1.06/ Enteral Nutrition Intolerance - PART 1

INTRO: Hello and welcome to Clinical Nutrition Notes – a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition – brought to you by Nestlé Health Science Canada. This podcast is intended for health care professionals, for education purposes.

I am your host, Bethany Hopkins, Medical Affairs Manager with Nestle Health Science.

Today we'll be talking with Anton Emmanuel M.D. about enteral nutrition intolerance, its prevalence, impact and approaches to assessment. Dr. Emmanuel is an academic neuro-gastroenterologist at University College London and consultant gastroenterologist at University College Hospital and the National Hospital for Neurology and Neurosurgery at Queen's Square. His clinical work encompasses being director of the G.I. physiology unit at University College Hospital as well as providing a gastroenterology service at Queen Square. Dr. Emmanuel's research includes basic gut neurophysiology and the study of the pathophysiology and management of gastrointestinal disorders of the upper and lower gut, and neurological disease and functional conditions. He is the editor of the journal Frontline Gastroenterology.

Hopkins: Thank you for joining us today Dr. Emmanuel. As a neuro-gastroenterologist, you're involved in the management of many individuals receiving enteral nutrition. And today we'll be talking about enteral nutrition intolerance, which can be a serious issue for some tube fed patients, one that can have an impact on their quality of life as well as delivery of adequate nutrition/hydration and the use of healthcare resources. I'd like to start by having you describe what the term enteral intolerance means to you as a clinician.

Emmanuel: The term is kind of an umbrella term, and I think from my perspective it really refers to patients’ individual symptoms. That's what I'm invested in, is somebody who's got a set of complaints, what can I do to find a solution to that.

And recognizing that underneath that umbrella there are countless symptom presentations, which are really the primary way in which we should be addressing these patients. So, how common is it? Now if you talk to someone like me on my own, I would say to you enormously common because the patients that I get referred are by definition those who have symptoms. But, if you talk to colleagues in the field who are seeing patients in the community-type setting they would say upwards of 50 to 60 percent of patients have this problem of not tolerating their tube feed. In a hospital setting, it could be a tiny bit higher, but it certainly I think if you say a conservative estimate of 50 percent plus you'd be on safe ground. Now the fact is that the other thing apart from that range of severity is also the fact that there are people there at that milder end of the spectrum who sort of self-manage. They work out that adjusting their position or timing it half an hour after this, or before their bowel action means that they can manage their symptoms. But of that half, probably at least a half, find it a really limiting symptom which they need help with. And that's where the professional can come in, and we can discuss ways in which they can make small adjustments and try to assess the patient in the first instance and then make those adjustments to improve function.

Hopkins: You know it’s interesting to think that something that we do hundreds of times a day and we normally take for granted, is really complex, and there’s a number of things can go wrong along the way. So Peter, thinking about all that and what you just talked about, how does dysphagia usually present, and what should clinicians be looking forI know sometimes these G.I. symptoms may be considered by some clinicians or some patients and families to be a normal or expected part of tube feeding. We hear people say sometimes that what's liquid going in is going to be liquid coming out, or it's natural to have a full belly and a bit of nausea or reflux in someone who's receiving a tube feeding. Can you comment on whether some of these G.I. symptoms should be considered a normal part of enteral feeding?

Emmanuel: Absolutely, that's the really key issue. I think that's certainly something which comes with training. I think at the start of one's career one tends to assume that these are sick people – what do you expect? But I would say it's absolutely wrong to accept that as our standard. It may be that we have to, if we can't fix it, we have to try and counsel the patient somewhat. So, I’m not saying we should ignore that part of it, but it's absolutely essential we make the effort to understand the cause of these symptoms. So, no, it's absolutely not okay to say that this is acceptable, it's what you should expect just because you are being tube fed. The whole point of this in most people is to improve quality of life. For some it's to establish a stable new normal. But in any event, if you’re trying to improve quality of life that doesn't mean adding symptoms, it means minimizing those. So, no, we are really very invested in the idea of disillusioning the patient and our colleagues sometimes that this is what's normal.

