Download managing malabsorption and poor feed tolerance

MANAGING MALABSORPTION AND POOR FEED TOLERANCE IN ADULTS:
A PRACTICAL GUIDE
The following specialist dietitians came together in May 2012 to debate and reach a consensus on issues relating to the identification and management
of poor feed tolerance: Catherine Collins, Principal Dietitian, St George’s Hospital, London; Alison Culkin, Research Dietitian, St Mark’s Hospital, Harrow;
Barbara Davidson, Senior Dietitian, Freeman Hospital, Newcastle; Kirstine Farrer, Consultant Dietitian, Salford Royal NHS Foundation Trust; Yvonne
McKenzie, Acting Chair for the Gastroenterology Specialist Group of The British Dietetic Association; Mary Phillips, HPB Specialist Dietitian, Royal Surrey
County Hospital, Guildford; Joanne Scantlebury, Senior Specialist Dietitian in GI Surgery, St James’ University Hospital, Leeds. This feature captures some
of the key points from their discussion.
CONDUCT A CLINICAL ASSESSMENT OF THE PATIENT
Defining the problem
Poor feed tolerance can occur in both enterally tube fed patients and those on oral
nutritional supplements. It can manifest in a number of ways and is best defined according
to the predominant site of the symptoms:
t Upper gastrointestinal (GI): signs include reflux or vomiting, nausea and high
nasogastric (NG) aspirates
t Lower GI: indicators include bloating, diarrhoea or steatorrhoea
Conditions or situations in which poor feed tolerance can be prevalent, include:
t
t
t
t
t
t
t
Pancreatic insufficiency
Liver disease or hepato-biliary disorders
Inflammatory bowel disease
Short bowel and intestinal failure
Gastrointestinal ischaemia
Fistulae
Patients in intensive care
The consequences of poor feed tolerance
Poor feed tolerance may compromise a patient’s nutritional status by delaying or reducing
overall nutrient provision, potential digestion and absorption and increasing the risk of
malnutrition. Malnutrition affects every system in the body and results in, amongst other
outcomes, an increased vulnerability to illness, a reduced ability to fight infection and
impaired wound healing.2
There are also financial costs associated with managing the signs and symptoms of poor
feed tolerance, ranging from the direct costs of medications, bowel management systems
and other consumables, as well as indirect costs such as healthcare resources (e.g.
extended hospital stay) and patients being out of the workforce.
Assessing poor feed tolerance can be highly subjective. It is therefore suggested that a
baseline picture of the patient’s symptoms (ideally self-reported) and nutritional status are
obtained, and then correlated with an objective diagnosis and medical history. This can aid
the identification of any symptoms that would be expected to be ‘normal’ or ‘abnormal /
unusual’ in a given patient, and allows the MDT to consider all the potential reasons for
poor feed tolerance.
Symptoms of steatorrhoea
t Frothy stools
t Presence of an oily film on the stools
t Variable stool colour (pale, yellow, orange
to grey), which can occur in the event of a
liver / pancreatic disorder#
MANAGE THE SIGNS AND SYMPTOMS
Note: All management strategies should be considered in consultation with members of the MDT, including the pharmacist, and referrals made where deemed appropriate.
Predominant site of signs and symptoms
Upper GI symptoms
1. Medical history and primary diagnosis:
t Look for possible non-feed related causes for the symptoms. These commonly include:
– Medical or surgical causes for altered gastrointestinal motility, maldigestion or
malabsorption e.g. short bowel*, intestinal failure, inflammatory bowel disease*,
pancreatic insufficiency, diabetes, hepatic failure, previous gastric surgery or
biliary gastritis
– Presence of infection (e.g. C.difficile, Helicobacter pylori and other bowel
pathogens) – if infection is suspected, send a stool sample for culture and
sensitivity (anti-diarrhoeals should not be prescribed in the event of infection)
t Assess for GI bleeding e.g. dark / black / tarry stool (lower GI) or dark / red vomit
(upper GI) – refer any patients with evidence of new bleeding or a history of bleeding
for urgent medical assessment
t Consider the effect of antibiotics, laxatives, proton pump inhibitors (PPIs), opiates,
liquid medications in sugar-free syrups which contain sorbitol/mannitol, drugs that
influence fluid and electrolyte balance (e.g. antihypertensive agents, diuretics), induce
vomiting (e.g. cytotoxic drugs, opiates, antibiotics), or diarrhoea (e.g. metformin,
digoxin, antibiotics)1
t Use of Lanreotide, Octreotide or Sandostatin to ‘switch off’ pancreatic function as part
of clinical management will cause pancreatic enzyme insufficiency
ASSESS THE SYMPTOMS
Diarrhoea / high stoma
output
Check position of the
feeding tube
Consider replacing water
with oral rehydration
solution, including the
water used for flushing the
feeding tube
Consider using a higher
energy, lower volume feed
at a lower feeding rate, or a
peptide-based feed
If symptoms persist, consider
the use of prokinetic agents,
such as metoclopramide /
erythromycin, and/or antiemetics to help manage the
symptoms. Erythromycin loses
its prokinetic effectiveness
after 3–4 days so should be
discontinued after this time
STOP the feed if fresh blood
is present in the vomit or
aspirate or there is evidence of
aspiration pneumonia – seek
further advice
It is rarely necessary to stop feeding when diarrhoea has been identified, and doing
so could compromise the patient’s nutritional status. If feeding has been stopped,
restart as soon as possible, seeking advice from the MDT.
