Managing diarrhoea in tube-fed patients

Diarrhoea is one of the most common problems associated with enteral or intestinal tube feeding, with incidences ranging from two to seventy per cent. [1,2]  Diarrhoea is commonly described as having more than three loose stools per day [3], while persistent diarrhoea is defined as having continuous diarrhoea for 14 days or more. [4]

Causes of diarrhoea in tube-fed patients

There are many causes of diarrhoea in enterally tube-fed patients, which can include:

• Gut infection diarrhoea caused by bacteria such as Clostridium difficile
• Gut pathology underlying disease state e.g. Crohn’s disease, Ulcerative Colitis
• Drugs - there are a wide range of drugs which may effect the gut and lead to the occurrence of diarrhoea including antibiotics, digoxin, protein pump inhibitors, alcohol, laxative abuse, drugs containing sorbitol
• Feed malabsorption
• Faecal impaction
• Stress
• Bacterial contamination of the enteral tube feed
• Feeding route gastric or postpyloric

Managing diarrhoea

The role of fibre
The effect of fibre in controlling the incidence of diarrhoea in tube-fed patients varies depending on the type of fibre used in the enteral formula, with most evidence supporting the role of soluble fibre. The table below shows the types of fibres and their physiological effects.

The types of fibre and their physiological effects

Type of Fibre	Example of fibre	Physiological Function
Water in-soluble fibre (NSP)	Cellulose, wheat bran, isphagula, husk, lignin	Do not dissolve in water Influences mainly the lower gut Water holding capacity – increases stool bulk and transit time
Water soluble fibre (NSP)	Guar gum, partially hydrolysed guar gum, Fructo-oligosaccharides (FOS), Galacto-oligosaccharides (GOS), inulin pectin, xanthan	Dissolve in water nfluences mainly upper gut Reduces gastric emptying Reduces transit time through small bowel Reduces rate of absorption of nutrients e.g. glucose and bile acids Reduces pH of colon – modulates colonic flora and stimulate short chain fatty acid (SCFA) production

Partially hydrolysed guar gum

What is partially hydrolysed guar gum?
Partially hydrolysed guar gum (PHGG) is a natural water-soluble dietary fibre.  It is produced by controlled partial enzymatic hydrolysis of guar gum – an extract of the Indian Cluster bean.  PHGG is stable, does not hold water and is soluble at the pH levels commonly found in foods. 

PHGG enriched tube feeds and diarrhoea
Clinical studies have found that enteral tube feeds enriched with PHGG can:

• Reduce the occurrence of diarrhoea
• Reduce the mean frequency of diarrhoea days
• Reduce the need to discontinue an enteral feed due to diarrhoea
• Increase tolerance to enteral feeds

Please see here for a summary of the clinical studies highlighting the benefits using a
PHGG enriched tube feed.
< Click to download PDF

Novasource® GI Control and Novasource® GI Forte are tube-feeds enriched with PHGG. 

Comparison of volume of feed administered in patients receiving a soluble fibre enriched feed vs. group receiving a fibre-free feed

Adapted from Rushdi et al 200416

Comparison of the number of liquid stools in patients receiving a soluble fibre enriched feed vs. group receiving a fibre-free feed.

Adapted from Rushdi et al 200416

Clinical recommendation for the use of PHGG enriched tube feeds

The ESPEN consensus recommendations on the effects and benefits of fibre in clinical practice provide a Recommendation A for the use of PHGG in enteral feeds concluding:  “To prevent enteral nutrition induced diarrhoea in post-surgical and in critical ill-patients supplementing enteral nutrition with PHGG is effective.” [3]