When is a gastrostomy (G) tube recommended for patients with severe malnutrition?

Gastrostomy Tube Recommendations for Malnourished Patients

A gastrostomy (G) tube should be recommended for malnourished patients when enteral nutrition is required for more than 4-6 weeks and the patient has a functional gastrointestinal tract but cannot meet nutritional requirements orally. 1

Indications for G-tube Placement

• G-tube placement should be considered when oral intake is absent or likely to be absent for 5-7 days, with earlier intervention needed in already malnourished patients 1
• G-tube is indicated when oral intake will be inadequate (<50% of requirements) for more than 7 days 1
• Long-term enteral nutrition (>4 weeks) necessitates placement of a percutaneous tube such as percutaneous endoscopic gastrostomy (PEG) 1
• Patients should be at high risk of malnutrition and unlikely to recover their ability to feed orally in the short term 1

Specific Clinical Scenarios Warranting G-tube Placement

• Neurological disorders of swallowing (stroke, multiple sclerosis, motor neurone disease, Parkinson's disease, cerebral palsy) 1
• Cognitive impairment and depressed consciousness (head injury) 1
• Mechanical obstruction to swallowing (oropharyngeal or esophageal cancer, radiation enteropathy) 1, 2
• Long-term partial failure of intestinal function requiring supplementary intake (short bowel, fistulae) 1
• Severe gastroparesis with malnutrition requiring jejunal access 3

Patient Selection Considerations

• The patient's gastrointestinal function must be adequate to absorb and tolerate the proposed feeding 1
• Ethical issues must be considered, and G-tube placement must be in the patient's best interest 1
• The concept of gastrostomy feeding must be acceptable to the patient and their family or carers 1
• Suitability should be confirmed by an experienced gastroenterologist or a suitably trained member of a nutrition support team 1

Contraindications to G-tube Placement

• Intestinal obstruction or ileus 1
• Severe shock 1
• Intestinal ischemia 1
• Gastro-esophageal reflux (relative contraindication) 1
• Previous gastric surgery (relative contraindication) 1
• Ascites (relative contraindication) 1

Timing of G-tube Placement

• For patients requiring long-term enteral nutrition (>4 weeks), PEG placement is recommended 1
• In post-surgical patients not tolerating oral intake, enteral nutrition should be considered within:
  • 1-2 days of surgery in severely malnourished patients 1
  • 3-5 days of surgery in moderately malnourished patients 1
  • Within 7 days of surgery in normally or over-nourished patients 1

Alternative Feeding Routes Before G-tube Consideration

• For short-term feeding (<4 weeks), nasogastric tubes are appropriate 1
• Nasojejunal tubes or needle catheter jejunostomy should be considered for patients undergoing major upper gastrointestinal and pancreatic surgery 1
• Post-pyloric feeding (jejunal) is appropriate for patients with severe gastroparesis to bypass gastric emptying issues 3

Implementation of Feeding via G-tube

• Start tube feeding with a low flow rate (10-20 ml/h) and increase carefully due to limited intestinal tolerance 1, 3
• It may take 5-7 days to reach target intake 1
• In most patients, a standard whole protein formula is appropriate 1
• For technical reasons related to tube clogging and infection risk, home-made (blenderized) diets for tube feeding are not generally recommended 1

Monitoring and Follow-up

• Regular reassessment of nutritional status during hospital stay is necessary 1
• Continuation of nutritional support therapy including qualified dietary counseling after discharge is advised for patients who still do not adequately cover their energy requirements orally 1
• Monitor for complications such as tube dysfunction, infection, bleeding, peristomal leakage, and accidental removal 4

Outcomes and Benefits

• G-tube feeding has shown significant improvements in nutritional parameters in malnourished neurologically impaired children 5
• Prophylactic gastrostomy placement in head and neck cancer patients has demonstrated advantages in terms of reduced hospital readmissions, less weight loss, and improved overall health status 2

Common Pitfalls and Caveats

• Despite low immediate morbidity with PEG placement, overall mortality within weeks of placement can be high due to poor patient selection 1
• The 2004 UK National Confidential Enquiry into Patient Outcome and Death report found almost a fifth of PEG placements were for futile indications that negatively influenced morbidity and mortality 6
• Placement in patients with dementia is considered controversial 7
• Careful assessment of prognosis and goals should be discussed before placement, with consideration of palliative care or clinical ethics consultation in complex cases 4