Management of Diarrhea in Patients Receiving Enteral Feeding
When diarrhea develops in a tube-fed patient, immediately stop all laxatives (including magnesium-containing antacids and medications with sorbitol), review all medications for diarrhea-inducing agents, and send stool samples for Clostridium difficile testing before considering any changes to the feeding regimen. 1, 2
Initial Systematic Approach
The diarrhea is rarely caused by the enteral formula itself—medications, infections, and underlying disease are far more common culprits. 1, 3, 4
Step 1: Medication Review and Elimination
Discontinue all laxatives immediately, including magnesium-containing antacids (e.g., Maalox, Mylanta) and any medications containing sorbitol or other osmotic fillers. 1, 2
Review and consider stopping or substituting H2 blockers, proton pump inhibitors, antibiotics, antiarrhythmics, antihypertensives, and NSAIDs—all are recognized causes of diarrhea that occur with higher incidence in tube-fed patients. 1, 2
Antibiotics are the most common medication culprit, causing diarrhea through alteration of intestinal flora and reduction of short-chain fatty acid production. 1
Step 2: Rule Out Infection
Send stool samples for culture and C. difficile toxin testing immediately—20-50% of antibiotic-associated diarrhea in tube-fed patients is due to C. difficile. 1, 2
Implement strict infection control: Discard administration sets and nutrient containers every 24 hours, as enteral feed is an ideal culture medium that can cause not only diarrhea but also sepsis, pneumonia, and urinary tract infections. 1, 2
Ensure proper handling: No part of the delivery system or feed should contact hands, clothes, skin, or non-disinfected surfaces; feeds should never be decanted before use. 1
Step 3: Assess Feeding Regimen
Check gastric residuals every 4 hours—if residual volume exceeds 200 mL, review and potentially reduce the feeding rate. 1, 2
Consider temporarily reducing feeding rate if diarrhea persists after addressing medications and infections, but do not discontinue feeding unnecessarily. 2, 4
Iso-osmotic feeds cause less delayed gastric emptying than hyperosmolar feeds; consider switching if using a high-osmolality formula. 1
Feed Modification Strategies (Secondary Interventions)
Fiber-Enriched Formulas
Fiber-enriched feeds normalize transit times but have limited evidence for reducing diarrhea in tube-fed patients, likely because the diarrhea is usually unrelated to the feed itself. 1
The theoretical benefit is through increased short-chain fatty acid production, which promotes salt and water reabsorption in the colon, but manufacturing limitations mean little fiber reaches the distal colon where it would be most helpful. 1
Feed Temperature
- Feed temperature does not significantly alter gastrointestinal complications—neither refrigeration nor warming has proven benefit. 1
What NOT to Do
Do not give albumin supplements—hypoalbuminemia does not directly cause diarrhea through intestinal edema; both low albumin and gut dysfunction reflect generalized membrane leakiness from systemic inflammation. 1
Do not use loperamide in tube-fed patients with suspected inflammatory diarrhea or fever—antimotility drugs should be avoided when toxic megacolon is possible. 1, 5
Do not discontinue enteral feeding prematurely—this delays adequate nutrition unnecessarily when the cause is almost always something other than the feed. 1, 4
Adjunctive Therapies (Weak Evidence)
Probiotics may be offered to reduce symptom severity and duration in immunocompetent patients with infectious or antimicrobial-associated diarrhea, though evidence is moderate at best. 1
Promotility agents (metoclopramide or erythromycin) may help if delayed gastric emptying is contributing to symptoms. 1
Monitoring Requirements
Monitor fluid status and electrolytes closely—tube-fed patients are at risk for both overhydration (especially if receiving supplementary IV fluids) and electrolyte disturbances. 1, 2
Check vital signs, intake/output every 8 hours, and daily weights until diarrhea resolves. 6
Rehydration with oral rehydration solution (ORS) or IV fluids should follow standard diarrhea management protocols if dehydration develops. 1
Critical Pitfall to Avoid
The most common error is attributing diarrhea to the enteral formula and reducing or stopping feeds, when medications (especially antibiotics) and infections are the actual culprits in the vast majority of cases. 1, 3, 4 This unnecessarily compromises nutritional support and delays recovery.