Hopkins: Picking up on the concept of quality of life that you mentioned, in terms of the impact of intolerance on patients and caregivers, clinicians, healthcare resources, what sort of impact have you seen in your practice and with your colleagues?

Emmanuel: At the most extreme end we have patients who decide, or have it decided for them, to discontinue their feeding because their symptoms are so intolerable, and it's not as though any of us go into a tube feeding program thinking – oh well, we'll give it a go, it's a sort of small issue. This is always a big decision made in a large group by the patient and their family and by the professionals and their multidisciplinary group. So, that's a reflection of how serious this is because then you move up the ladder towards much more invasive intravenous options, and that's never an easy decision either. So, no, this is this is not a trivial issue for some people. And there are, as I say, a minority who are either mild in the spectrum who can self-manage. And what we're hoping is that we can help professionals to recognize small things they can do, which sometimes are slightly counterintuitive. Sometimes a patient is complaining of symptoms of heartburn or vomiting, sometimes we actually need to think about lower down the gut as a cause of symptoms. So, it's really opening our eyes to try and find solutions to reduce the impact because this is a big deal for patients. And we also know that if you look at the quality of life data that's published on patients with long-term tube feeding, whilst the average is when you're on feeding improve – so, patients with a high level of dissatisfaction improve with tube feeding – within that improved group there’s a real spectrum there as well. So, there are some patients who actually are no different and some who are dramatically different, and we’re after trying to make everyone in that second group of people who are dramatically improved.

Hopkins: On that note, what can be done then to help tube fed individuals experiencing G.I. symptoms? Where does the clinician begin with their assessment when they're presented with someone that has symptoms?

Emmanuel: So you made the key point there, I can say that, which is to assess the patient and not just assume that immediately if they've reported a symptom, that's the only thing. These patients… we believe there's sort of six or seven symptoms in families that can be considered. So, if we take this in a sort of practical sense, there’s the upper-G.I. family of symptoms, which we would consider as being reflux-type symptoms, nausea- and/or vomiting-type symptoms, and that sensation of early satiety – so quickly after the tube feeding starts they feel full. Then there’s the sort of general abdominal symptoms, which are more to do with abdominal pain and bloating. And then the last family, the lower G.I. symptoms, the diarrhea and the constipation side of things. So, if we take that as a whole your assessment begins by recognizing that that six or seven set of symptoms can coexist. And actually, the cause of one may be something else. And one of the prior symptoms that is really key to this is constipation. So, it’s really key from our point of view that patients have an assessment of their bowel function made. This can be somewhat intrusive and embarrassing at times, but trying to get as much of a carer or patient history, to look at not just frequency but sort of degree of completeness – how long it's taking – because sometimes patients find that they don't like talking about these kinds of personal, embarrassing symptoms. So they say, “oh it's all fine, it's all fine,” but actually what you’re finding is that they're sort of accelerating their toilet training and habit just to get it out of the way and never fully voiding. So, there's a lot of hidden constipation out there. And it's easier to talk about vomiting and nausea than it is to talk about our bowels not working. So we need to be prepared to explore that a bit with our patients.

Then for vomiting specifically, we are really keen on the idea of keeping a vomiting diary, to ask the patient or the carer just to keep a little note on paper or on their smartphone of when it's occurring – in relationship to their meals, and in relationship to their exertion, in their relationship to getting out of bed, and to feeding – just to make a note of roughly when it's occurring but also sort of how much is coming up and what it looks like because it sounds a bit unpleasant, but actually patients in our experience don't mind doing that if they feel like it's getting to the root of where the problem is to see what it's like out of that setting when they're see you face to face for that 10 minutes. And so we find it's a very helpful way, an analysis later on looking at.. you may notice that when you've had your second day without a bowel action that's when your vomiting is worse or when you put the feed on straight-away maybe we slow it down or whatever. So, we often find little clues in the vomiting diary. And beyond that we then would very much talk about ruling out systemic things.