1. Classify symptoms:
t Classify symptoms as predominantly upper or lower GI
Abdominal and Lower GI symptoms
Vomiting, posset, reflux and
high aspirates
Consider the use of antacids
and/or PPIs
2. Nutritional screening:
t Consider using the ‘Malnutrition Universal Screening’ Tool (‘MUST’) to determine a
malnutrition risk score based on height, weight and body mass index**
Every patient has individual needs and requirements – the four-step approach below
therefore provides a guide for the management of poor feed tolerance and a list of factors
to consider within each Trust’s existing protocols. It is important to remember that, due to
the complex nature of poor feed tolerance and the variety of factors involved, these patients
should be managed using a MDT approach.
CONDUCT
A CLINICAL
ASSESSMENT
1. Medical history
and primary
diagnosis
2. Nutritional
screening
ASSESS THE
SYMPTOMS
1. Classify
symptoms
2. Assess severity
and frequency of
symptoms
CONSIDER
THE
PATIENT’S
FEEDING
HISTORY AND
REGIMEN
MANAGE
THE SIGNS
AND
SYMPTOMS
1. Nutritional
history
2. Current feeding
regimen
Consider
management
algorithm
2. Assess severity and frequency of symptoms
t Reflux, nausea and vomiting: regular vomiting episodes where feed is included within
the vomit, posseting of feed into mouth
t NG aspirates and fistula or stoma output: consider if the aspirate volume and fistula
output is appropriate for the individual patient, based on fluid input from feed, food
and other sources
t Diarrhoea: the abnormal passage of three or more loose or liquid stools per day (daily
stool weight >200g/day).3 Use the King’s Stool Chart for those receiving tube feeding
to characterise stool consistency, weight, frequency and other characteristics such as
incontinence and colour 4
t Steatorrhoea: occurring at every or most bowel motion
t If feed aspiration is highly likely – STOP the feed
CONSIDER THE PATIENT’S FEEDING HISTORY AND REGIMEN
1. Nutritional history:
t Obtain a feeding history for every patient, documenting:
– The length of time on nutritional support and the method of feed delivery
e.g. oral intake, tube feeding route – gastric, duodenal, jejunal
– Onset of symptoms e.g. previous history of tolerance to diet or current feed, start
of a particular antibiotic, drug or liquid medication
*For further information see the British Society of Gastroenterology (BSG) guidelines for management of patients
with a short bowel or patients with inflammatory bowel disease
(www.bsg.org.uk)
**See the on-line ‘MUST’ toolkit for more information (http://www.bapen.org.uk/musttoolkit.html).
Floating stools which are difficult to flush#
Weight loss and fatigue
Faecal incontinence
Increased frequency of stools
Loose bowel motions§
#
These symptoms will not occur in patients on very low fat diets
§
In the presence of iron supplements / opiates / other constipating medications the patient may
experience constipation
If non-infective, consider
the use of an anti-diarrhoeal
medication such as
loperamide to slow bowel
and allow fluid absorption
Consider increasing
the sodium provision to
90–100mmol/l enterally
Consider whether an
alternative feed could
be better tolerated
e.g. a peptide-based sip
or tube feed
Steatorrhoea
Bloating, pain, cramping
Be aware that symptoms
suggestive of steatorrhoea
may occur in patients acutely
jaundiced, and where biliary
stenting occurs, and if jaundice
settles quickly, no change in
feed is required
Ensure that severe abdominal pain, or pain
associated with fevers is referred for urgent
medical review
Consider whether an alternative
feed could be better tolerated e.g.
a peptide-based sip or tube feed
with a proportion of fat as medium
chain triglycerides (MCTs).
