Tube feeding into the gut (enteral nutrition) and cancer

Enteral nutrition (EN) is a type of tube feeding used for nutrition support. EN is where the nutritional fluid or feed goes into the gut, through a tube into the stomach or small bowel (intestine).

EN works best if your digestive system is working normally. You may have it if 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. A dietitian will assess you to see if you are likely to need nutrition support. They then choose the type and amount of feed you need. This will depend on: 

• your nutritional needs
• where the tube is placed
• any other health conditions you may have.

Feeding tubes can also be used to give medications and water.

You will usually be encouraged to eat some food as you normally would, if you can. This means you will get some of your nutrition through food that you eat normally, and the rest as a liquid through the tube. Some people may need to have all their nutrition through a tube. You dietitian will assess your swallowing and explain what is best for you.

You can have EN through different types of tube. 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:

Gastrostomy feeding is when a feeding tube is passed into the stomach. A gastrostomy is a surgical procedure used to pass a feeding tube through the tummy (abdominal) wall 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 need extra nutrition support for more than a few weeks. Sometimes you have a gastrostomy procedure done if your doctor thinks you might you need nutrition support in the coming weeks or months. It may not be used straight away.

Your treatment team will explain the type of gastrostomy that is most suitable for you. Gastrostomy feeding is done with a PEG tube or RIG tube.

A PEG feeding tube is a percutaneous endoscopic gastrostomy tube. It is inserted through the skin using an endoscope. An endoscope is a thin, flexible tube. The tube has a light and a camera at the end. Percutaneous means through the skin.

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.

Gastrostomy feeding

A doctor or specialist nurse will explain the procedure to you before you agree (consent) to have the PEG put in.

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 infection. You will be given a sedative to make you feel sleepy.

The health professional putting the PEG in will pass the endoscope into your mouth and down the gullet into the stomach. They use the light on the endoscope to help position the PEG tube.

They use local anaesthetic to numb the area on the tummy (abdomen). They then make a small cut through the skin and muscle and insert the feeding tube into the stomach. The PEG is held in place with a plastic disc around the tube, just inside the stomach. This disc is called a bumper.

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 at least 30ml of water before and after each feed. It will also need to be flushed before and after you have any medicines through the feeding tube.

It takes about 3 weeks for the skin to heal around the tube. During this time, you should avoid getting the area too wet. You can shower, as long as the tube site is protected. Avoid having a bath until the skin is fully healed.

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. You will have an NG feeding tube put in first. The person putting in the RIG tube will use local anaesthetic to numb an area on your tummy (abdomen).

Some air is pumped down the NG feeding tube and into your stomach. The doctor uses x-rays to find the best position for the tube. They will give you some local anaesthetic. Then they use 2 small clips or buttons with stitches on the surface of the abdomen to hold the stomach close to the wall of the abdomen. The buttons or clips may fall off a few weeks after the procedure, or they can be removed. The stitches are removed in the weeks after the procedure.

The healthcare professional inserts a gastrostomy tube through a small cut in the stomach. After this, the NG feeding tube is removed. The RIG is held in place with an internal balloon filled with water. This helps to keep it in the correct place in the stomach.

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 can be removed easily if they are no longer required.

Your dietitian will talk to you about the best way of having the feed so it does not affect your daily life too much. You may be able to have a bolus feed using a special syringe. These take 10 to 20 minutes. You may also be able to have your feed through a special pump that you can put in a backpack if you go out.

Gastrostomy feeding tubes cannot be seen when covered with clothes. But an NG feeding tube can be seen where it is taped to the nose and cheek. Gastrostomy tubes are less likely to fall out or block than NG tubes. You also do not need to check the acidity (pH levels) before each feed.

There may be problems when you have a PEG or RIG tube in. If you are at home, you should have been given the name and contact number of a healthcare professional at the hospital or from the community team to contact if you develop any problems.

The most common complications with a PEG or RIG include the following:

Other problems include developing an infection 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 darker, depending on your skin type
• the surrounding area becomes swollen or sore
• you notice fluid coming from around the tube
• you have 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 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.

Using home-made blended food through an enteral feeding tube is also called having a blended diet. This may be used with a gastrostomy feeding tube. More research is needed to find if home-made blended food is as nutritional and safe to use compared to as using ready-prepared formulas provided by the hospital pharmacy. Home-made blended food may also block the tube, and can cause an infection. If you want to try to use a blended diet, speak with your dietitian or doctor first.

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. The tube is put in in a similar way to a PEG or RIG tube. But the tube goes into the middle part of the small bowel, called the jejunum.

You look after a jejunostomy feeding tube in the same way as a PEG or RIG tube. The possible problems are the same as with these other tubes. But you have a jejunostomy feed more slowly. Water put into the jejunostomy needs to be sterile, or boiled then cooled.