Enteral nutrition (EN) is a type of tube feeding for nutritional support. EN is where the nutritional fluid or feed is given into the gut, through a tube going into the stomach or small intestine.
EN works best if your digestive system is working normally, but you are not able to eat or drink enough. This could be because of a cancer in the head or neck area or after surgery for stomach cancer or gullet (oesophagus) cancer.
EN uses specially prepared liquid feeds. Your dietitian chooses the type and amount of feed you need. This depends on your nutritional needs and where the tube is placed. You may get all your nutrition in this way. Or you may get some by eating food as you normally would, and have the rest as a liquid through the tube. You will be encouraged to eat normally if you can.
Different types of tube can be used to give EN. The type of tube you have depends on:
- your nutritional needs
- how long you are likely to need EN for
- how well your digestive system is working.
These are the most common ways of giving EN:
Nasogastric or NG feeding tube
A thin tube is passed through the nose and into the stomach.
Nasojejunal or NJ feeding tube
A thin tube is passed down the nose, into the stomach and into the jejunum (part of the small bowel).
Percutaneous endoscopic gastrostomy or PEG feeding tube
A tube is passed through the skin and muscle of the tummy (abdomen) into the stomach.
Percutaneous endoscopic jejunostomy or PEJ feeding tube
A tube is passed through the skin and muscle of the tummy (abdomen) into the middle of the small bowel (the jejunum) just below the stomach.
Radiologically inserted gastrostomy or RIG feeding tube
An x-ray is used to guide a tube through the skin and muscle of the tummy (abdomen) into the stomach.
Nasogastric feeding is usually recommended if you are likely to need nutritional support for only a short time only (about 4 to 6 weeks). You may need it if you have had radiotherapy to the mouth, throat or gullet (oesophagus). Radiotherapy can cause swelling and make swallowing difficult.
How an NG tube is put in
You need to be in a comfortable position, sitting upright. The NG feeding tube is a thin, flexible tube which is gently put in your nostril. It goes down the back of the throat, down the gullet (oesophagus) and into your stomach. A local anaesthetic may be sprayed into the nostril to make it more comfortable when it is put in.
The person putting in the tube will check it is correctly positioned in your stomach. They do this by drawing a small amount of fluid from the tube using a syringe. Stomach fluid is very acidic, so the fluid is tested for acidity with a pH indicator. This shows if the tube is in the stomach. Sometimes you need an x-ray to make sure the tube is in the stomach.
Once the tube is correctly positioned, the other end will be taped to your nose or cheek to keep it in place. There is a stopper on this end of the tube for when it is not being used.
Having the liquid feed
Your dietitian works out how much liquid feed you need to have each day. The hospital team then gives this to you through the tube. To prevent side effects, the fluid is often given slowly at first.
If you are at home, the liquid feed may be delivered to you by a specialist company. Sometimes the feed is prescribed by your GP. They will ask your local pharmacy to supply it for you. You or your carer will be shown how to give the liquid feed safely. A district nurse might also visit you to help.
Other fluids, such as liquid medicines, can also be given through the tube. They need to be flushed through with plenty of water, so they do not block the tube. Your dietitian, doctor, nurse or pharmacist can show you how to do this. They can also tell you which medicines you can have this way.
Possible problems with NG feeding
There are some possible disadvantages and
Discomfort when the NG tube is put in
You may find it uncomfortable when the tube is inserted. Sometimes, it can take more than one attempt to get it into the right place.
Some people may find the tube embarrassing and feel self-conscious about it.
The NG tube may move
If they are not fixed securely, the tube can come out of the stomach.Sometimes the tube can move and the tip enters the lungs. If the pH level does not confirm the tube is in the stomach, the tube must not be used. It may need to be removed and replaced.
The NG tube may fall out
Sometimes the tube may fall out completely. This can sometimes happen if you are sick (vomit) or if you are coughing a lot. If your tube falls out, it will need to be replaced. If you are at home, you will have contact numbers of health professionals you can call if this happens.
The NG tube may get blocked
Sometimes the tube may become blocked. Water is flushed down the tube regularly to try to stop this from happening. But if the tube gets blocked and it cannot be cleared, it will need to be removed and replaced.
Having the feed can take time
You usually need to have liquid feed slowly over several hours. You may people prefer to have it overnight. Your dietitian will talk to you about the best way of having the feed, so that it does not affect your daily life too much. It may be possible to use a small pump you can carry around with you.
Some people get reflux with NG feeding. This is where feed flows up into the gullet. Reflux can be unpleasant and may make you feel sick. Sitting upright in bed or in a chair while you are having the feed helps stop this happening. You should avoid lying flat. Tell your doctor if you get reflux. They can give you medicines to help.
For gastrostomy feeding, an opening is made through the tummy (abdominal) wall. This opening is called a fistula. A feeding tube is then passed through the opening into the stomach.
The tube is held in place with a small, water-filled balloon, or a plastic disc (a bumper) around the tube, just inside the stomach.
Your doctor may recommend you have gastrostomy feeding if your digestive system is still working but you may need nutritional support for more than a few weeks.
Gastrostomy feeding is done with a PEG tube or RIG tube.
A PEG feeding tube is a percutaneous endoscopic gastrostomy tube. Percutaneous means through the skin. Endoscopic refers to the endoscope that is used when the tube is put in. Gastrostomy means an opening into the stomach.
A RIG feeding tube is a radiologically inserted gastrostomy tube. It is very similar to a PEG tube, but it is put in using x-ray as a guide.
