Treating delayed gastric emptying

Incidence and effect

DGE occurs in 30-70% of ICU patients [Columb et al, 1992] and contributes to few patients (22%) receiving their EN prescription [McClave et al, 1999]. However, despite recommendations to improve EN delivery using prokinetic drugs (metoclopramide, erythromycin) or NI feeding [Heyland et al, 2009] only 58% of patients suffering DGE receive these treatments [Cahill et al, 2010].

Feeding via an NI vs nasogastric (NG) tube reduces ventilator acquired pneumonia (VAP)-risk when combining deep tip placement and gastric acidification attained. NI feeding may reduce gastroesophageal regurgitation (NI vs NG: 25% vs 40%) and microaspiration (3.9% vs 7.5%, ns) [Heyland et al, 2001] particularly if the tube is sited in the distal duodenum or jejunum [Metheny et al, 2011]. However, a recent RCT confirms a reduction in VAP-risk in NI vs NG-fed patients [Hsu et al, 2009] possibly by simultaneously increasing EN delivered, reduced vomiting and gastric acidification. These data contradict meta-analysis showing similar VAP-risk from NI vs NG feeding [Marik and Zaloga, 2003] because they used measures to counter increased gastroduodenal reflux during NI feeding [Dive et al, 1999], increased GRVs [Taylor et al, 2010b] and oesophageal regurgitation [Lien et al, 2000]. Crucially, the above studies used ICU patients from admission; a greater effect might be expected by restricting treatment to those suffering DGE.


Metoclopramide and erythromycin improve gastric emptying [gastric residual volumes (GRVs) decline [MacLaren et al, 2008] and fewer people vomit (35% vs 70%)] [Reignier et al, 2002]. However, the treatment effect fails within 2-3 days on a single drug and 6 days on combined drugs due to tachyphlaxis [Nguyen et al, 2007]. There are case-report concerns regarding erythromycin-induced bacterial resistance and cardiac effects [Heyland et al, 2009] but it remains the most potent prokinetic drug and inadequate EN represents a higher risk [Heyland et al, 2009]. However, patients with DGE are under-treated (prokinetics: 59%, NI feeding: 15%) and most centres don’t always treat DGE (prokinetics: 22%, NI feeding: 3%) and some never treat DGE (prokinetics: 15%, NI feeding: 58%) [Cahill et al, 2010].

NI feeding

                                                      Figure 1: Cumulative deficit as a percentage of daily energy goal. Figure 1: Cumulative deficit as a percentage of daily energy goal.

Small intestinal function is usually retained in cases of DGE [Grahm et al, 1989] therefore NI feeding can deliver more EN than NG feeding [Montecalvo et al, 1992; Kearns et al, 2000]. However, delayed NI tube placement means that NG feeding is quicker to start (11.2h vs. 27h) and achieve the goal rate (28.8h vs. 43h) [Neumann and DeLegge, 2002] and, in DGE, NG feeding plus erythromycin delivered more EN [Boivin et al, 2000]. In addition, blind NI tube placement has poor success whereas procedures that give better success through visualisation are costly and incur more risk by being invasive (endoscopic) or ‘off-ICU’ (fluoroscopic).

In contrast, electromagnetically-guided nasointestinal tube placement (EGNT) minimizes the risk of trancheobronchial misplacement, time delay to NI intubation and cumulative nutrition deficit compared to NG feeding plus prokinetic drugs (See: Figure 1) [Taylor et al, 2010a; Foote et al, 2004].


