Tube feeding (TF) should be considered for patients with liver disease when nutrient intake is inadequate and oral supplementation fails. There are some circumstances that warrant consideration when providing TF to patients with liver failure. The type of tube to be used is determined by the expected duration of feeding as well as the presence or absence of ascites. Typically, a small-bore nasoen-teral tube is selected for this group because it is more comfortable than a larger-bore nasoenteral tube. Ascites usually precludes the use of gastrostomy or jejuonostomy tubes because of leakage of ascites and the potential for peritonitis. Active gastrointestinal bleeding and recent variceal banding may delay the insertion of a feeding tube, but varices themselves are not always deterrents for placing a feeding tube. Thrombocytopenia may need to be corrected before placing a tube. Once a tube is placed, one must be aware that a patient with encephalopathy may pull the tube unless restrained and that diarrhea induced by lactulose may worsen when nutrient intake is given in the form of a liquid formula.
A study by De Leninghen et al.  highlights difficulties associated with providing TF to patients with severe liver disease. This report compared a group of 12 cirrhotic patients receiving 1,665 calories/day via a nasogastric tube with 10 cirrhotic patients who remained NPO for 4 days after a gastrointestinal bleed. Although the patients who received TF had a significant improvement in nitrogen balance compared with the control group, they also had a higher rate of rebleeding.
Several other studies have shown benefits of providing TF to patients with liver disease. A summary of study design and results are listed in Table 4.4.
Tube Feeding Studies in Adult Patients with Liver Disease
Cabre 35 patients with cirrhosis et al.  were randomized to a 1990 low-sodium diet vs. TF.
Caloric intake, serum albumin level, Child's score and survival rate were improved in the TF vs. control group Compared with the control group, the mean nutrient intake, hepatic encephalopathy measurements and serum bilirubin levels were improved in the study group.
Nitrogen balance improved 5-fold at 2 weeks.
Kearns 31 patients with alcoholic et al.  liver disease were
1992 randomized to receive either a general diet alone or a diet supplemented with casein-based TF.
Soberon 35 kcal/kg provided as TF or et al.  diet for 6 days in a crossover 1987 design to 14 patients.
Cabre A randomized, controlled et al.  study was performed 2000 whereby 71 patients were randomized to receive TF via a nasogastric tube (2,000 calories, 72 g protein) or a diet (1 g/kg protein) plus 40 mg prednisone. Campillo Authors reported the et al.  outcomes of 24 patients with 2003 ESLD who received TF
Hu et al.  135 patients with Child's B 2003 or C cirrhosis undergoing surgery were randomized to receive TF (n = 65), parenteral nutrition (PN, n = 40) or nothing (control, n = 3o).
et al.  (Novartis, Minneapolis, 2005 MN) was given via nasojejunal tube at a maximum dose of 2,100 ml, by postoperative day 4 and compared with PN (40-50% of calories as medium-chain/long-chain triglyceride blend). The 40 patients in this study had portal hypertension and were undergoing pericardial devascularization.
There was an equal improvement in the groups with regards to serum albumin level, Child's score, Maddrey score and infection rate.
When compared with patients who did not receive TF, those who were tube-fed were older, had a higher Child-Pugh score and a higher mortality rate. However, TF was initiated late in the patients' course and survival reflects the severity of the liver disease and not the presence of TF. Those receiving TF reached positive nitrogen balance first and had the lowest body weight loss. TF also showed a benefit in gut barrier integrity as measured by urinary excretion of lactulose and mannitol. This was not true of the PN or control groups. Nutritional status improved in both groups. However, there were fewer complications in the TF vs. PN group. In addition, TF increased blood velocity of the portal vein, stimulated gut motion, prevented bowel bacterial translocation, shortened hospital stay and reduced costs.
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