How a PEG feeding tube is put in
Before a PEG feeding tube is put in, a doctor or specialist nurse will explain the procedure to you. You will be asked to sign a form saying that you agree (consent) to having the PEG put in, and that you understand why it is being done.
You will not be able to eat or drink for several hours before the procedure. This is to make sure your stomach is empty. Your doctor may also give you antibiotics to reduce your risk of getting an infection.
You will be given a sedative to make you feel sleepy. The person putting the PEG in will pass a flexible tube with a light at the end (an endoscope) into your mouth. This goes down the gullet and into the stomach. They inflate the stomach with air, and position the endoscope so the light shines through the abdominal wall. This shows the position of the stomach. The person putting the PEG then cleans the skin of the abdominal wall and uses local anaesthetic to numb the area. They make a small cut (incision) through the skin and muscle and insert the feeding tube into the stomach.
When the tube is in place, the area around the tube (the tube site) is cleaned. The tube site needs to be cleaned daily with soap and water and dried thoroughly. You may need a dressing at first, but the area is then usually left uncovered. The tube needs to be flushed with a minimum of 30ml of water before and after each feed.
It takes about 3 weeks for the skin to heal around the tube. During this time, you should avoid getting the area too wet. It is fine to shower, as long as the tube site is protected. You should avoid having a bath until the skin is fully healed.
How a RIG is put in
A RIG feeding tube is put in in a similar way to a PEG feeding tube, but x-ray scanning is used to guide it instead of an endoscope. An NG feeding tube is put in first. You will then have some local anaesthetic injected to numb an area on your tummy (abdomen). They will then make a small cut (incision) in your tummy.
Some air is pumped down the NG feeding tube and into your stomach. This helps position the RIG tube accurately. The gastrostomy tube is then inserted directly into the stomach using x-ray guidance.
Once the gastrostomy tube is in place, some dye is flushed into it and you have another x-ray. This is to make sure the tube is in the right place. After this, the NG feeding tube is removed. The RIG is held in place with stitches. These are usually removed 10 to 14 days later.
Benefits of PEG or RIG feeding
PEGs and RIGs allow people who cannot eat in the usual way to get enough nutrients through the liquid feed and fluids. These tubes are often more suitable if you need long-term feeding. They cannot be seen when a person is wearing clothes, whereas an NG feeding tube is more visible.
Possible problems with PEG or RIG feeding
The most common complications with a PEG or RIG include the following:
Blockage in the tube
Sometimes a blockage can develop in the tube. Flushing the tube before and after each feed reduces the chance of this happening.
The feed taking a long time
You need to have the feed slowly. This can stop you from moving around freely. You may prefer to have the feed overnight. Your dietitian will talk to you about the best way of having the feed so it does not affect your daily life too much.
If you have the feed too quickly, you may feel sick or have reflux. This is where the feed flows up into the gullet. Reflux can be unpleasant and may make you feel sick. Tell your doctor if this happens. They can give you medicines to help.
Other problems that may sometimes happen. For example, an infection can develop in the tissues around the site. It is important to tell your doctor as soon as possible if:
- the skin around the tube becomes red or swollen
- you notice fluid coming from around the tube
- you develop a high temperature or feel unwell.
Rarely, more serious complications may develop. Contact your hospital straight away if you:
- have any swelling around your tummy area
- have any pain
- are bleeding
- start to feel very unwell.
If you are at home, you should have the name of a healthcare professional at the hospital or from the community team. Contact them if you develop any problem with your PEG or RIG.
If you are having long-term feeding, your PEG or RIG tube will need to be replaced. How often it is replaced depends on the type of tube you have. Your doctor, specialist nurse or dietitian can give you more information.
For feeding into the small bowel (jejunostomy feeding), an opening is made through the abdominal wall. This opening is called a fistula. A feeding tube is then passed through the opening into the middle part of the small bowel (the jejunem). You may have jejunostomy feeding if you have had surgery for stomach or oesophageal cancer. The tube may be inserted at the same time as the surgery.
Jejunostomy feeding is done with a PEJ tube. A PEJ tube is a percutaneous endoscopic jejunostomy tube. It is sometimes called a surgical jejunostomy (JEJ).
The tube is put in in a similar way to a PEG or RIG tube.
You look after a PEJ tube in the same way as a PEG or RIG tube. And the possible problems of a PEJ tube are the same as with these other tubes. But a PEJ feed is given more slowly. And the water put into the PEJ needs to be sterile, or boiled then cooled.
Below is a sample of the sources used in our nutritional support information. If you would like more information about the sources we use, please contact us at firstname.lastname@example.org
Arends J, Baracos V, Bertz H, et al. ESPEN expert group recommendations for action against cancer-related malnutrition. Clinical Nutrition, 2017; 36, 5, 1187-1196. Available from www.espen.org (accessed Jan 2020).
Bischoff SC, Austin P, Boeykens K, et al. ESPEN guideline on home enteral nutrition. Clinical Nutrition, 2020; 39, 1, 5-22. Available from www.espen.org (accessed Jan 2020).
National Institute for Health and Care Excellence (NICE). Nutrition support in adults. Quality standard [QS24]. Published: 30 November 2012. Available from www.nice.org.uk/guidance/qs24 (accessed February 2020).
This information has been written, revised and edited by Macmillan Cancer Support’s Cancer Information Development team. It has been reviewed by expert medical and health professionals and people living with cancer. It has been approved by Chief Medical Editor, Professor Tim Iveson, Consultant Medical Oncologist.
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