  • Boivin M, Levy H, Hayes J A multicenter, prospective study of the placement of transpyloric feeding tubes with assistance of a magnetic device. Journal of Parenteral and Enteral Nutrition. 2000; 24: 304-7.
  • Cahill N, Dhaliwal R, Day A, Jiang X, Heyland D. Nutrition therapy in the critical care setting: What is “best achievable” practice? An international multicenter observational study. Critical Care Medicine.2010;38:395-401.
  • Columb MO, Shah MV, Sproat LJ, Sherratt MJ, Inglis TJ. Assessment of gastric dysfunction: current techniques for the measurement of gastric emptying. British Journal of Intensive Care. 1992;2:75-80.
  • Foote JA, Kemmeter PR, Prichard PA, Baker RS, Paauw JD, Gawel JC, Davis AT. A randomized trial of endoscopic and fluoroscopic placement of postpyloric feeding tubes in critically ill patients. Journal of Parenteral and Enteral Nutrition. 2004;28:154-7.
  • Grahm TW, Zadrozny DB, Harrington T: The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery 1989; 25:729–735.
  • Heyland D, Dhaliwal R, Alberda C, Christman C, Drover J, Garrel D, Grahmlich L, Greenwood J, Jeejeebhoy K, Jureswitsch B, Kutsogiannis J, MacDonald G, McCall M, Muscedere J, Pagliarello G, Somers-Balota C, McClave S, Rice T Stapleton R, Wischmeyer P. Canadian Clinical Practice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients. Updated recommendations. 2009.
  • Heyland DK, Drover JW, MacDonald S, Novak F, Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: Results of a randomized controlled trial. Critical Care Medicine.2001;29:1495–1501.
  • Hsu C-W, Sun S-F, Lin S-L, Kang S-P, Chu K-A, Lin C-H, Huang H-H. Duodenal versus gastric feeding in medical intensive care unit patients: A prospective, randomized, clinical study. Critical Care Medicine 2009; 37:1866–1872.
  • MacLaren R, Kiser T, Fish D, Wischmeyer P. Erythromycin vs metoclopramide for facilitating gastric emptying and tolerance to intragastric nutrition in critically ill patients. Journal of Parenteral and Enteral Nutrition. 2008;32:412-419.
  • McClave S, Sexton L; Spain D, Adams J, Owens N, Sullins, Mary Beth RD; Blandford, Barbara S. RD; Snider, Harvy L. Enteral tube feeding in the intensive care unit: Factors impeding adequate delivery. Critical Care Medicine.1999;27:1252-1256.
  • Metheny NA, Stewart BJ, McClave SA. Relationship between feeding tube site and respiratory outcomes. Journal of Parenteral and Enteral Nutrition. 2011; 35: 346-55.
  • Montecalvo M, Steger K, Farber H et al, . Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. Journal of Parenteral and Enteral Nutrition. 1992; 20, 1377-87.
  • Neumann DA, DeLegge MH. Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy. Critical Care Medicine.2002;30:1436-8. Comment in: Critical Care Medicine.2002;30:1654-6.
  • Nguyen NQ, Chapman M, Fraser RJ, Bryant LK, Burgstad C, Holloway RH. Prokinetic therapy for feed intolerance in critical illness: one drug or two? Critical Care Medcine. 2007;35:2561-7.
  • Nguyen NQ, Ching K, Fraser RJ, Chapman MJ, Holloway RH. Risk of Clostridium difficile diarrhoea in critically ill patients treated with erythromycin-based prokinetic therapy for feed intolerance. Intensive Care Medicine. 2008 ;34: 169-73. 
  • Reignier J, Thenoz J, Fiancette M, Legendre E, Lebert C, Bontemps F, Clementi E, Martin L. Early enteral nutrition in mechanically ventilated patients in the prone position. Critical Care Medicine. 2004;32:94-9.
  • Taylor S, Manara A, Brown J. Treating delayed gastric emptying in critical illness: Metoclopramide, erythromycin and bedside (Cortrak™) nasointestinal tube placement. Journal of Parenteral and Enteral Nutrition. 2010; 34:289-94.
Article Summary: 
Delayed gastric emptying (DGE) contributes to underfeeding, particularly in ICU patients. Prokinetics and nasointestinal (NI) feeding are effective but underused methods of treating DGE; best therapy has not been determined.