Types of nutritional support

There are two main types of feeding system:

  • enteral tube feeding - sometimes called enteral nutrition (EN)
  • parenteral nutrition (PN)

Enteral nutrition (EN) is when nutritional fluid is given through a tube going into the stomach or small intestine. It may be given when your digestive system is working well, but you have problems eating enough.

If you only need nutritional support for a short time, the tube may be passed through the nose down into the stomach.

If nutritional support is likely to be needed for more than a few weeks, a tube is passed through the skin and muscle of your abdomen straight into your stomach or small bowel.

Parenteral nutrition (PN) is when nutrients and fluid are given directly into the bloodstream. This can be through a tube going into a vein in the neck, chest or arm. It is sometimes called total parenteral nutrition (TPN). It is usually only used for short periods of time.

There are some other types of feeding options. Your doctor will decide which feeding system is best for you based on your individual circumstances.

Types of nutritional support

The two main types of feeding system are enteral tube feeding or enteral nutrition (EN) and parenteral nutrition (PN). The type of system used depends on a number of things.

Enteral tube feeding or enteral nutrition (EN)

This is where the nutritional fluid is given into the gut through a tube going into the stomach or small intestine. There are different ways of giving EN.

EN is the best system if your digestive system is working but you are not able to eat enough - for example because of a cancer in the head or neck area.

Parenteral nutrition (PN)

This is where the nutritional fluid is given through a tube that is put into a vein (intravenously). PN aims to provide nutritional support when it is not possible to take nutrients through your digestive system.

PN is usually used if people are not able to have EN. This may be due to major surgery on the small bowel, a bowel obstruction or a difficulty with inserting the tubes used for EN. This may happen after some types of surgery to the head, neck or stomach.

We have a section on diet after stomach surgery, which you may find helpful.

Enteral tube feeding or enteral nutrition (EN)

There are several ways of giving EN. The most common methods are:

  • nasogastric (NG) feeding – a thin tube is passed down the nose and into the stomach
  • percutaneous endoscopic gastrostomy (PEG) or radiologically inserted gastrostomy (RIG) feeding – a tube is passed through the skin and muscle of the abdomen into the stomach
  • percutaneous endoscopic jejunostomy (PEJ) feeding – a tube is passed through the skin and muscle of the abdomen into the middle of the small bowel (the jejunum), just below the stomach.

Nutritional support through a NG tube or PEG and RIG feeding is often used after surgery to the head, neck, stomach or gullet (oesophagus).

Nasogastric (NG) feeding

Your doctor may talk to you about nasogastric feeding if you are only likely to need nutritional support for a short time. NG feeding may also be used if you are having radiotherapy to the mouth, throat or gullet and swallowing becomes difficult.

How an NG tube is put in

You will need to be in a comfortable position, sitting upright. A thin, flexible tube is gently inserted into your nostril, down the back of the throat, down the gullet (oesophagus) and into your stomach.

It is important that the person inserting the NG tube checks it is correctly positioned in your stomach as rarely it may go into a lung. The tube will not be used until its position has been checked. Once the tube is correctly positioned, it will be taped to your nose or cheek to keep it in place. The position will be checked each time the tube is used.

The check is done by drawing fluid (aspirate) from the stomach through the NG tube using a syringe. This fluid is then tested for acidity with a pH indicator. Stomach fluid is very acidic so this will show if the tube is in the stomach. Sometimes an x-ray may be needed to check the tube is in the stomach.

How an NG tube is used

Your dietitian will work out how much liquid food you need to have each day. The hospital staff will give you this through the tube. The food usually comes in bags which are connected to a pump and attached to your NG tube. The feed is then run through the pump and into your tube slowly over a set time.

If you are at home, you or your carer will be shown how to check the position of the tube and give the liquid food. The liquid food can be prescribed by your GP or arranged by your hospital team. If you need support at home, a district nurse may visit you.

Other fluids, such as liquid medicines, can be given through the tube. Medicines can block the tube if they are not diluted properly or flushed through with plenty of liquid. Your dietitian, doctor, nurses or pharmacist can advise you about which medicines can be given through the tube, and how to do it.

