Gastrointestinal Complications
(related to enteral nutrition) in
Critically Ill Patients
Liz Goddard
Introduction
 Early enteral nutrition is recommended
 GIT Complications
 limit the ability to deliver adequate enteral
nutrition
 affect morbidity and mortality
Risk Factors of GIT complications
 Shock
 Poor gut perfusion
 Gastroparesis
- medication/disease process
 Impaired digestive enzyme secretion
 Increased gut permeability
 Cholestasis
 Diarrhoea
 Constipation
Metabolic Abnormalities Commonly
Associated With Bowel Dysfunction
 Hyperglycaemia
- Dysmotility noted at 150mg/dL
- Dysmotility almost linear with blood glucose
 Hypokalaemia
- k+ < 4mmol/L
 Hypomagnasaemia
- Mg < 2 mmol/L
 Hypophosphataemia
- Po4 < 3.5 mg/dl
 pH <7.27
- Transporter activity affected first
 Positive fluid balance
 Negative fluid balance
GIT Complications
 Related to route of access for EN
 Abdominal distension
 Excessive gastric residues
 Vomiting
 Diarrhoea
 Constipation
 GIT haemorrhage
GIT Complications
Aspiration
Vomiting
Abdominal distension
1.9%
17.9%
13.2%
Excessive gastric residues
Diarrhoea
Gastrointestinal haemorrhage
Constipation
4.7%
11.3%
0.9%
33-55%
Overall incidence GIT complications
11.5-15%
Gastrointestinal complications in adults and
children
Adults (%)
Children (%)
50-60
10-20
Withdrawal of the nutrition
15
2-7
Moderate Vomits
12
18
Abdominal distension,
excessive gastric residues
13-40
6-15
Diarrhoea
10-20
6-11
Constipation
5-80
ND
Gastrointestinal haemorrhage
1-2
0.2-1
Necrotizing enterocolitis,
small bowel necrosis,
nonocclusive ischaemia
ND
0.5
Frequency
ND, no data
GIT Symptoms related to Enteral Feeds
GIT symptoms : diarrhoea, bloating, abdominal discomfort
Treatment :
 Change the method of EN delivery
 Rate of infusion
- continuous vs bolus
 Feed sterility
- closed systems
- change delivery sets 12 hourly
- strict hygiene
 Temperature
- refrigeration
Route of Enteral nutrition
 Nasogastric
 Most widely used, easy to place, safe & well tolerated
 More physiological
 Nasojejunal
 Enables adequate energy delivery
 Reduces gastric residues
 Less time stopped for theatre , extubation
 Widely used for :GORD
,Cardiacs,Disordered motility
 Difficulties with NJ



More difficult to site & keep in,
Do not give: Bolus feeds, Water – risk of necrozing bowel
Complications: Misplaced, Perforation
 NO DIFFERENCE IN COMPLICATIONS
Continuous vs Bolus
 Bolus
More physiological but ICU is not a normal
environment!
 Difficulties with monitoring tolerance
 Requires additional nursing time
 Continuous
 Less time consuming, Easier to monitor
 May delay gastric emptying [adult ICU]
 Pro’s & Cons to both
 Often remains preference of unit
 Complication rate re gastric residues and tracheal
aspiration were similar

Abdominal Distension and Increased Gastric
Residues
 Excess gastric residues is a common complication
 Excessive gastric volume = >50% of volume of feed
given in the previous 4h
 Mechanism – 2° to alteration in GIT motility
 Aetiology – multifactorial
- underlying illness –  with cerebral, gastric,
peritoneal disease
- hyperglycaemia
- diet – consistency, temp, osmolarity, composition
- drugs – sedatives, catecholamines
Abdominal Distension and Increased Gastric
Residues
 Complications
- risk of aspiration
- bacterial overgrowth
-enteral feeds
 Treatment
- reduce drugs that  GIT motility
- prokinetic agents
erythromycin
metaclopramide
Vomiting
Incidence of GOR in critically ill children is high
Aggravating factors:
 Increased gastric residues
 Supine position
 presence of NG tube
 dysfunction of LOS
Recommendations:
 semi-recumbent position
 small calibre NG tubes
 nasojejunal feeds
Constipation
 No standard definition in critically ill children
 Incidence 33-50%
 Aetiology
- immobilization
- dehydration
- drug administration
- diet low in fibre
 Constipation leads to abdominal distension and
affects tolerance of feed
Constipation
 Treatment
- use a diet with fibre
- decrease drugs which  GIT motility (opioids,
sedatives, catecholamines, muscle relaxants)
- laxatives, naloxone, enemas
Diarrhoea
 Incidence ??
 No standard definition in children
- 1 loose stool 75% patients
- ≥ 3 loose stools 35% patients
- ≥ 4 loose stools 20% patients
- ≥ 2 loose stools for 2 days 10% patients
Diarrhoea
Causes: Diverse






Infections
Rotavirus
 clostridium difficile
Antibiotics
Drugs
enteral nutrition
 high osmolar feed
 route of feed
presence of hypoalbuminaemia
underlying disease (shock)
Diarrhoea
 Treatment
- Diet with fibre
- Probiotics, prebiotics
 No studies in children
GIT Haemorrhage
 Incidence 1 - 10%
 Overt GIT bleed 10%
 Clinically significant bleed 1.0%
 Risk Factors
 Organ failure
 High pressure ventilation
 Presence of a coagulopathy
 Treatment
 ?? Prophylactic treatment to prevent GIT bleeds
 Cost
 ?increase in nosocomial pneumonia
Summary
 Early EN in critically ill children is recommended
 GIT complications are a major cause of inadequate
enteral feeds
 SHOCK is a major risk factor for GIT
complications
 No consensus on definitions of excessive gastric
residues, constipation and diarrhoea
 Increased mortality in children with GIT
complications
 Be aware of the complications : prevent or Rx early
Diarrhoea or abdominal
bloating/pain complicating
enteral nutrition
Confirm diarrhoea. Check stool
chart, discuss with nursing staff
No diarrhoea,
continue current
management
Yes diarrhoea
evident
Medication involvement?
Antibiotics, sorbitolcontaining medications,
laxatives
Positive for C difficile?
Yes, treat
No
Does formula contain
FODMAPs?
Yes switch to a
FODMAPs-free
formula
Is osmolality of formula or
feeding regimen high?
Yes, trial
continuous
or low energy
density formula
Potential sites of contamination
(HACCP)?
Yes improve
handling of formula
and equipment
Does modifying fiber content
improve symptoms?
Trial fiber or fiberfree formula
No
Consider elemental formula or
parenteral nutrition if unsuccessful
Figure 1. A suggested flow chart for the management of patients with diarrhoea or other abdominal symptoms complicating enteral nutrition. FODMAPs,
Fermentable, Oliogo-, Di-, Mono-saccharides, And Polols; HACCP, Hazard Analysis and Critical Control Point guideline