Long‐term enteral nutrition with a nasogastric tube can be safe and effective: A case report

Abstract

Home enteral nutrition (HEN) is a vital feeding practice for those who have chronic disorders that prevent them from eating normally. Although short‐term feeding is predominantly done via nasogastric (NG) tubes and long‐term feeding is done via percutaneous endoscopic gastrostomy (PEG) tube, we present a case that demonstrates that the long‐term use of NG tubes may be possible. Our case involves an adult woman who has been fed via an NG tube for >3 years with no complications. She has had three replacement tubes inserted over these 3 years and has not required any healthcare visits related to tube dysfunction or complications. She continues to do well. A literature search determined that there are no reports of long‐term use (greater than a year) of NG feeding tubes in outpatient adults, and thus the true rate of complications related to NG tubes is unknown. We review the reported complications associated with long‐term PEG tubes. Although PEGs are typically regarded as safer in long‐term feeding situations, this case demonstrates that NG tubes could prove effective under certain circumstances in which the insertion of a PEG may not be possible.

INTRODUCTION

Within the context of long‐term nutrition support, home enteral nutrition (HEN) has become a therapeutic mainstay. This method of feeding allows patients with various chronic gastrointestinal (GI) and non‐GI disorders involving eating difficulties to receive long‐term nutrition in a home environment. HEN can be delivered through nasally placed tubes (nasogastric [NG] or nasojejunal) or percutaneously placed (endoscopic, radiologic, or surgical) gastric or jejunal tubes. The least invasive method involves the insertion of a small‐bore NG tube (NGT) through which nutrition and pharmaceuticals can be administered. Alternatively, a gastrostomy can be performed to administer nutrition directly into the stomach. NGT feeding, according to the recent European Society for Parenteral and Enteral Nutrition (ESPEN) HEN guidelines, should only be used for a maximum of 4–6 weeks, ¹ and, if longer term enteral nutrition support is needed, a percutaneous gastrostomy tube should be used. This recommendation was based on expert opinion with a high level of consensus because there have been limited studies on this issue. In some cases, it may not be possible for anatomic reasons to insert a percutaneous tube, or the patient my prefer a less invasive approach. In this report, we describe the successful use of an NG feeding at home over a 3‐year period. The successful use of NG feeding in an adult over this long a period of time has not been previously reported.

CASE REPORT

A 32‐year‐old woman was admitted to hospital with a chronic history of generalized weakness, dysphagia, and weight loss of approximately 20% of usual body weight. She had seen numerous specialists in the past, had a diagnosis of a possible seizure disorder and postural orthostatic tachycardia syndrome, and had evidence of muscle wasting and deconditioning. A gastroscopy with esophageal biopsies was normal. She had ongoing neurologic and rheumatologic investigations pending. Because of her malnourished state and inability to maintain her nutrition status with oral nutrition, she was considered for specialized nutrition support. She favored NGT feeding and the potential risks and benefits of both NG feeding and gastrostomy feeding were discussed with her. After considering these options she chose NG feeding and a small bore feeding tube NG tube (Kendall Enteriflex 12 F 55 inch NG tube) was inserted at the bedside in the right nares, and she was discharged from hospital to begin HEN.

She was able to infuse a 1 cal/ml formula (750–1000 kcal per day) using bolus feeding and was also able to tolerate some water and minimal soft food intake. Based on the Harris Benedict equation, her estimated resting energy expenditure was 1191 kcal. She was on no medications. She was reassessed 6 months later, and her weight had increased by 20 lb, close to her usual body weight, with no apparent issues related to the NG tube. She had not noted any local complications related to the tube. She was securing the feeding tube to her cheek with Duoderm (Convatec) (she did not use any tape in the nasal region), which alleviated the pressure on her nose, and she found this was very comfortable. This was changed on a weekly basis. The prospect of a gastrostomy tube including the risks and benefits was again discussed with her, given the ESPEN guidelines. She was still unable to manage her nutrition orally. The patient was happy to continue with NG feeding and declined a gastrostomy tube. A new NG tube was inserted in her left nares as an outpatient. One year later, after having cancelled several appointments because she was feeling well, the patient was seen again to examine her progress. Her weight was stable, and she still had no signs of local necrosis, sinusitis, or any pain relating to the tube. A new NG tube was inserted in the right nares at this time because the left nares seemed less patent for her. She continued to do well and waited another 16 months before seeking another tube change. The old tube was removed (Figure 1) and, aside from darkening of the tube and some very mild dilation, the tube was intact. There was some cracking of the connector hub, which had been secured with tape (Figure 2). She once again declined insertion of a G‐tube, and a new 12 F NG feeding tube was successfully inserted into the right nares and into the stomach. She has continued her same regime of nutrition support, and her weight has been stable. It is estimated that 90% of her nutrition is provided for by enteral nutrition. To date, she continues to use the tube without complication or the need to access healthcare for tube related dysfunction.

Figure 1.

Small‐bore (12 F) feeding tube that had been in place for 16 months, showing blackening with mild dilation.

