COMPLICATIONS OF ENTERAL NUTRITION

Michele Port, P.Dt.

Clinical Dietitian March 2014

Outline

★ Gastrointestinal Complications: ○ ○ ○ ○ Diarrhea Constipation Delayed gastric emptying Nausea and vomiting ★ ★ ★ ★ ○ Abdominal distention Metabolic Complications Administrative Complications Case Study Conclusion

Learning Objectives

★ ★ Recognize various complications of enteral feeding and how to prevent and treat them.

Identify medications which often play a role in the diarrhea and constipation of enterally fed patients.

Gastrointestinal Complications

★ ★ ★ ★ Incidence in tube fed patients: 2-63% of tube fed patients depends on definition Common GI side effect in tube fed patient Tube feeding formula usually blamed Impact of diarrhea: ○ Fluid, electrolyte and acid-base disturbances ○ ○ ○ ○ Inadequate nutrient intake which leads to malnutrition Trace mineral deficiencies (Se, Zn) Contamination of pressure ulcers and excoriation skin Increases cost (Need rectal tube, cultures and linen changes)

Gastrointestinal Complications

★ Universal definition does not exist: ○ ○ > 3 stools per day for 2 consecutive days

OR

> 500 mL stool every 8hr

Mobarhan et al. 1995; Williams et al. 1998

> 200g stool per day

OR

≥ 3 or more liquid stools per day

Bliss et al. 1992

o Studies on diarrhea in tube fed patients use different definitions o Clinically useful definition: Abnormal volume or stool consistency for an individual

Gastrointestinal Complications

DIARRHEA

★ What is patient’s normal stool consistency and frequency at home?

★ Measurement of stool volume ○ Using pad or bed pan under patient, weight of stool lg / mL stool ○ Rectal tube or fecal management device where stool can be quantified

Boullata et al. , eds. 2010

Gastrointestinal Complications

★ ★ Osmotic Diarrhea ○ Caused by osmotically active substances in intestines ○ ○ The osmotic force pulls fluid into the intestinal lumen Examples: Lactulose, sorbitol, magnesium, phosphate, hyperosmolar enteral formula Secretory Diarrhea ○ Imbalance between absorption and secretion of electrolytes with a net water secretion in bowel lumen ○ Examples: C. difficile infection, enteroviruses, laxatives such as senna, colchicine

Btaiche et al. 2010

Gastrointestinal Complications

★ Common Causes: ○ Medication ■ Antibiotic therapy ■ ■ Hyperosmolar medications Sorbitol: containing medications ○ ■ Other (ex.: colchicine) Infection ■ C. difficile ■ CMV: cytomegalovirus in post transplant or immunosuppressed pts

Gastrointestinal Complications

★ Common Causes: ○ Enteral formula contamination ○ Maldigestion or malabsorption ○ ■ Steatorrhea Bacterial overgrowth ○ ○ ○ Overflow diarrhea Lactose intolerance Severe hypoalbuminemia

Gastrointestinal Complications

★ Common causes medication-induced: ○ Antibiotic therapy ■ Non-infectious ○ ■ ● Commonly cause diarrhea without causing CDAD (C. difficile associated diarrhea) Infectious ● C. difficile associated diarrhea (Ex.: Clindamycin, Ampicillin) Oral electrolyte supplements (Ex.: Magnesium)

Gastrointestinal Complications

DIARRHEA

★ Common causes medication-induced: ○ Laxatives ■ ■ Lactulose: Osmotic type diarrhea Senna: Secretory type diarrhea ○ ○ Prokinetics (Ex.: Maxeran, Erythromycin) Hyperosmolar medications (Ex.: Liquid multivitamins, nystatin suspension, docusate syrup, kayexalate) ■ Can cause osmotic diarrhea, nausea, abdominal cramping if undiluted on administration via SB ● Ex.: Cimetidine solution (Tagamet), furosemide (Lasix), doxycycline (Vibramycin), hydroxyzine (Vistaril), isoniazid, nortriptyline

