From the Guidelines
Diarrhea in a patient with enteral nutrition (tube feeding) is a common complication, occurring in up to 30% of enterally fed patients on medical and surgical wards and more than 60% of patients on intensive care units.
Causes of Diarrhea
- Formula osmolality and rate of delivery may be associated with diarrhea 1
- Bolus feeding can cause bloating and diarrhea, especially when delivered into the jejunum, and should be avoided 2
- Certain medications, such as hyperosmolar drugs, crushed tablets, potassium, iron supplements, and sucralfate, can cause problems 3
- Liquid medicines containing sorbitol or with high osmolality (>500-600 mOsm/kg) can contribute to diarrhea 4 ### Management of Diarrhea
- Continuous infusion may help with diarrhea or prevent "dumping" in some patients, but it also results in higher intragastric pH levels than bolus feeding, which can promote bacterial growth 2
- Intermittent infusion provides moderate rates of feed provision and can be used to manage diarrhea 2
- The administration of medicines through enteral feeding tubes should be done with caution, and pharmacists can advise on the administration of medicines and suggest alternative medicines or patient management options 4
- Flushing the tube with fresh tap, cooled boiled, or sterile water before and after every feed or medication can help prevent blockages and diarrhea 3
From the Research
Causes of Diarrhea in Patients with Enteral Nutrition
- Diarrhea in patients with enteral nutrition (tube feeding) is often attributed to various factors, including hypoalbuminemia, bacterial contamination of formula, characteristics of enteral feeding formula, and concomitant drug therapy 5
- However, studies have shown that the feeding formula is not always the primary cause of diarrhea, with medications and other factors playing a significant role 6, 7
- Antibiotic consumption, particularly the combination of two or more antibiotics, has been identified as a significant factor associated with nosocomial diarrhea in patients receiving enteral tube feeding 8
Prevalence and Impact of Diarrhea
- Diarrhea occurs in 2 to 70% of tube-fed patients, depending on their disease and the definition of diarrhea used 9
- Diarrhea can increase morbidity and make it harder to reach nutritional goals, particularly in critically ill patients 9
Diagnostic Approach and Treatment
- When diarrhea develops in properly tube-fed patients, the feeding formula is usually not responsible for the diarrhea, and other causes such as medications and Clostridium difficile infection should be considered 7
- Review of medications and determination of the stool osmotic gap are the initial diagnostic steps of highest yield 7
- Treatment of diarrhea in patients with enteral nutrition should focus on identifying and addressing the underlying cause, as well as providing symptomatic relief and preventing further complications 9