e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e209–e211

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e-SPEN, the European e-Journal of

Clinical Nutrition and Metabolism
journal homepage: http://www.elsevier.com/locate/clnu

Educational Paper

Basics in clinical nutrition: Complications of enteral nutrition

Gyorgy Bodoky a, Luiza Kent-Smith b
a
St. Laszlo Teaching Hospital, Budapest, Hungary
b
University of Porto, Porto, Portugal

a r t i c l e i n f o

Article history:
Received 8 May 2009
Accepted 13 May 2009

Keywords:
Diarrhoea
Nausea
Vomiting
Constipation
Aspiration

Learning objectives
To know the basic types of complications connected with
tube feeding
To be able to prevent complications of enteral nutrition
Enteral nutrition (EN), as a form of nutritional therapy, is
intended to compensate or overcome the inability of patients to
voluntarily ingest food. EN is a relatively safe procedure with
limited complications that can usually be avoided or managed. Very
often the complications arise from inadequate formula and/or
delivery site and rate, as well as being the indirect result of the
underlying disease or medical treatment.
EN complications can be classified as primarily gastrointestinal,
mechanical and metabolic, however, when they occur, the
distinction may not be so clear cut, which renders the correct
diagnosis of the aetiology a very important issue.
1. Gastrointestinal complications
appropriately used i.e. adequate formulation, taking into account
the delivery site and patient adjusted rate of infusion. Nevertheless
diarrhoea can occur in spite of these safeguards, and it has been
shown repeatedly that antibiotics or pathogenic microflora are
usually implicated. If clinically significant, the following issues
should be addressed:
- Review patient’s EN prescription;
- Rule out constipation or stool incontinence independent of
feeding. Exclude infectious diarrhoea through stool culture;
- Review medication profile, searching for diarrhoea inducing
drugs, in particular prolonged use of antibiotics;
- Should diarrhoea persist, these options ought to be considered:
 Decrease delivery rate
 Change to EN formula with a source of soluble fibre
 If malabsorption is suspected, change to oligomeric or
monomeric diets
 If, despite the above measures, the problem persists,
parenteral nutrition should be considered.

1.1. Diarrhoea 1.2. Nausea and vomiting

Diarrhoea is perhaps the most common complication in EN,
occurring within a wide range (2–63%), depending on how it is
defined. Definitions vary from one liquid stool a day to over 500 ml
of soft or liquid stools/day on two consecutive days. Diarrhoea is not
an inherent complication of EN, it can be prevented if EN is
E-mail address: espenjournals@gmail.com (Editorial Office).
Approximately 20% of patients on EN experience nausea and
vomiting. The last greatly increases the risk of aspiration pneu-
monia. Although multifactorial, delayed gastric emptying is the
most common cause. Warning signs, in the conscious patient,
include abdominal discomfort and/or a sense of bloating. If delayed
gastric emptying is suspected, consider reducing sedating medi-
cation, switching to a low fat formula, reducing the rate of delivery
and administering prokinetic drugs.

1751-4991/$ - see front matter Ó 2009 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.eclnm.2009.05.003
e210 G. Bodoky, L. Kent-Smith / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e209–e211

1.3. Constipation Table 2

The most frequent metabolic complications of enteral nutrition.

Constipation can result from inactivity, decreased bowel Type Cause Solution
motility, decreased water intake (calorie dense formulas), impac- Hyponatraemia Overhydration Change formula
tion, or lack of dietary fibre. Poor bowel motility and dehydration Restrict fluids
may cause impaction and abdominal distension. Constipation Hypernatraemia Inadequate fluid intake Increase free water
Dehydration Diarrhoea Evaluate diarrhoea causes
should be clearly differentiated from bowel obstruction. Adequate
Inadequate fluid intake Increase free water intake
hydration and the use of insoluble fibre containing formulas usually Hyperglycaemia Excessive energy intake Assess energy intake
resolve the problem. Persisting situations may require stool soft- Insufficient insulin Adjust insulin dosage
eners or bowel stimulants. Hypokalaemia Refeeding syndrome Adjust for K depletion
Diarrhoea Evaluate diarrhoea causes
Hyperkalaemia Excessive K intake Change formula
2. Mechanical complications Renal insufficiency
Hypophosphataemia Refeeding syndrome Increase phosphate intake
Decrease energy load
2.1. Aspiration Hyperphosphataemia Renal insufficiency Change formula