It's not uncommon for people to have low grade sepsis or other systemic inflammation, and sometimes, once somebody starts feeding, it becomes easy to blame the feed for everything. So, any sort of low grade chest or ear infection, so oh well that that's the nausea; must be the feed. Well actually it may just be a UTI that's developed along the way which we're not taking care of. And so, within that then if there is no constipation and no infection we then start looking at thinking about other causes that may be there. Checking the position of the feed tube is a key first thing, which I'm sure most of the listeners will already do; considering the patient posture when they're feeding, are they slouched, or they slumped in their bed; is it being done in some strange angle with the tube being tethered and stretched because of the layout of their room is a funny one. Consider what their symptoms are occurring related to medications they're taking or with feedings, so is there reflux or pain occurring shortly after taking a dose of their say Parkinson's medication or their multiple sclerosis medication or whatever else. And then it's worth considering whether, in relationship to their medications, whether the volume of feed we're giving them is excessive. Sometimes we need to change feed volume and concentration just to accommodate their drugs if those drugs can't be corrected. So, it's really about excluding the systemic things, constipation priority, but also the other infection and inflammatory things that can go on. Then, looking for very specific feed-related things in terms of the mechanics of feeding, and those will help us in our assessment of the upper G.I. sort of symptoms.

We then consider that sort of middle set of symptoms – the epigastric pain and the abdominal bloating or discomfort. From our perspective there's a kind of dichotomous way of looking at this: one, is there a functional cause or is there an organic cause, and an organic cause is one of the things that we see as often a hidden issue is this question of small intestinal bacterial overgrowth. Now SIBO as it's known, is a situation where the small intestine, which as you know is normally sterile, can get colonized by bacteria because of the slow movement of content or the feeding we're giving it and therefore the change in immunity. And in that situation, especially if the patient is taking a drug like a proton pump inhibitor to reduce acid secretion, in that situation, that's quite a good environment for bacteria to grow. They've got lots of lovely nutrients, they've got not much acid to fight, they've got a slow-moving gut, and they can take over, and they can really be a significant cause of bloating and discomfort and pain for patients. And thinking about that and the hallmark symptoms would be things like bad breath being noticed, episodic diarrhea, this abdominal cramping and discomfort and bloating that's there, and if that's present it's worth thinking on whether the bacterial overgrowth is there. It can be tested for reasonably easily with something called a hydrogen breath test. Alternatively, we may just choose to treat somebody empirically and say, well, that's what it sounds like, all the features are there, let's give you a course of five to seven days of antibiotic to eradicate that and see whether their symptoms improve, and if it does, then that may need repeating in months’ or years’ time after that.

And of course, beyond that there are gallstones that can be a real issue. You know gallstones affect as many as one in four people and amongst the tube-fed population it is slightly higher than that even, because of the relationship with reduced mobility and inflammation ongoing and if the patient has an inflammatory bowel disease as part of their cause for why they're being fed – that makes it especially likely – if they're female, if they've had many children. These are all risk factors of gallstones, and they'll present often in a rather unusual way, you know the classical presentations we're used to in healthy individuals maybe were different, so it's worth thinking about that. Similarly, things like peptic ulcers, hiatal hernias, these are all common conditions, and in patients who are being tube fed they can present in unusual ways and I say it's important that we don’t assume everything in a tube fed patient is due to their enteral feed.

