affected the metabolic responses to starvation and refeeding in Siberian sturgeon(P < 0.05). During prolonged starvation, Siberian sturgeon firstly mobilized the liver glycogen and then improved gluconeogenesis when the dietary carbohydrates were abundant, whereas preserved the liver glycogen stores at a stable level and more effectively promoted gluconeogenesis when the dietary carbohydrates are absent to maintain glucose homoeostasis.During refeeding, as most teleostean, Siberian sturgeon failed controlling the activities and mRNA levels of phosphoenolpyruvate carboxykinase cytosolic forms(PEPCK-C), fructose-1,6-bisphosphatase(FBPase),but particularly controlled phosphoenolpyruvate carboxykinase mitochondrial forms(PEPCK-M) activities and mRNA expression of glucose-6-phosphatase(G6 Pase, except in GL group). Siberian sturgeon has a full compensatory ability on growth, but this ability would be obstructed by early glucose stimuli when refeeding the low carbohydrate diet after S21.

YAP regulates the liver size during the fasting-refeeding transition in mice

Liver is the central hub regulating energy metabolism during feeding-fasting transition.Evidence suggests that fasting and refeeding induce dynamic changes in liver size,but the underlying mechanisms remain unclear.Yes-associated protein(YAP)is a key regulator of organ size.This study aims to explore the role of YAP in fasting-and refeeding-induced changes in liver size.Here,fasting significantly reduced liver size,which was recovered to the normal level after refeeding.Moreover,hepatocyte size was decreased and hepatocyte proliferation was inhibited after fasting.Conversely,refeeding promoted hepatocyte enlargement and proliferation compared to fasted state.Mechanistically,fasting or refeeding regulated the expression of YAP and its downstream targets,as well as the proliferation-related protein cyclin D1(CCND1).Furthermore,fasting significantly reduced the liver size in AAV-control mice,which was mitigated in AAV Yap(5SA)mice.Yap overexpression also prevented the effect of fasting on hepatocyte size and proliferation.Besides,the recovery of liver size after refeeding was delayed in AAV Yap shRNA mice.Yap knockdown attenuated refeeding-induced hepatocyte enlargement and proliferation.In summary,this study demonstrated that YAP plays an important role in dynamic changes of liver size during fasting-refeeding transition,which provides new evidence for YAP in regulating liver size under energy stress.

Exploring the precision redox map during fasting-refeeding and satiation in C.elegans

Fasting is a popular dietary strategy because it grants numerous advantages,and redox regulation is one mecha-nism involved.However,the precise redox changes with respect to the redox species,organelles and tissues remain unclear,which hinders the understanding of the metabolic mechanism,and exploring the precision redox map under various dietary statuses is of great significance.Twelve redox-sensitive C.elegans strains stably expressing genetically encoded redox fluorescent probes(Hyperion sensing H_(2)O_(2) and Grx1-roGFP2 sensing GSH/GSSG)in three organelles(cytoplasm,mitochondria and endoplasmic reticulum(ER))were constructed in two tissues(body wall muscle and neurons)and were confirmed to respond to redox challenge.The H_(2)O_(2) and GSSG/GSH redox changes in two tissues and three organelles were obtained by confocal microscopy during fasting,refeeding,and satiation.We found that under fasting condition,H_(2)O_(2) decreased in most compartments,except for an increase in mitochondria,while GSSG/GSH increased in the cytoplasm of body muscle and the ER of neurons.After refeeding,the redox changes in H_(2)O_(2) and GSSG/GSH caused by fasting were reversed in most organelles of the body wall muscle and neurons.In the sati-ated state,H_(2)O_(2) increased markedly in the cytoplasm,mitochondria and ER of muscle and the ER of neurons,while GSSG/GSH exhibited no change in most organelles of the two tissues except for an increase in the ER of muscle.Our study systematically and precisely presents the redox characteristics under different dietary states in living animals and provides a basis for further investigating the redox mechanism in metabolism and optimizing dietary guidance.