Gastrointestinal Complications

DIARRHEA

★ Common causes medication-induced: ○ Sorbitol: Containing medications ■ ■ Sorbitol: a sugar alcohol used as a sweetener in oral medications May cause osmotic diarrhea and abdominal cramps or bloating ○ ○ ○ ■ Inactive ingredient in liquid medications, amounts often not listed on label or package insert Acid-suppressive medications (Ex.: Proton-pump inhibitor ) Chemotherapeutic drugs Other: colchicine

Boullata J et al. 2010, Btaiche IF, et al. 2010, Malone A, et al. 2007

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Infection ■ ■ Need stool assay to rule out C. difficile associated diarrhea Enteroviruses: Rotavirus, norwalk ○ ■ CMV colitis in immunosuppressed Contamination of enteral feeding solution ■ ■ Needs to ensure gloves are clean when handling enteral spike sets/ tubing for open tube feeding formulas All equipment to prepare enteral feeding must be clean ■ Open tube feeding formula needs to be refrigerated and formula discarded after 24hr. Label with date and time opened

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Contamination of enteral feeding solution ■ ■ ■ Only 4hr of feeding should be hung at one time for open feeding systems Feeding bags and tubing should be washed after each intermittent feeding and discarded after 24hr Closed feeding systems need to be labelled with date and time when bag spiked and discarded after 48hr

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Maldigestion / Malabsorption ■ Definition ■ • • Maldigestion: Impaired breakdown at nutrients Malabsorption: Defective mucosal uptake and absorption from bowel Diarrhea, weight loss, steatorrhea (fat malabsorption)

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Maldigestion / Malabsorption ■ ■ Celiac disease Short bowel syndrome ■ ■ Resection of terminal ileum Human immunodeficiency virus ■ ■ ■ ■ Pancreatic insufficiency Inflammatory bowel disease Protein-losing gastroenteropathies GVHD of gut

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Maldigestion / Malabsorption ■ • Past medical history part of nutrition assessment When interviewing patient / family ask regarding usual bowel habits ■ • • • • Medications which affect bowel movements. Lactulose, Imodium, herbal teas Tests Look at stool - fat floating on top?

Steatocrit to assess fecal fat content Check B12, folate, vitamin A level

Malone et al. 2007

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Bacterial overgrowth ■ ■ ■ Diagnosed by distal duodenal or jejunal aspirates, high serum folate (de novo synthesis) or hydrogen-methane breath tests Chronic diarrhea with minimal steatorrhea Associated with achlorhydria, bile acid deficiency, dysmotility (pseudo obstruction, diabetic neuropathy, narcotics) ○ Overflow diarrhea ■ ■ ■ Occurs in chronic-care immobilized patients Liquid flowing around hard feces Volume of stool not large usually

Gastrointestinal Complications

DIARRHEA

★ Common causes: ○ Lactose intolerance ○ ■ ■ Majority of commercial tube feeding formulas are lactose free Patient on food and tube feeding may be receiving lactose in diet Severe hypoalbuminemia ■ ■ Decreases oncotic gradient across bowel wall May be due to malnutrition, stress, fluid overload ○ Edematous bowel ■ Patient with anasarca likely has edema of the bowel also ■ Diarrhea often improves with fluid removal such as continuous dialysis

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ ○ Rule out C. difficile associated diarrhea Medication review with pharmacist ■ Discontinue medications suspected of causing diarrhea if possible ■ ■ ■ ■ Sorbitol-containing oral liquid medications should be discontinued and replaced with tablets Mg or K-elixir given via tube should be given IV to see if it makes a difference Review antibiotic use Dilute drugs introduced into jejunum to avoid dumping-like syndrome

Btaiche IF, et al. 2010

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ Review medical / surgical history ■ ■ Is patient with pancreatic insufficiency on a high fat formula (ex.: renal formula) without pancreatic enzymes?