Ensure the medical team are
aware that a change in feed could
mask symptoms of malabsorption
In consultation with the MDT,
consider medications which may
aid symptoms
DO NOT initiate a low fat diet
without a medical consultation as
this can have a detrimental effect
on nutritional status
‡
A schema for identifying and managing poor feed tolerance
t
t
t
t
t
The following steps should be considered when managing the signs and symptoms of malabsorption and poor feed tolerance.
Symptoms
Poor feed tolerance in enterally fed patients is more likely in patients with diseases and
conditions that involve maldigestion and malabsorption, and is often a consequence of
these.1 Although poor feed tolerance rarely requires cessation of nutritional support, there
is limited consensus or guidance in place to help healthcare professionals (HCPs) to best
manage this particular feeding challenge. This article offers practical advice for HCPs faced
with patients showing signs of poor feed tolerance. It contains a step-by-step approach to
support the multidisciplinary team (MDT) in identifying and managing these patients, with
the aim of maintaining an appropriate feeding regimen.
Management considerations
Introduction
2. Current feeding regimen:
t Confirm whether the feeding regimen is being followed and confirm
that the correct feed and any additional fluid is being administered
t Check the following:
– Is the patient correctly positioned?
– If the feed is a modular feed (made from powder) has it been stored
correctly before administration?
– Is the feed being administered at the correct rate?
– Are feeds being set up following clean handling technique guidelines?†
The abdomen is bloated and full and resonates like a drum when it is struck
Bloating in a patient with pancreatic insufficiency already on a peptide feed may indicate carbohydrate fermentation secondary to malabsorption
¶
Feed should be halted in the case of a rapidly
distending abdomen, tympanic‡ or ‘tinkling’ bowel
sounds, all of which suggest obstruction
If the bloating is accompanied by reduced bowel
function, hiccups / belching or vomiting faeculent
smelling fluid refer for urgent medical opinion as
this may indicate an ileus / bowel obstruction
If the bloating is presumed due to constipation,
consider using a fibre-containing feed and ensure
fluid requirements are met, refer for medical opinion
if laxatives are required
Consider reducing the rate and volume of the feed
Consider whether an alternative feed could be
better tolerated e.g. a peptide-based sip or tube feed
Determine if the type and amount of fibre in the
feed is appropriate for the patient
If bloating occurs in a patient with pancreatic
insufficiency, already on a peptide feed, consider
the addition of pancreatic enzymes (2 hourly)
or an elemental feed¶
Feed considerations when a patient shows signs of poor tolerance:
t Energy density of the feed
– Does the patient require a feed with a higher energy density?
– Would a higher energy feed allow for a lower rate or feeding
volume and thus be better tolerated?
t Peptide versus whole protein
– Would a peptide-based sip or tube feed support absorption and
digestion and improve tolerance?
t Medium chain triglycerides (MCTs)
– Would a sip or tube feed with a high proportion of fat as MCT
increase fat absorption, prevent fat malabsorption and improve
symptoms and nutritional status?
t Osmolality
– Osmolality is unlikely to affect tolerance or
symptoms of diarrhoea, and feeds should not be
disregarded as suitable treatment options on
this basis
Feeding strategies should be trialled and monitored
for a minimum of 48 hours, unless poor feed tolerance
contributes to serious complications such as aspiration.
Patients who do not respond should be considered for
dietetic and/or medical referral.
References
1
Stroud M, et al. Gut 2003;52 Suppl VII:vii1–vii12
2
http://www.bapen.org.uk/about-malnutrition/introductionto-malnutrition?showall=&start=2. Accessed 24th July
2012
3
Thomas PD, et al. Gut 2003;52 Suppl V:v1–v15
4
King’s Stool Chart. (Copyright King’s College London
2001). Accessed 11th July 2012. Available at http://
www.kcl.ac.uk/medicine/research/divisions/dns/projects/
stoolchart/index.aspx
This article has been sponsored by an educational grant
from Abbott Nutrition. However, the views expressed within
it are of independent healthcare professionals.
†
For further information, see the National Institute for
Health and Clinical Excellence (NICE) guidelines on
Prevention and control of healthcare-associated infections
– http://pathways.nice.org.uk/pathways/prevention-andcontrol-of-healthcare-associated-infections
CONCLUSION
Identification of poor feed tolerance is often delayed and, all too often, oral nutritional support and enteral tube feeding
are abandoned as soon as signs are identified. This places patients at risk of malnutrition, in turn resulting in increased
vulnerability to illness, increased complications and, in very extreme cases, even death.2
Wherever possible, oral nutritional supplements or enteral tube feeding can be maintained if appropriate steps are taken.
The four stage process outlined here is designed to be a practical guide to help HCPs to identify and manage poor feed
tolerance quickly and effectively, thus improving the patient’s nutritional intake, and clinical outcomes.
RXANI120277 / July 2012
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