So, there’s organic causes and then for these sorts of mid-abdominal symptoms, there’s also the functional causes which we would consider, things like gastroparesis as the key one of those. And gastroparesis is a sort of funny term. It implies that kind of a condition where the stomach doesn’t empty properly. But we know it’s a bit more complex than just emptying. It is also a question sometimes of the patients not having a stomach which accommodates the meal, which holds onto the feed well enough, so it doesn’t stretch in the normal physiological way to hold on to content, and if it doesn’t stretch then obviously it's going to cause discomfort because you have a stiff stomach which isn't being allowed to distend and of course if it isn't empty then you get those upper symptoms I was mentioning in terms of nausea and vomiting. But it's worth thinking about that gastroparesis, which may not present simply with vomiting, it may present with discomfort and bloating as a real feature because of this we would say kind of vagal involvement. You get this stiff stomach which then makes your vagus activated which makes your tummy distend. So, it's you know gastroparesis which is sort of underlying everything we said about upper G.I. presentations may cause pain and the like. So, it's important not just to assume it's only vomiting. It can also be pain.

And if we move finally then to the kind of lower G.I. symptoms, the kind of diarrhea and constipation, obviously as I've said now a few times, and hope I'm not making myself repetitive, constipation is a really key thing to assess. Our estimate of prevalence would say that something like 65 to 70 percent of patients on a tube feed regime are constipated.

So, it's really important to assess that, whether by taking a careful history from the patient and from carers, but also from what actually happens in the bathroom and this may be something we feel uncomfortable about. So, if I spend the next one minute trying to explain how to approach that I hope you don't mind. It's really trying to get the clinician to feel comfortable differentiating between what we’d consider slow transit, where the content moves slowly through the intestine. And that is really the hallmark by the fact that the stools are rather hard and pellety or that the call to open your bowels is very infrequent – once every couple of days. So, that people only feel the urge to go every couple of days, and they have hard stools when they do go – that's more transit problem versus the alternative family which is an evacuation problem where they're getting that urge to go, they’re getting the need to go, the stools are normal, but when they tried to pass them they just can't – they get discomfort, pain, they have to strain, they feel a bit gassy, they bloat, they don't feel like they can empty very easily, they have to help themselves sometimes. These are questions that are often hard to ask a patient, but just gradually allowing them to talk will often reveal that history. And of course, sometimes patients have both symptoms, so really assessing the constipation number one for its presence and number two for which type – transit versus evacuation or both – is really key.

And if we finally consider diarrhea and how we assess the patient who has diarrhea, of course everyone tends to think as you said earlier on that everyone with liquid in means liquid out, but it's actually a minority of patients happily who have diarrhea because diarrhea is a pretty distressing symptom often given the physical problems patients have getting to a bathroom in time can be difficult and actually a lot of people are describing as problems with bowel control and continence. So actually, what people call diarrhea may be a continence problem. What people call diarrhea may be an overflow problem. You know we remember this from our years in training that patients with constipation can get this kind of impaction and overflow and even without full-blown impaction people can get some soiling and overflow from there. So, what is considered diarrhea again needs careful exploration.

And then we need think about what is going on IBS type problem which again you know just because you have a tube feed doesn't mean you don't have a problem which is a common functional thing like IBS. And of course, one other thing which is often overlooked especially in our older patients with tube feeding is that they present with diarrhea but what they actually have is a rectal prolapse. And this is something which is something which is very hard to talk about, but especially in our female patients who've had children, when they've strained their pelvic floor, this can be an issue in the older female patient – and what they're getting is a bit of tissue coming down. And again, they don't even aware of it themselves, but it causes them to lose stools. So, there's a number of things I'd like us to think about when we consider patients as having diarrhea or constipation – it isn't as simple as what's written on the tin, it needs a tiny bit more detail of opening up the case a bit.

Hopkins: It's clear from what you've been talking about that these G.I. symptoms may have multifactorial causes, and we can't make assumptions that an upper G.I. symptom is not related to something that's happening further down in the gut. So, thank you very much for providing that perspective on intolerance, and as we've mentioned it is a real concern for tube fed individuals and those involved with their care. We'll continue this conversation on our next podcast where we'll have you address the management concerns for some of these symptoms that you've talked about assessing. So, I'd like to thank you Dr. Emmanuel for joining us and thank all of our listeners.

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CLOSING: This concludes this episode of our Clinical Nutrition Notes podcast.

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For the Nestlé Health Science podcast team, I'm Bethany Hopkins.