Use a lower fat formula or a formula with 50%-70% of fat as MCT ■ ■ ■ • • Steatorrhea Use lower fat formula Severe GVHD of gut: consider parenteral nutrition until diarrhea decreases, use trophic feeding at low rate if tolerated Extensive SB resection Trial of elemental formula (low fat) or semi-elemental formula (protein in peptides, at least 50% fat in form of MCT)

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ Review medical / surgical history ■ Irritable bowel syndrome (IBS) • High fructose corn syrup, fructooligosaccharides (FOS), galactooligosaccharides and inulin can cause diarrhea, pain and bloating in IBS patients

Barrett, et al. 2009

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ Enteral Formula ■ Trial of formula with fibre ■ ■ ■ In ICU patients: use soluble fibre but only when hemodynamically stable and fully resuscitated Soluble fibre is fermented to SCFA SCFA are absorbed in the colon pulling water and electrolytes with them

McClave et al. 2009; Btaiche, et al. 2010

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ ○ ○ If feeding with a hypertonic formula consider trial with an isotonic formula Decrease rate temporarily Avoid intermittent feeds

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ Fiber supplements may help ■ Pectin (Certo): for diarrhea every 4-8 hr ● Mix 30mL pectin with 100 mL warm water, syringe into feeding tube and flush well with 60mL water ■ ■ Benefiber (Novartis) (Inulin) ● Rounded 1 tsp (312g) provides 3g fibre, mix 1-2 tsp benefiber with ½ cup (125mL) water Clearly fibre (Inulin) ● 3.2g sachet provides 3g fibre

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ Antimotility agents (loperamide, lomotil) ■ ■ ■ ■ Loperamide: lower risk of central nervous system adverse effects Slows intestinal motility Contraindicated in C. difficile diarrhea and may aggravate toxic megacolon Use only when all other causes of diarrhea have been addressed ○ Cholestyramine ■ An insoluble ion exchange resin that binds bile acids in intestines ■ May be beneficial in diarrhea due to bile acid malabsorption, Ex.: cholestasis, short bowel syndrome, terminal ileum resection

Gastrointestinal Complications

DIARRHEA

★ Treatment ○ Fluid and electrolyte replacement to replace GI losses ○ Chronic diarrhea can lead to micronutrient deficiencies especially selenium and zinc, may require supplements

Gastrointestinal Complications

CONSTIPATION

★ ★ ★ Clinical definition: accumulation of excess waste in colon Can identify this with abdominal X-ray, able to rule out ileus or obstruction Causes of constipation ○ Immobility ○ ○ ○ ○ ○ ○ ○ Neurological disorders Dehydration Inadequate fibre in enteral nutrition Excessive fibre in enteral nutrition Some medications (Ex.: sedatives, analgesics, opioids)  gut motility Acute colonic pseudo obstruction (Ex.: Ogilvie’s syndrome) GI motility disorders

Gastrointestinal Complications

CONSTIPATION

★ ★ Consequences ○ ○ ○ ○ ○ ○ Delayed transit time Vomiting Abdo. distension Risk of perforation Bacterial overgrowth Prolonged ventilator dependence in ICU patients Electrolyte disturbances ○ ○ Severe hypokalemia and hypomagnesemia may result in  bowel motility Severe hypokalemia may result in paralytic ileus

Gastrointestinal Complications

CONSTIPATION

★ Treatment and Prevention ○ ○ ○ Use a bowel regimen when you start enteral feedings Calculate the fluid requirement for a patient that is on enteral feeding: ■ 30-40 mL/kg OR 1 mL/Kcal (minimum for adults) Use fibre-containing enteral feeding with adequate fluid. Avoid formula with fibre if fluid restricted ○ Medication review: Medication-induced dysmotility?

Gastrointestinal Complications

CONSTIPATION

★ Treatment and Prevention ○ Laxatives ■ Emollients (Ex.: Sodium docusate) ■ ■ • • • • • Maintain soft fecal texture Onset of action: 1-3 days Not likely beneficial after stools harden Osmotics (Ex.: Lactulose) • • Non absorbable sugar Onset of action: 1-3 days Stimulants (Ex.: Senna, bisacodyl) Increase lower GI motility and anal sphincter tone Onset of action: 6-12 hr after oral dose

