Peg Enteral feeding and Gaviscon Advance

[Enteral]

I’m writing on behalf of my wife as she is disabled and bed ridden

My wife is Peg Feed and has been so for many years Lately her feed and flush has been refluxing up into her throat and is a cause of discomfort for her . She swallows what comes up or I suction it using a suction device It doesn’t go on for the whole time of her feed just sometimes but it happens daily .

We were prescribed Gaviscon Advance but I don’t think it works and our pharmacist is convinced it shouldn’t work as Gaviscon is not able to lie on her stomach contents like it’s designed to do as it’s not being administered orally but through the Peg which is in her stomach

I would appreciate any suggestions or advise to help my wife with what’s happening to her

[Mauser1905]

Hi there,

Sorry to know of your wife's discomfort. I am reading in between the lines and the advice is speculative non-clinical only, as her health history and Conditions are better understood by the team treating her.

Hope her weight is stable?

Is she having constipation? Any issues passing stools or any traces of blood in stool, or cough?

Assuming your wife is not a oesophagectomy survivor?

Tey elevating her upper body while lying in the bed. Guessing if she is bed bound then she has medical bed which can be adjusted? Most of us use wedge pillow with or without extra pillows etc. Adjustable bed for stopping the nighttime reflux for oesophagectomy patients is spoken to be of good help on this forum.

H.Pylori breathe testing can be done by the GP to rule out bacterial infection in the stomach. Please ask your GP for this. Very simple blow in the bag type test.

May be also tey adjusting the feed quantity/timing/feeding rate. You will need to do everything one by one to find which is of help and not.

She didn't have this issue while being in same condition for years but only recently started. How is physical movement earlier the lockdown and recently? This does attribute to reflux as well.

Also visit opa.org.uk for more information on reflux and how to manage it.

Because your wife has underlying conditions it will be also useful if you can read up the information on the OPA website, s it seems you are doing a good job caring for her. And the people on this forum are of great help.

Also there is patient buddy if you need just dial the OPA headquarter number during day time and speak to the lovely staff.

Gaviscon advance syrup is taken orally to layer up the oesophagus and parts of stomach lining if empty. If in excess quantity with the feed, it will rather reduce the strength (pH) of the stomach acid and cause indigestion and nauseating symptoms eventually as to throwing up etc.

From what you explained is not a holistic approach.

With peg feeding gaviscon advance is no use directly into stomach, in my view. Rather its counter action. If I were you I would push to find out the root cause of the symptoms and not tey to manage the reflux on daily basis. Especially in your wife's case it is more important to diagnose the root cause and fix it, else her immobility while lying in the bed is just going to make it worst for her progressively.

Not scaring you but if she is continually experiencing episodes, persistently I am concerned that the sleep fatigue will eventually make her swallow the contents into the lungs and causing pneumonia. This could be one of the worst scenarios in her case, again my non qualified speculation.

[Enteral]

Hi Mauser 1905 thank u for your reply and input and interest

Yes her weight is stable and has no constipation I change her incontinent pads and she has easy bowel movements just soft as it should be no blood in stool or cough

She hasn’t had a oesophagectomy

She is in a medical bed Which is fully adjustable Do u suggest I should try a wedge pillow ? Even though her head is adjustable.

I don’t think she needs a H.Pylori breathe test

I have adjusted her feed speed down from 150 to 125 ml/h I’ve also split her feeding into 2 sessions

Her Dietician is due this month to change her PEG which she does every 6 months

She’s had the reflux condition for a long time but recently got worse I hardly used the suction device but now use it daily maybe 2 or 3 times daily and otherwise she swallows . Sometimes hours after her feed has ended she’ll suddenly start coughing and she mostly is able to swallow and then after a bit is ok again . Also sometimes when I give her a flush when she’s not feeding the water goes straight up to her throat .

Thanks for the opa.org.uk site I’ll certainly go and have a look at it

Ok I’ll try and get someone in to find out the root cause of the symptoms

I hear what u say about pneumonia. She does sleep very well If she is asleep and then starts coughing she’ll swallow and go straight back to sleep

Thank u again for your very good advise

[Mauser1905 in reply to Enteral]

Thats good to know. Thank you.

No wedge pillow is not required if the bed is adjustable. I use a wedge pillow with additional pillows stacked on it to make a dummy adjusted elevated bed. It's great she has the adjustable bed.

Will she be able to confirm she has heartburn pain when these episodes happen? Although the enteral feed is ph controlled without any additional stuff in it. There is no external provocative intake in her feed,so the reflux may not be very badly acidic if she is able to go back to sleep soon enough. Also you can find how acidic it is using litmus strips on the sectioned contents or using in the throat/ back of the tongue. Severe acid reflux cases involve painful episodes lasting from hours to days.

