Exploring small bowel feeding intolerance in dysmotility v1.0
Research type
Research Study
Full title
Exploring intolerance of small bowel feeding in severe gastrointestinal dysmotility: a feasibility study.
IRAS ID
331384
Contact name
Peter Paine
Contact email
Sponsor organisation
Northern Care Alliance NHS Foundation Trust
Duration of Study in the UK
1 years, 0 months, 0 days
Research summary
The diagnosis of severe gastrointestinal dysmotility (a disorder of the muscles of the small bowel and other parts of the gut) is challenging. Some patients who cannot eat enough to maintain nutrition experience difficulties with tube feeding into their small bowel due to the symptoms this produces, especially pain. This can occur with very small amounts of feed, severely limiting feeding rates and can lead to problems with supporting nutrition. Patients with this problem then often receive feeding into their veins, which is higher risk than tube feeding and can be associated with poorer quality of life.
The inability to tolerate tube feeding at low rates is one of the features used to help make a diagnosis of severe gastrointestinal dysmotility but it is poorly understood why this occurs. It is difficult to explain why very small amounts of feed given very slowly causes severe pain. Sometimes psychological factors limiting tolerance may be just as important as physical ones.
A novel way of exploring intolerance of tube feeding in a clinical setting was previously described in a child. This was done by using two feed pumps instead of the usual one pump, (but still only one feeding tube). The two pumps were used to safely vary the rate and type of feed given. Both the patient and team were unaware of the rates delivered. The rates ranged from very slow up to the normal speed given in standard care.
At the end of the study the patient and the team were made aware of rates used which provided important clinical information, helping the patient’s holistic care.
This study would aim to see whether the approach is also feasible and acceptable in adults, to guide their clinical care, and to help the patient and clinicians better understand their symptoms.Lay summary of study results: Introduction: Small bowel (jejunal) feeding intolerance to low feed volumes, with no clear structural cause, is a significant challenge for patients and their clinical nutrition teams. We have no good tests currently to understand what might potentially be going wrong with the sensory or pain systems. This study aimed to determine whether a “blinded” feeding protocol, first described in children, is something which can be used and might be both helpful and acceptable in adults.
What the study entailed: Adult patients who had small bowel feeding intolerance and no clear cause were recruited from clinical nutrition team referrals. They received up to 3 days of 10 hours of daily small bowel feed. The feed was delivered using a feeding system where neither the patient nor the researcher determined the feed characteristics and two pumps were used with a cover so they couldn’t be seen during the feed administration (i.e. “blinded”). The feed rate was randomly altered every hour. Sometimes there was no feed running (although it would still sound like there was to the researcher and the patient) and at other times up to 70mls per hour were running, with other 10ml/hour increments varied randomly in between. Participants scored their perceptions of pain, nausea and bloating every 30 minutes using a rating scale of 0-10. The feed type was also varied on subsequent study days. Participants who declined to participate in the trial were interviewed to explore what barriers there were to their taking part.
Results: 16 patients were screened, of whom 13 were eligible. 9 patients declined due to either feeling unwell or being unwilling to have a further nasojejunal tube placement. 4 patients entered the trial; 2 completed a 10hr feeding period on 3 separate days and 2 patients tolerated two and six hours of feeding respectively, before asking to stop due to symptoms. Results were adjusted for daily baseline symptom score variation as needed, and then provided to the participant and main clinical team using a standardized template report. There was no clear relationship found between feed rate, type and symptom scores, either for individual or combined participant scores. The patients and teams reported finding the the results helpful for exploring possible central rather than peripheral mechanisms of symptom generation in these cases.
Conclusions: This blinded small bowel feeding method can be achieved in adults to help explore the relationships between small bowel feed types, volumes and rates with symptoms. No relationship was observed in the cases we studied between participant scores of pain, bloating and nausea, and feed rate, volume and type. The findings appeared to be useful for patients and the clinical teams for exploring central rather than peripheral mechanisms of symptom generation. Approaching patients with a nasojejunal feeding tube still in place and shorter feed durations might improve take up for patients in future studies.
REC name
North West - Liverpool Central Research Ethics Committee
REC reference
23/NW/0364
Date of REC Opinion
9 Jan 2024
REC opinion
Further Information Favourable Opinion