Nasogastric tube
Nasogastric tube

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Possible problems with NG feeding

There can be some possible issues with NG feeding, such as:

  • You may find it uncomfortable when the NG tube is put in. It can usually be put in quite quickly, although sometimes it can take more than one try to get the tube into the right place. Some people continue to feel the tube in their throat when they swallow.
  • The end of the tube comes out through the nostril and is taped to your face. You may feel self-conscious about it.
  • NG tubes can be pulled out of the stomach if they are not fixed securely. Before each feed, the position of the tube needs to be checked. Sometimes the tube may fall out completely and you will need a new one.
  • Occasionally the tube may be moved out of place. Rarely this can result in the tip of the tube entering a lung. If the tube does move, it will be removed and replaced with a new one.
  • NG tubes can sometimes become blocked. Water is flushed down the tube regularly to try to prevent this. If the blockage cannot be cleared, the tube will need to be removed and a new one put in.
  • An NG feed is often given slowly through a pump into the tube over several hours. Some people prefer to have their feed overnight. Or you may be able to have your feed through a pump that fits in a backpack you can carry about with you. Your dietitian will talk to you about the best way of having the feed, so that it does not interfere too much with your lifestyle. Sometimes a syringe can be used to give larger amounts at any one time. This is called bolus feeding.
  • If the feed is given too quickly, it can flow up into the gullet. This can be unpleasant or make you feel sick. Talk to your dietitian or doctor if this happens. It may help to slow the feed down. Sometimes medicines can be given to help with any sickness.

Talk to your doctor or nurse if you are worried about any of these issues.

Percutaneous endoscopic gastrostomy (PEG) and radiologically inserted gastrostomy (RIG) feeding

If your digestive system is working but you need nutritional support for four weeks or more, your doctor may talk to you about having a gastrostomy feeding tube put in. This can be done as a day patient in hospital, or you may need to stay overnight.

Gastrostomy feeding involves having a doctor making a small opening in your tummy (abdomen) wall. A feeding tube is then passed through the opening and into the stomach.

The feeding tube is held in place with either temporary stitches, a small inflated balloon in the stomach or a disc (flange) around the tube just under the skin.

Your doctor, nurse or dietician will tell you or a carer how to look after your tube.

The feeding tube needs to be flushed with 30 to 50mls of water before and after feeds and medicines. Your dietitian will discuss with you how much liquid feed and water you need to have through the tube each day.

How a PEG is put in

Before a PEG is put in, a doctor or specialist nurse will explain the procedure to you. You will be asked to sign a consent form saying that you agree to having the PEG put in, and that you understand why it is being done.

Your stomach needs to be empty for this procedure. So you will be asked not to eat or drink anything for about six hours beforehand. Your doctor may give you antibiotics to reduce your risk of getting an infection.

Your doctor or nurse will give you an injection to relax you (a sedative). The doctor then passes a flexible tube with a light at the end (an endoscope) into your mouth, down your gullet and into the stomach. The doctor will then inflate your stomach with air, and position the endoscope so that the light shines through the tummy (abdominal) wall to show the position of the stomach.

The doctor will clean the skin in the area and use a local anaesthetic to numb it. They will make a small cut through the skin and muscle. They will then put a feeding tube through this opening into the stomach.

You will not need a dressing unless there is leakage of fluid from the site. The area around the tube needs to be cleaned daily with soap and water and thoroughly dried. It takes approximately three weeks for the skin to heal around the tube.

How a RIG is put in

The way a RIG is put in is similar to a PEG, but the doctor will use x-ray scanning equipment to position it. An NG tube is put in (as above).

Your doctor will then inject some local anaesthetic to numb an area on your tummy (abdomen) before making a small cut (incision). They will pump some air down the NG tube and into the stomach to help position the RIG tube accurately. The gastrostomy tube is then put directly into the stomach, guided by an x-ray.

Once the gastrostomy tube is in place, the doctor will flush some dye into it and take an x-ray to make sure it is in the right place. After this the NG tube can be removed. The RIG is held in place with stitches, which are removed about 10 to 14 days later.

Percutaneous endoscopic gastrostomy
Percutaneous endoscopic gastrostomy

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Benefit of PEG or RIG feeding

  • PEGs and RIGs allow people who cannot eat in the usual way to get enough liquid food and fluids.
  • These tubes cannot be seen when you are wearing clothes.

Possible problems with PEG or RIG feeding

The most common complications with a PEG or RIG tube are:

  • a blockage in the tube – flushing the tube before and after each feed reduces the chance of this happening
  • infection or inflammation around the site.

It is important to tell your doctor or specialist nurse 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.

If the feed is given too quickly, some people may feel sick, or feel that the feed is flowing back up the gullet (reflux). Let your doctor, nurse or dietitian know if this happens. They may advise you to slow the feed down or give you medicines to help.

As with NG feeding, the feed needs to be given slowly. For this reason, many people prefer to have their feed overnight. Your dietitian can discuss this with you.

If you are at home, you should be given the name of a healthcare professional at the hospital. You can contact them if you develop any problem with your PEG or RIG tube.