Instead of gaviscon advance she should be offered any prezole capsule which could be opened and contents fed mixed with the liquid feed through peg tube. But this won't solve the root cause.

My speculation is that her sphincter is gotten more lax as well her hiatus hernia. Thats causing even the liquid used for Flushing to run straight up to throat. This will be possible when there is slight pressure on her stomach by compressing abdomen. Please note her posture and how it pressurises the abdomen. if you can find this pattern which immediately results in reflux symptom then the suspicion can be confirmed by judgement. Please do ask GP for referral to GI team for endoscope on urgent basis. Endocopy if possible on her can diagnose her status of sphincter and hernia. This conditions is an mechanical one and can not be fixed by medicines. In my view.

For her condition with nil oral she may benefit from nissen fundoplication 360, again non qualified view here.

[Enteral]

Hi again thank u so much for taking your valuable time to reply again

She definitely doesn’t have heartburn or acid reflux . The reflux that I suction looks like diluted feed .

You hit the nail on the head I think re the Sphincter Her background is that she had a subarachnoid haemorrhage in 2012 followed shortly after that with a stroke and has lost the use of her left side .When she was in Neurorehab her consultant told me about the sphincter as the stroke had affected her swallow.

I don’t know if she has hernia . I appreciate everything you’ve said about sphincter and hernia .

I’ll look up the fundoplication 360

Your advise is really so valuable Thank u so much

[052517 in reply to Enteral]

I agree that endoscope would be most helpful, and a trip back to her stroke team.

[Enteral]

Also wanted to add she definitely doesn’t have a hiatus hernia doesn’t have any of the symptoms. A few years ago she also was put on prezole type medication and side effects were no good ie diarrhoea

Thank you again

[Mauser1905]

Glad to know you are on top of the things in her care. Pleasantly persist for root cause fix with GI team as this is not going to be resolved with medications. And she has very complex history so normal 7 min GP appointment won't do any good.

Please do keep us updated if you happy to let us know how things going. Wish you all the best

[Mauser1905]

Thanks for the additional information of her stroke history, the stroke consultant did confirm damage to her lower oesophageal sphincter (LES) previously and that should be in her records. Believe her speech and language therapist did work in rehab.

Aspiration Pnuenonitis and requiring tracheostomy is a life threatning condition and is common cause of death among the long-term care facilities/care. Please do mention this to the GP if you find resistance to offer urgent referral. Because even the GI cosultant wont be able to recommend a solution in isolation; as stroke, speech and language input will be required rest apart other imaging and diagnostics outwith GI.

A holistic view will require MDT to decide the optimal treatment plan for this issue and GP on their own are not going to be of any help except kindly refer urgently to the mentioned departments in the hospital and co-ordinate the teams response between yourselves and the hospital, in the least.

In the meantime I would suggest you write a detailed diary of those incidences, dates, times, symptoms, duration of the episodes, times requiring to use suction device, timing of the feed etc. this will save significant time if drs decide to gather this data themselves.

Chances are GI team may propose to do Oesophageal manometry to find out the pressure within. Hope she will be able to tolerate this. These would have been carried out during the rehab to decide the feeding route for her. Time to revisit the base case.

Options could be as below (in the least):

Nissen Fundoplication (NF) to tighten the sphincter, this has benefit that the PEG feeding continues post NF surgery healing, howere there may be short-term jejunostomy for feeding for the surgery, or may be not. As goes with this specific surgery its subjective in regards to the tightening achieved due to obvious variants. Meaning some patients find it too much tight or some find it not enough tight at the LES after the NF. Having said that in your wife's case I assume she is permanently on oral nil due to the complications, if thats correct then the NF option might be more sensible in the long term as this way her stomach is still used long term for feeding (instead of bowels in jeg tube) with the best outcome to avoid the most common aspiration issue.

LINX (magnetic) band is of use in cases of lesser of hiatus hernia, with patient tolerating the oral feed. In this particular case it may be doubtful of the outcome of this technique. Because the sphincter if confirmed lax (even if smaller grade), doesnt matter as the content will still continue travel up through the oesophagus and LINX may not help stop it.

Switching from PEG to Jejunostomy feeding for long-term, this will remove the PEG tube and do not require to fiddle with the LES. However this may come with its own complications down the line. Comparison of worst case scenario of death due to aspiration pnuenomia against other potential risk factors with the other options will be considered by the MDT and suggest you to get on board that information as possible to make a long-term plan rather piecemeal symptom management currently being offered.

Hoping that you are looking after yourself too in these circumstances. Take care.

As goes always, I am a non-qualified person in clinical matters, and all the gibberish above should be taken with a lot of salt.