Pulmonary aspiration is extremely serious and may be a life

threatening complication, with an incidence of 1–4%. Symptoms
include dyspnoea, tachypnea, wheezing, tachycardia, agitation and
cyanosis. Fever in EN fed patients may be a delayed symptom of
aspiration pneumonia, caused by small amounts of formula aspi-
ration. Risk factors for aspiration include:
- decreased level of consciousness;
- diminished gag reflex;
- neurological impairment;
- incompetent lower esophageal sphincter;
- GI reflux;
- supine position;
- use of large bore feeding tubes;
- large gastric residues.
In order to reduce the risk of aspiration, periodic assessment
of gastric residue should be undertaken, in association with
prokinetic drugs. Nasojejunal feeding is less associated with
aspiration pneumonia, and therefore should be preferred in high
risk patients. Another standard of practice in these patients, is
keeping the head of the bed elevated, maintaining a semi
recumbent position (45 ).
a gastrostomy tube should be placed instead of a nasogastric one.
Stoma sites may also present complications, with leakage indi-
cating tube dysfunction, infection or incorrect stoma size. Tube
dysfunction can be solved with tube replacement, whereas infec-
tion requires medication and eventually tube removal.
2.3. Tube clogging
Obstruction is a very common complication during EN. Most
clogging is secondary to coagulation or inadequate flushing of the
tube after feeding of formula. And it is more likely to occur with
intact protein and viscous products. Other causes of obstruction
include administering medication, which may fragment and
precipitate, and tube kinking. The rate of tube obstruction is related
to tube diameter, quality of nursing care, tube type (jejunostomy vs.
gastrostomy) and duration of tube placement. Dislodging the
obstruction is usually preferable to tube replacement. Experienced
nurses use various methods to unclog feeding tubes, from warm
water alternating with gentle pressure and suction to pancreatic
enzymes and sodium bicarbonate solution to help ‘‘digest’’ the
precipitate (Table 1).

2.2. Tube related complications 3. Metabolic complications

Tube malposition could cause bleeding and tracheal, paren-
chymal or GI tract perforation. These complications can be mini-
mized, through the use of trained staff and adequate post-
placement monitoring.
Presence of the feeding tube itself may cause necrosis, ulcera-
tion and abscess formation of the nasopharyngeal, oesophageal,
gastric and duodenal points of contact. It may cause upper and
lower airway complications, aggravate oesophageal varices,
necrotizing fascitiis, fistulas, and wound infections. Use of soft
small bore feeding tubes and attentive nursing care can help reduce
many of these problems. When long term EN is anticipated,
Metabolic complications of EN are, in fact, very similar to
those occurring during parenteral nutrition, despite their lower
incidence and severity. Careful monitoring can help reduce or
prevent these problems, which are detailed in the following table
(Table 2):
3.1. Refeeding syndrome
Refeeding of severely malnourished or long term fasting
patients may result in ‘‘refeeding syndrome’’, this metabolic
complication is connected both with enteral and parenteral
nutrition.

Table 1
Complications of enteral nutrition.
4. Summary

Gastrointestinal (30–38%) Mechanical (2–10%) The type and frequency of complications during EN may be
Abdominal cramping Rhinitis, otitis, parotitis related to the formulation and delivery of the diets, as well as the
Abdominal distension Pharingitis, oesophagitis
underlying disease. There are three major categories of EN
Nausea and vomiting Pulmonary aspiration
Oesophageal reflux Oesophageal erosions complications: gastrointestinal, mechanical and metabolic. GI
Diarrhoea Tube dislodgment complications are undoubtedly the most frequently described.
Malabsorption Tube obstruction Careful consideration should be given to the use of enteral nutrition
GI bleeding Perforation therapy, but once implemented, close monitoring of patients is an
Ileus
efficient safeguard against complications and side effects. Similarly
 G. Bodoky, L. Kent-Smith / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e209–e211
to the development of an enteral product formulary, standards of
practice for delivery and monitoring of EN should be established
and followed by all the staff involved in nutritional therapy.
Conflict of interest
There is no conflict of interest.
e211
Further reading
1. Rombeau JL, Rolandelli RH, editors. Enteral and tube feeding. 3rd ed. W.B. Saun-
ders; 1997.
2. Russell M, Cromer M, Grant J. Complications of enteral nutrition. In:
Gottschlich M, editor. The science and practice of nutrition support. ASPEN; 2001.
p. 189.
3. American Gastroenterological Association Medical Position Statement. Guide-
lines for the use of enteral nutrition. Gastroenterology; 1995::1280.