What are the management options for dysmotility in peg (percutaneous endoscopic gastrostomy) feeding aside from prokinetics?

Management of Dysmotility in PEG Feeding Beyond Prokinetics

For patients with dysmotility in PEG feeding who cannot use prokinetics or have failed prokinetic therapy, the most effective approach is to implement post-pyloric feeding via jejunostomy or nasojejunal tube placement, combined with antibiotic therapy for bacterial overgrowth and dietary modifications. 1

Nutritional Interventions

• Dietary Modifications: Encourage patients to eat according to individual tolerance, generally following a low-lactose, low-fiber, low-fat diet divided into 5-6 small meals daily to optimize gut motility and decrease risk of bacterial overgrowth and gastric bezoar 1

• Enteral Nutrition Approach: For localized motility disorders, enteral nutrition is preferable to parenteral nutrition, with fewer complications, though clinical experience suggests it's often poorly tolerated 1

• Post-Pyloric Feeding: When gastroparesis is significant, bypass the stomach with:

  • Temporary or permanent small bowel access via endoscopic, surgical, or radiological placement 1
  • Nasointestinal tube placement, which has been shown to increase feed goal tolerance (87-95% vs 50-89% with dual prokinetics) in patients with delayed gastric emptying refractory to metoclopramide 2

• Venting Gastrostomy: In cases of severe gastroparesis, add a venting gastrostomy to the jejunostomy to relieve pressure and symptoms 1

• Parenteral Nutrition: Reserve for cases when small bowel function is diffusely affected and enteral nutrition is obviously inadequate 1

Antibiotic Therapy

• Sequential Antibiotic Therapy: Very effective for treating intestinal bacterial overgrowth, which is common in dysmotility and can lead to malabsorption and potentially life-threatening bacterial translocation 1

• Preferred Antibiotics:

  • Poorly absorbable antibiotics like aminoglycosides and rifaximin are preferred 1
  • Alternating cycles with metronidazole, amoxicillin-clavulanate, doxycycline, and norfloxacin may be necessary to limit resistance 1
  • For long-term metronidazole use, monitor for peripheral neuropathy; for ciprofloxacin, watch for tendonitis 1

• Preventive Approach: Consider periodic antibiotic therapy to prevent intestinal bacterial overgrowth in patients with chronic intestinal motility dysfunction who have frequent relapsing episodes 1

Surgical Interventions

• Avoid Surgery When Possible: Surgery should generally be avoided due to risk of postoperative worsening of intestinal function and need for subsequent reoperation 1

• Venting Ostomy: Despite the general caution against surgery, endoscopic or surgical venting ostomy can diminish symptoms in selected patients 1

Special Considerations for PEG Feeding

• Gastric Emptying Effects: PEG tube placement itself may affect gastric motility. Studies show that enteral feeding after PEG tube placement can improve gastric motility in patients previously on total parenteral nutrition 3

• Risk of Reflux: About 7.3% of patients develop gastroesophageal reflux after PEG placement, with esophageal hiatus hernia being a major risk factor rather than gastric motility issues 3

• Bacterial Overgrowth Risk: Patients on long-term PPI therapy (common with PEG) have increased risk of small intestinal bacterial overgrowth (SIBO) - 13.2% compared to only 1.8% in those taking PPIs with prokinetics 4

Post-Procedural Management

• Bowel Regimens: Initiate bowel regimens to avoid and treat constipation 1

• Gastric Decompression: Consider gastric decompression with a nasogastric tube in patients with GI dysmotility 1

• Early Nutrition: Start parenteral nutrition or enteral feeding via a small-diameter tube if oral feeding is delayed for 24-48 hours postoperatively 1

Common Pitfalls and Caveats

• Avoid Prolonged Delay: Do not delay parenteral nutrition in malnourished patients when oral or enteral nutrition is clearly inadequate 1

• Monitor for Complications: Watch for catheter-related bloodstream infections, which are more common in dysmotility patients than in short bowel patients on home parenteral nutrition 1

• Recognize Functional Disorders: Be cautious about escalating to invasive nutrition support in patients with functional symptoms, especially pain-predominant presentations without objective biochemical disturbances or in those with normal BMI 1

• Micronutrient Deficiencies: Ensure adequate supplementation of micronutrients, particularly iron, vitamin B12, and fat-soluble vitamins (A, D, E), as well as magnesium, which is commonly deficient in patients with high-output stomas 1