Gastrointestinal Complications

CAUSES OF DELAYED GASTRIC EMPTYING

★ ○ ○ ○ ○ ○ ○ ○ ○ ○ Causes of delayed gastric emptying Hypotension Hypokalemia Sepsis Medication(anesthesia, opioids, anti-cholinergics) Diabetes mellitus (gastroparesis) Rapid infusion of formula or cold formula Formula infusion High fat feeding formula Hyperglycemia

Gastrointestinal Complications

CAUSES OF DELAYED GASTRIC EMPTYING

★ Treatment ○ Duodenal or jejunal feeding ○ ○ ○ Prokinetic agents (Ex.: Maxeran, erythromycin) Low fat feeding formula Check residual volume every 4hr and assess tolerance ■ Follow feeding algorithm

Gastrointestinal Complications

NAUSEA and VOMITING

★ ★ Nausea may be caused by high enteral feeding rate or volume or medications ○ Treat with antiemetics ○ ○ Decrease rate or volume Review medications Vomiting may be caused by GI obstructions, medications, delayed gastric emptying ○ Hold enteral nutrition if GI obstruction ○ ○ Use antiemetics Hold feeds x 1hr then reassess

Gastrointestinal Complications

ABDOMINAL DISTENTION

★ Abdominal Distention ○ Causes ■ ■ ■ ■ ■ GI ileus Obstruction Obstipation Ascites Lactose intolerance ○ ■ ■ Rapid infusion of enteral formula Infusion of cold formula Rule out ileus or obstruction, do abdominal Xray

Metabolic Complications

Problem Overhydration Possible Causes

● ● Excessive fluid intake Heart Failure, renal failure

Dehydration

● ● ● ● ● ● Excessive fluid loss: Vomiting, Diarrhea, Ileostomy output Inadequate fluid intake Hypertonic fluid intake Hypertonic feeding formula High protein feeding formula Hyperglycemia ● ● ● ● ● ● ● ● ● ● ●

Prevention / Treatment

Limit fluid intake Use calorie dense formula Use diuretic if appropriate Monitor intake and output (I/O) Weight patient Monitor I/O Check skin turgor Monitor wt Monitor urea: Cr (normal 1:10) Increase enteral fluid flush Use less concentrated formula

Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

Metabolic Complications

Problem Possible Causes Prevention / Treatment Hyponatremia Hypernatremia Hypokalemia

● ● ● ● ● ● ● ● Dilution,  ADH levels Hepatic, renal or cardiac failure Excessive losses Dehydration Increased Na intake Refeeding syndrome Excess losses Use of diuretics (Ex.: Lasix) ● ● ● ● ● ● ● ● ● ● ● Monitor Na level Assess fluid status Limit fluid intake Na depletion, add Na Diuretic, if appropriate Monitor I/O Provide adequate fluid Reassess IV fluid Monitor serum K + Replete K + feedings before starting enteral Use a K + supplement

Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

Metabolic Complications

Problem Hyperkalemia Hypophosphatemia Hypomagnesemia

● ● ●

Possible Causes

● ● ● ● ● ● Excessive K + Renal Failure intake Use of spironolactone Metabolic acidosis Refeeding syndrome Binding by drugs (epinephrine, phosphate binders, insulin) Refeeding syndrome Increased losses (diarrhea) Drugs (Ex.: Cyclosporine) ● ● ● ●

Prevention / Treatment

Remove K + form IV Use kayexalate Use low K + TF formula Correct acidosis ● ● ● Replete phosphorus before starting TF Monitor phosphorus Reassess drugs ● ● Monitor Mg Supplement Mg before starting feeding if possible

Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

Metabolic Complications

Problem Hypoglycemia Hyperglycemia

● ● ● ● ●

Possible Causes

● ● Sudden cessation of TF in a patient on insulin therapy without adjustment of insulin Severe liver failure Diabetes Steroid therapy Stress, sepsis Pancreatic insufficiency Insulin resistance ● ● ●

Prevention / Treatment

● ● Use an insulin protocol Use D10W IV until TF provides adequate carbohydrate Adequate insulin Low carbohydrate formula Correct serum glucose before feeding

Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

Metabolic Complications

Problem Vitamin deficiencies



Vitamin A, D, E, K Possible Causes

● ● Fat malabsorption Pancreatic insufficiency

Prevention / Treatment

● ● Use water soluble supplement Use pancreatic enzymes

Vitamin deficiencies



Vitamin D Vitamin deficiencies



Zn, Se

● ● Lack of sunlight Inadequate vitamin D in enteral formula ● Excessive losses in diarrhea, ostomy, wound ● Vitamin D supplement ● Supplement Zn,Se

Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

Refeeding Syndrome

★ ★ ★ ★ ★ Occurs when severely malnourished patients are refed Acute intracellular shifts of electrolytes as cell anabolism is stimulated Results in decreased circulating levels of K + , Mg, phos Can cause hematologic, neuromuscular, cardiac and respiratory dysfunction Prevention / Treatment: ○ ○ ○ ○ Identify patients at risk Correct electrolytes before starting EN For the first day limit energy provided to 25% of requirements and progress gradually over 3-5 days to 100% of energy requirement Supplement with thiamine 100mg/day X 3-5 days ○ ○ Monitor for signs of fluid retention Monitor electrolytes daily until at mantenenace and replete low levels

Administrative Complications

ASPIRATION

★ ★ ★ Tube feeding, gastric secretions, or oral secretion enter the lungs A severe complication of enteral feeding Risk factors ○ supine position ○ regurgitation ○ ○ ○ ○ vomiting delayed gastric emptying decreased level of consciousness patient pulling out nasoduodenal tube while feeding is running ○ ○ ○ poor oral hygiene mechanical ventilation neurological disease

Administrative Complications

ASPIRATION

★ ★ Progression from aspiration of tube feeding formula to pneumonia depends on the amount, acidity of formula, and the microbial content and the health of the patient To decrease aspiration risk ○ ○ ○ HoB 30-45 o if not contraindicated Small bowel feeding tubes Motility agents ○ ■ Ex.: Metoclopramide: ineffective in head-injured patients, Erythromycin Oral Hygiene ■ Chlorhexidine mouthwash should be used twice daily to  mechanically ventilated patients VAP risk in

Case Study

66 year old male, post liver transplant 2009 with recurrent HCV on liver bx admitted to hospital due to cholangitis due to stones and needs surgery to remove one of the stones. Transferred to ICU with respiratory failure, anasarca, hyponatremia, hyperkalemia, C. difficile diarrhea and AKI with anuria and  Cr.

Intubated, ventilated, bronchoscopy performed. Found gastric fluid in lungs, vocal cords which didn’t close. Aspiration pneumonia diagnosed.

Continuous veno-venous hemodialysis will be started. The patient had a PEG inserted 2 weeks before ICU admission due to inadequate food intake. (He had pulled out 3-4 nasoduodenal tubes) He was also eating some food. (200-300Kcal per day)

➔ Abdomen: ◆ ◆ ◆ Non-tender CT scan of abdo: nothing acute Diarrhea but not copious amounts ➔ GU: ◆ ◆ ◆ High potassium treated with kayexalate On CVVHDF, urea, Cr, K, phos decreasing Still anasarca

Case Study

Problems: ➔ Aspiration: ◆ ◆ Gastric contents seen on bronchoscopy Vocal cords not closing ➔ Diarrhea ◆ C. Difficile ➔ Electrolyte abnormalities ➔ ◆ ◆ Acute kidney injury (AKI) Likely not related to tube feeds Overhydration ◆ Treated with continous dialysis

Case Study Should you use PEG for feeding?

Case Study

➔ Decision at morning rounds to use PEG until PEG/J can be arranged through radiology ◆ Promotility drug initially (despite diarrhea) ◆ Check residuals every 4hr

Case Study Which formula?

