What is the treatment for diarrhea secondary to tube feedings?

Treatment of Diarrhea Secondary to Tube Feedings

Fiber-containing enteral formulas should normally be used for patients with diarrhea related to tube feeding. 1

Initial Assessment and Common Causes

Before modifying the feeding regimen, recognize that tube feeding formula is responsible for diarrhea in only 21% of cases 2:

• Medications (especially liquid elixirs containing sorbitol) cause 61% of diarrhea in tube-fed patients 2
• Clostridium difficile infection accounts for 17% of cases 2
• Hypoalbuminemia and prolonged antibiotic therapy are associated with increased diarrhea risk, though not directly causal 3
• Bacterial contamination of feeds can contribute 4

Review all medications first—particularly liquid formulations, antibiotics, and sorbitol-containing elixirs—before attributing diarrhea to the feeding formula itself. 2, 3

Primary Treatment Strategy: Fiber-Containing Formulas

Switch to fiber-containing enteral formulas, especially those with fiber mixtures, as they provide significant benefits for patients with diarrhea. 1

• A systematic review and meta-analysis demonstrated significant benefits of fiber-containing formulas (particularly fiber mixtures) for patients with diarrhea 1
• Fiber nearly doubles bowel movement frequency and fecal wet weight without causing diarrhea in stable patients 1
• This represents a Grade A recommendation with 92% consensus from ESPEN guidelines 1

Feeding Administration Modifications

For Gastric Feeding:

• Reduce feeding rate temporarily rather than stopping entirely 5
• Implement intermittent feeding with 4-8 hour breaks rather than continuous feeding 1
• Continuous pump feeding at controlled rates may help reduce diarrhea compared to bolus feeding 1
• Avoid overnight continuous feeding in at-risk patients 1

For Jejunal Feeding:

• Maintain continuous administration (never bolus) to prevent dumping syndrome 1, 5
• Start at 10-20 mL/hour and increase gradually by 20 mL/hour increments 1, 5
• Target rates may take 5-7 days to achieve 5
• Despite massive diarrhea, continuing enteral nutrition at reduced rates is preferable to stopping 5

Additional Interventions

Add a bulk-forming agent (psyllium/Metamucil) at approximately 7 grams per liter of liquid formula 6:

• Dramatically reduces diarrhea in tube-fed patients 6
• Increases colonic transit time and produces formed but soft stools 6
• No rebound constipation or obstructive symptoms reported 6

What NOT to Do

Avoid anti-motility agents (loperamide, diphenoxylate) unless absolutely necessary and only with concurrent appropriate antibiotic therapy if infection is present 1:

• 16% mortality rate when anti-motility agents used alone in C. difficile infection 1
• 49% had unknown outcomes in literature review 1
• If used, must always be accompanied by appropriate medical therapy 1
• Loperamide carries risks of cardiac arrhythmias, especially at higher doses 7

Do not use elemental or predigested formulas routinely 1:

• Prolonged elemental diets deprive colonic microbiota of nutrition (dietary fibers, fructose oligosaccharides, resistant starch) 1
• This suppresses colonic fermentation and creates a permissive environment for C. difficile 1
• Standard polymeric feeds are preferred 1

Diagnostic Workup When Diarrhea Persists

Calculate stool osmotic gap to distinguish osmotic from secretory diarrhea 2:

• Osmotic gap >100 mmol/L indicates osmotic diarrhea (likely medication-related) 2
• This test correctly distinguished diarrhea types in 100% of cases 2

Test for C. difficile toxin in all cases of persistent diarrhea 2:

• Tube-fed patients have 2.5 times higher risk of C. difficile (20% vs 8%) 1

Monitoring Requirements

Check fluid status, electrolytes (sodium, potassium, magnesium, calcium, phosphate) closely in first few days 1:

• Dehydration and electrolyte depletion commonly occur 7
• Fluid and electrolyte replacement is essential and not precluded by continuing feeds 7

Monitor glucose every 6 hours until stable, vital signs and intake/output every 8 hours, daily weights 4

Common Pitfalls to Avoid

• Do not automatically stop tube feeding when diarrhea develops—investigate other causes first 2, 3
• Do not assume hypertonic formulas cause diarrhea—they are not associated with increased risk 3
• Do not use Lactobacillus preparations—they do not reduce diarrhea incidence 3
• Do not flush tubes with carbonated drinks or pineapple juice—these can degrade tubes 1