Prevention of Gastroesophageal Reflux Using an Application of Half‐Solid Nutrients in Patients with Percutaneous Endoscopic Gastrostomy Feeding

To the Editor: Although percutaneous endoscopic gastrostomy (PEG) feeding is widely used as a convenient method of long-term nutritional support,1 administration of liquid nutrients often accompanies complications such as vomiting or diarrhea. Gastroesophageal reflux (GER) presumably causes vomiting, which may result in aspiration. Therefore, half-solid nutrients were used for PEG feeding, and whether this approach can reduce GER was examined. Seventeen patients (mean age±standard deviation=79.9±10.5) who were on PEG feeding participated in this study. Written informed consent was obtained from all patients. Liquid or half-solid nutrients were administered via PEG tubing in a randomized order. Half-solid nutrients were prepared by mixing 5 g of agarose with 500 mL of liquid nutrients diluted with the same volume of water. Incidence of GER was assessed using computed tomography (CT) scan of the esophagus. Liquid nutrients were administered over 15 minutes in portions of 400 mL containing 20 mL of the water-soluble contrast material, Gastrografin® (methylglucamine diatrizoate). The half-solid nutrients were administered via bolus injections of the same volume of nutrients, which were contained separately in 50 mL syringes. Thirty minutes after the administration, a CT scan was performed in 1-cm-thick slices of the esophageal portion. GER was confirmed if the Hounsfield number exceeded 100 in each slice examined. A Hounsfield number of 100 was employed because it can unequivocally distinguish the mixture of the nutrients containing contrast material from the esophageal and other surrounding tissues. A radiologist who was not informed of the type of nutrients used assessed the CT images. Statistical comparison of the incidence of GER between the two types of nutrients was made using McNemar test. GER was confirmed in 10 of the 17 subjects (58.8%) when they received liquid nutrients. By contrast, when they received half-solid nutrients, only four of 17 subjects (23.5%) showed evidence of GER from CT findings (χ2=6.0, df=1, P=.014, by McNemar test) (Table 1). The advantages of PEG feeding over nasogastric feeding have been discussed elsewhere, although there have been some complications reported.2 Of the complications, vomiting can be a cause of fatal aspiration due to a reflux of the administered nutrients.3 The tubing used for PEG feeding has made it possible to apply half-solidified nutrients, which we hypothesized would cause less reflux from the stomach.4 As expected, less evidence of GER was observed when using half-solid nutrients than when using liquid nutrients. It was also confirmed that solidifying nutrients using agarose did not clog the tube. Continuous infusion and careful observation of the patient's symptoms are considered necessary to reduce the risk of GER in PEG feeding. Also, the patients are advised to remain in a sitting position during administration, which may increase the risk of developing or exacerbating decubitus ulcers. Thus, this pilot study suggests that the use of rapid administration of half-solid nutrients in PEG feeding can reduce the risk of GER substantially and may eventually contribute to a reduction of complications and to improvement in the quality of life of patients and their caregivers.