• • • On continuous dialysis with DNFL 100 If anasarca likely has gut edema and may have decreased absorption History of C. difficile diarrhea diagnosed and treated X 5 days

Case Study

➔ Vivonex plus and protein powder ◆ Elemental: easier to absorb ◆ Low fat

Case Study

➔ Estimated calorie requirement: Ht = 170 cm Wt = 66.5 kg Tmax = 36.9

0 C Ve = 9:44 ➔ Mifflin St. Jeor: REE Kcal / day Male: 10 (wt) + 6.25 (ht) - S (age) + 5 Female: 10 (wt) + 6.25 (ht) - S (age) - 161 ➔ Mifflin St. Jeor: ➔ Penn state(mifflin) = 10 (66.5) + 6.25 (170) - 5 (66) + 5 = 1402 Mifflin (.96) + Tmax (167) + Ve (31) - 6212 = 1402 (.96) + 26.9 (167) + 9.44 (31) - 6212 = 1589 ➔ Estimated protein requirements on CVVHDF: 133 - 166 g (2-2.5 g/kg)

➔ Vivonex plus: 1000 Kcal / mL 45 g protein / litre ➔ Beneprotein powder: 6 g protein / scoop ➔ No need to calculate Na, K, phosphorus because pt on CVVH (continuous dialysis)

Kcal Protein (g) 1200 mL Vivonex Plus 1200 54 g Beneprotein 325 78 g (13 scoops) Total 1525 132 g ➔ Start Vivonex plus slowly at 20 mL/hr and advance by 15 mL/hr every 8hr to 50 mL/hr with 13 scoops protein powder daily

Case Study

➔ Good tolerance ➔ No residuals ➔ Pasty and loose stools approx 3 times per day ➔ Good glycemic control ➔ Electrolytes monitored

➔ ➔ ➔ ➔ 1 week later, PEG/J inserted Extubated on HHM Continuous dialysis stopped U/O: 150-200 mL / 8 hr

Which formula should I use?

➔ Formula ◆ Renal formula: high in fat so did not want to use this in patient with diarrhea ◆ ◆ Vivonex plus: 1 Kcal / mL, not calorie dense. Need to limit fluid volume No hemodialysis at present time ◆ ◆ ◆ Used semi-elemental formula 1.5 Kcal / mL Able to keep protein in recommended range, potassium less than 60 mmol, phosphorus a little high at 1350 mg, fluid approximately 1200 mL Monitor: electrolytes, diarrhea

Case Study Can this patient eat?

➔ ➔ ➔ ENT service says pt has voice so vocal cords not paralyzed Swallowing assessment by OT OT will do modified barium swallow

➔ Patient stable and transferred to transplant ward.

Conclusion

➔ It is important to be aware of the various complications which can occur with enteral feeding.

➔ All members of the medical team should monitor the patient to try to prevent these problems from occurring and should be aware of how to treat them ➔ The gastrointestinal complications often lead to enteral feeding being held and if feedings are held too often this compromises the nutritional status of patients.

➔ Often takes trial and error to solve problems with diarrhea and constipation.

References

Barrett JS, Sheperd SJ, Gibson PR. Strategies to manage gastrointestinal symptoms complicating enteral feeding. JPEN 2009; 33: 21-26.

Bliss DZ et al. Defining and reporting diarrhea in tube-fed patients – what a mess! Am J Clin Nutr. 1992; 55: 753-759.

Boullata J, Nieman Carney L, Guenter P, eds. A.S.P.E.N. Enteral Nutrition handbook. Silver Spring, MD: American Society for Parenteral and Enteral nutrition; 2010: 267-307.

Btaiche IF, et al. Critical illness, gastrointestinal complications and medical therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract 2010; 25: 32-49.

Malone A, Serres DS, Lord L. Complications of enteral nutrition. In Gottschlich M, ed. in chief. The A.S.P.E.N. Nutrition Support Care Curriculum, Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2007: 246-263.

References

McClave SA, Martindale RG, Vanek VW, et al; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine, Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically I ll Patient: Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN 2009; 33: 277-316.

Mobarhan S, DeMeo M. Diarrhea induced by enteral feeding. Nutr. Rev. 1995; 53: 67-70.

Williams MS, et al. Diarrhea management in enterally fed patients. Nutr Clin Pract. 1998; 13: 225-229.

St-Laurent L. Nutrition entérale: guide practique pour le clinicien. Montréal: McGill University Health Centre, 2009: 12.1-12.6.