Enteral nutrition is best taken by mouth if the patient can ingest the required amount. If the patient cannot, then either supplements or full tube feeding is the method of choice. Protein in the peptide form is better absorbed than the free amino acid form due to specific transporters in the small intestines for amino acids, dipeptides, and tripeptides. Feeding tube placement is best in the small bowel up to the ligament of Treitz. This can be obtained best by the direct use of fluoroscopy or may be obtained by the passage of the feeding tube into the small bowel by a corkscrew technique, in which the distal tip of the feeding tube is bent at an approximately 30° angle with the wire stilet in place. Upon placement into the stomach, the tube is rotated so that the tip may pass via the pylorus into the small bowel. The infusion of enteral products into the small bowel will reduce the incidence of aspiration because the infusion is below the pylorus. Intubated patients have a low risk for aspiration due to the endotracheal cuff, so placement of a feeding tube into the small bowel is less essential.
Supplementation of enteral products with higher than standard amounts of the amino acid arginine has been done to enhance immune function. Published data on its beneficial effect in surgical patients have demonstrated some benefit; however, data from nonsurgical patients suggest harm. Immuno-nutrition should not be given to patients with severe infection, especially patients with pneumonia.
Branched-chain amino acid-enriched enteral products are available and have been shown to improve mental function and mortality in patients with hepatic encephalopathy. Albumin synthesis is also stimulated by branched-chain-enriched amino acid solutions. However, additional branched-chain amino acids did not improved morbidity or mortality in trauma or septic patients randomized to receive branched-chain-enriched amino acids compared to conventional feeding.
Glutamine-enriched enteral formulas are very common. There are many enteral products used in hospitalized patients and for home enteral nutritional support. These can be found at several enteral nutrition pharmaceutical Web sites.
The choice of lipid composition in enteral products is a field that is rapidly evolving, and this is an important decision to be made by the clinician depending on the type of disease being treated. The use of omega-3-enriched fatty acids in the enteral product (fish oil-enriched) has been associated with an ability to modify the inflammatory response that may be related to the increased arachondic acid metabolism and a decrease in the omega-6 pathway fatty acid metabolism. Unfortunately, most commercially available enteral products that have omega-3 fatty acids also have other additives, such as argi-nine, glutamine, and nucleotides, so that the benefits attributed to the use of an omega-3-enriched fatty aid enteral diet await future clinical studies.
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