Some PEG or RIG tubes can stay in place for up to two years. Others need to be replaced every three to six months. Your doctor or nurse will discuss this with you.

Percutaneous endoscopic jejunostomy (PEJ) feeding

Some people may have a percutaneous endoscopic jejunostomy (PEJ), also called a jejunostomy tube. This procedure is similar to a PEG or RIG, but the tube is passed into the middle part of the small bowel (the jejunum) instead of the stomach. A jejunostomy tube may be put in at the same time as surgery to the gullet or stomach.

The possible problems and care needs are the same as for PEG or RIG tubes. But feed through a PEJ tube needs to be given more slowly, and the water put into the PEJ needs to be sterile, or boiled then cooled.

Parenteral nutrition (PN)

Parenteral nutrition (PN) means giving nutrients and fluid directly into the bloodstream. PN is sometimes referred to as TPN, which means total parenteral nutrition. However, as it is not always possible to provide total nutrition through the bloodstream, TPN is more commonly known as PN.

How PN is given

PN is usually given through a thin tube, which is inserted into a large vein in your neck or chest. The tube is known as a central line. Sometimes it is given through a thin tube in your arm that goes up into a vein in your chest. This is called a PICC line (peripherally inserted central catheter).

Occasionally, a vein in the arm may be used (like having an ordinary drip), but this is less common. It may be used if feeding is only necessary for a short period of time (fewer than 10 days) and if you are not on restricted fluids, as fluids need to be more diluted if an arm vein is used.

The doctors will take into account your individual circumstances and decide the best type of feeding for you.

How the central or PICC line is put in

Your central or PICC line will be put in at the hospital by a specially trained nurse or doctor. A central line is usually put in using a local anaesthetic, but sometimes a general anaesthetic may be used. A PICC line is put in using a local anaesthetic.

You will have an x-ray to make sure that the tube is in the right place.You shouldn't feel any pain when the tube is being put in, but you may feel a bit sore or stiff for a few days afterwards. A mild painkiller such as paracetamol will help.

Benefits of PN

PN allows nutrition to be given even when the digestive tract is not working or cannot be used. It can allow the digestive tract to rest so that it can heal – for example, after surgery to the stomach or bowel. It can also be used if you have severe sickness or diarrhoea and cannot have enteral feeding.

Possible problems with PN

It is possible for an infection to develop either inside the line or around the exit site. You should tell your doctor if:

  • the exit site becomes red or swollen
  • you notice fluid coming from it
  • you develop a high temperature or feel unwell.

You may be given antibiotics or, if the infection is serious, the tube may have to be removed.

It is possible for a blood clot (thrombosis) to form in your vein at the tip of the central line. If this happens, the tube may have to be removed. You may be given some anti-clotting medicines to prevent this from happening.

You will have regular blood tests while having PN. This is to check your levels of sugar, minerals and other substances. PN can sometimes alter your blood sugar levels and you may need insulin to control your sugars if they are too high. These will all be checked regularly and the feed will be altered depending on these results.

PN is usually started gradually to allow your body to become used to it. This is important if you have not eaten properly for a while. Your feed may be reduced gradually if you start eating again and no longer need it.

Home feeding

Many people can have their nutritional support at home. Having parenteral nutrition is more difficult to deal with than NG or PEG feeding. You may need to be referred to a specialist hospital to be shown how to manage the parenteral feeds at home.

The thought of having nutritional support at home may make you feel anxious. Before you are discharged from hospital, you will be given training in how to manage your particular feeding system. If you have a carer, or carers, they will be given training too.

Home nutritional support will not start until you or any carers feel confident in dealing with the tube and the feeds.

A team of healthcare professionals will also help to support you at home. The support offered to people may vary, but your GP and dietitian can help you. You may have a nutrition specialist nurse or a nutrition team who can support you. You will be given advice and contact numbers before leaving hospital.

Some NHS trusts work in partnership with specialist home-care companies to ensure that people who go from hospital care to home care receive the support and expertise they need.

Your feelings

Many people feel upset if they need nutritional support or cannot eat or drink as they normally would. You may find having enteral feeding such as an NG tube or a PEG affects how you feel about your body image. These are all normal reactions. It is part of the process many people go through in trying to come to terms with their condition.

Everyone has their own way of coping with difficult situations. It may be helpful to talk to your doctor, specialist nurse or dietitian about how you feel. Some people find it helpful to talk to family or friends, while others prefer to seek help from people outside their situation. Others may prefer to keep their feelings to themselves. There is no right or wrong way of coping, but help is available if you need it. You may wish to contact our cancer support specialists for information about counselling in your area.

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