Figure 2.

Connector tip of small bore feeding tube repaired with tape.

DISCUSSION

Percutaneous endoscopic gastrostomies (PEGs) were first introduced in the 1980s and are commonly recommended when long‐term feeding is required. ² In this case report, we describe the successful use of an NG feeding tube for 3 years. During that time there were no unscheduled healthcare visits related to tube dysfunction, the patient experienced no complications, and there were three elective tube removals/replacements that occurred. The successful use of long‐term enteral nutrition in an adult for this long period of time has not been previously reported.

Although PEGs are favored in the long‐term, the literature suggests that NGT use is significantly safer for short‐term feeding (4–6 weeks). In a 2‐month observational survey study of inpatient adults and intensive care unit (ICU) patients comparing NGT and PEG feeding with a mean follow‐up of 7 days, it was reported that gastrostomies are associated with both a higher rate and a higher severity of adverse events. ² Gastrostomies involved complications such as clogs, leaks, and tube feeding intolerance. They also carry some risk of dislodgement, which can pose a major threat to a patient, increasing the potential for sepsis. Adverse events associated with NGTs, however, mainly involved nasal discomfort. Furthermore, gastrostomies were reported to have (nonstatistical) higher rates of pain and discomfort relative to NGT feeding. Approximately 50% of the reported complications were not documented in the medical record. This observational study concluded that there may be an underappreciation of the adverse effects associated with gastrostomies. ²

In a prospective study of long‐term complications associated with enteral feeding tubes, it was reported that, over a mean period of 10.5 months, patients averaged 5.4 healthcare contacts to address issues with their PEG. ³ These issues included discharge from the tube site, tenderness, and granulation tissue, along with the breaking, plugging, or inadvertent tube removal. ³ There have been few studies comparing long‐term feeding with PEG feeding. In a retrospective pediatric study (with a mean age of 5.3 months) following patients for a mean duration of 7.8 months, it was reported that the overall PEG complication rate was twice that of NGT feeding, furthering the notion that PEG tubes may involve more risk than NGT feeding tubes ⁴ but that PEG placements resulted in greater improvement in anthropometrics and higher patient satisfaction.

Despite its safety and effectiveness in the short term, there is concern that long‐term NGT feeding can lead to serious adverse effects, including nasal mucosal ulceration, chronic sinusitis, pharyngitis, otitis media, GERD, and aspiration pneumonia. ⁵ Aspiration pneumonia resulting from tube feeding, however, seems to be more theoretical, because numerous studies regarding tube feeding have reported a distinct lack of pneumonia among their cohorts. ² , ⁴ , ⁵ Among the pediatric population, it was reported that when NGT feeding is undertaken for >3 months, there was a significant increase in the incidence of food refusal. Furthermore, despite the fact that PEG insertions carry a higher initial risk, long‐term NGT users were 12 times more likely to pursue the alternate feeding method (gastrostomy tube) compared with PEG users (pursuing NGT feeding). ⁴

In this case report, we describe the successful use of an NG feeding tube for 3 years with no complications and tube related interventions including three elective removal/replacements. There was no nasal discomfort or trauma, and this may be related to the method of securing the tube to the cheek with Duoderm, eliminating pressure on the nares. The successful use of long‐term EN via NGT in adults for this length of time has not been previously reported. In fact, there have been few case reports of complications related to long‐term NG tube usage. One report of a rare complication describes a 20‐year‐old man who received a 14‐F‐gauge NGT while in a coma, because his family refused the gastrostomy procedure. A blockage was noticed after 2 months of NGT feeding and presented as a white mass in the esophagus. The mass was removed endoscopically and was determined to be a bezoar that resulted from stagnant enteral feeds and medications. ⁶ Given the lack of data on this topic and the potential for long‐term local complications such as sinusitis and pressure necrosis, more experience is required to truly understand risks. Clinicians could consider using these long‐term NGT therapy in patients with contraindications to gastrostomy tube insertion.

In conclusion, this case demonstrates that it is possible to provide long‐term enteral feeding (over a period of 3 years) using an NG tube that is safe, tolerable and effective. The use of NGT feeding in adult patients needs to be individualized and can be considered in those that have contraindications or decline gastrostomy tube feeding. Although the ESPEN guidelines recommend gastrostomy feeding in the long‐term, it is also recognized that long‐term NGT feeding may be appropriate under extenuating circumstances in which gastrostomy tube insertion may not be possible. ¹ Further studies in the safety and tolerability of long‐term NGTs are needed to confirm the observations noted in this single case report.

AUTHOR CONTRIBUTIONS

James M. Duerksen drafted the initial manuscript; Bram Ramjiawan and Donald R. Duerksen edited the manuscript; Donald R. Duerksen conceived the idea; and all authors approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

None declared.

Duerksen JM, Ramjiawan B, Duerksen DR. Long‐term enteral nutrition with a nasogastric tube can be safe and effective: a case report. Nutr Clin Pract. 2025;40:492‐495. 10.1002/ncp.11263