Check out this overview of feeding tubes to provide enteral nutrition.
A number of options exist for enteral feeding tubes. Factors to consider when choosing the most appropriate tube include the animal's nutritional status, its ability to tolerate anesthesia, the length of time the animal is expected to require nutritional support, the function of the animal's gastrointestinal tract (and using as much of the gastrointestinal tract as possible), available hospital facilities, the cost, and your comfort level with different techniques for tube placement. Detailed information on placing these feeding tubes is described elsewhere.1-3
Nasoesophageal (NE) and nasogastric (NG) tubes are typically 3.5- to 8-Fr feeding tubes (red rubber, silicone, or polyurethane). Light sedation may be required; however, applying a local topical anesthetic agent (e.g. ophthalmic proparacaine hydrochloride) to the nares is usually sufficient for tube placement in most animals.
NE tubes terminate in the distal third of the esophagus, whereas NG tubes reach the stomach. There is some thought that NG tubes may interfere with the lower esophageal sphincter and contribute to gastric reflux; however, this relationship has not been proved. Placing an NG tube may be preferable if measurement or removal of residual gastric fluid is desirable or if occasional vomiting is possible. Secure the tube to the nasal planum by using sutures, skin staples, or glue, and perform radiography to confirm proper placement. Elizabethan collars are usually required to prevent early tube removal (Figure 1).
1. A dog with an NG tube. The dog was anorectic because of acute kidney injury due to leptospirosis, so enteral feeding was used to provide nutrition and to help maintain gastrointestinal function. An E-collar was used to reduce the risk of early tube removal.
Potential reasons to avoid placing an NE or NG tube include severe thrombocyctopenia, underlying coagulopathy (epistaxis may occur), or dyspnea since one nostril will be occluded. NE and NG tubes require a liquid diet and are best used for short-term (< five days) nutritional support.
Esophagostomy (E) tubes are typically > 14-Fr feeding tubes (red rubber, silicone, or polyurethane). Red rubber tubes are less expensive than tubes made of other material but do not last as long and may be less comfortable for the patient. However, anecdotally, tubes made of other material can be harder to place and may be more likely to displace if the animal vomits. For large dogs (> 55.1 lb [25 kg]), long E tubes are available commercially, or stallion urinary catheters can be used.
General anesthesia is required when placing E tubes. Although commercial tube placement devices are available, we prefer curved forceps for placement. E tubes should terminate in the distal third of the esophagus, and proper placement should be confirmed with radiography. Secure tubes with a purse-string and finger-trap suture pattern (Figure 2).
2. A cat with an oral squamous cell carcinoma with an E tube in place. The tube was secured with a purse-string and finger-trap suture pattern.
E tubes may be maintained for weeks to months if necessary and are good choices for long-term nutritional support. Liquid enteral diets, critical care diets, or canned food that has been liquefied by using a blender can be fed through an E tube. Choosing an appropriate diet will depend on the patient's underlying medical condition.
E tubes are contraindicated if esophageal disease is present (e.g. megaesophagus, stricture).
Gastrostomy (G) tubes can be placed surgically or with endoscopic guidance (percutaneous endoscopic gastrostomy [PEG]). While blind placement techniques exist, we do not recommend blind placement of G tubes. We recommend 18- to 30-Fr mushroom-tip (Pezzer) tubes, though some clinicians use commercial veterinary PEG tube kits, which can vary in the tubes' ease of placement and security. General anesthesia is required for placing G tubes. Tubes should be left in place for a minimum of 10 to 14 days to allow adequate adhesion to form between the gastric serosa and body wall and should be left longer if there is concern about wound healing.
E tubes vs. G tubes: Did you know?
For large dogs, a gastropexy may be performed to reduce the tension placed on the tube. For animals that require extended nutritional support, a low-profile gastrostomy device may be placed to reduce the amount of external tubing present and, thus, the risk of inadvertent removal.
Potential contraindications for the placement of a G tube include underlying gastric disease, ascites, hypoalbuminemia, or risk for poor adhesion formation (e.g. animals receiving immunosuppressive medication). To prevent pressure necrosis of the skin, care should be taken not to place too much tension on the skin with the external flange of the G tubes.
Indications for jejunostomy (J) tubes include the need to bypass the stomach, pancreas, or proximal duodenum (e.g. severe pancreatitis). J tubes are typically 3.5- to 8-Fr feeding tubes (red rubber, silicone, or polyurethane) that require surgical placement in most cases. New techniques have been described for the endoscopic and fluoroscopic guidance of nasojejunal5,6 and gastrojejunostomy7 tubes; however, placing these tubes is more technically difficult, and further studies are warranted to investigate their clinical relevance. J tubes require a liquid enteral diet and are usually reserved for hospitalized patients since continuous-rate infusion should be used for feedings because of the lack of a reservoir function of the small intestine (vs. the stomach).
1. Holahan ML, Abood SK, McLoughlin MA, et al. Enteral nutrition. In: Dibartola SP, ed. Fluid, electrolyte, and acid-base disorders in small animal practice. 4th ed. St. Louis, Mo: Elsevier, 2012;623-646.
2. Larsen JA. Enteral nutrition and tube feeding. In: Fascetti AJ, Delaney SJ, eds. Applied veterinary clinical nutrition. West Sussex, United Kingdom: Wiley-Blackwell, 2012;329-352.
3. Marks SL. Nasoesophageal, esophagostomy, gastrostomy, and jejunal tube placement techniques. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 7th ed. St. Louis, Mo: Saunders, 2010;333-340.
4. Ireland LM, Hohenhaus AE, Broussard JD, et al. A comparison of owner management and complications in 67 cats with esophagostomy and percutaneous endoscopic gastrostomy feeding tubes. J Am Anim Hosp Assoc 2003;39:241-246.
5. Beal MW, Brown AJ. Clinical experience utilizing a novel fluoroscopic technique for wire-guided nasojejunal tube placement in the dog: 26 cases (2006–2010). J Vet Emerg Crit Care 2011;21:151-157.
6. Pápa K, Psáder R, Sterczer Á, et al. Endoscopically guided nasojejunal tube placement in dogs for short-term postduodenal feeding. J Vet Emerg Crit Care 2009;19:554-563.
7. Jergens AE, Morrison JA, Miles KG, et al. Percutaneous endoscopic gastrojejunostomy tube placement in healthy dogs and cats. J Vet Intern Med 2007;21:18-24.