1. COMPLICATIONS OF ENTERAL NUTRITION Michele Port, P.Dt. Clinical Dietitian March 2014

2. Outline ★ Gastrointestinal Complications: ○ Diarrhea ○ Constipation ○ Delayed gastric emptying ○ Nausea and vomiting ○ Abdominal distention ★ Metabolic Complications ★ Administrative Complications ★ Case Study ★ Conclusion

3. Learning Objectives ★ Recognize various complications of enteral feeding and how to prevent and treat them. ★ Identify medications which often play a role in the diarrhea and constipation of enterally fed patients.

4. Gastrointestinal Complications ★ Incidence in tube fed patients: 2-63% of tube fed patients depends on definition ★ Common GI side effect in tube fed patient ★ Tube feeding formula usually blamed ★ Impact of diarrhea: ○ Fluid, electrolyte and acid-base disturbances ○ Inadequate nutrient intake which leads to malnutrition ○ Trace mineral deficiencies (Se, Zn) ○ Contamination of pressure ulcers and excoriation skin ○ Increases cost (Need rectal tube, cultures and linen changes) DIARRHEA

5. Gastrointestinal Complications ★ Universal definition does not exist: ○ > 3 stools per day for 2 consecutive days OR > 500 mL stool every 8hr Mobarhan et al. 1995; Williams et al. 1998 ○ > 200g stool per day OR ≥ 3 or more liquid stools per day Bliss et al. 1992 o Studies on diarrhea in tube fed patients use different definitions o Clinically useful definition: Abnormal volume or stool consistency for an individual DIARRHEA

6. Gastrointestinal Complications ★ What is patient’s normal stool consistency and frequency at home? ★ Measurement of stool volume ○ Using pad or bed pan under patient, weight of stool lg / mL stool ○ Rectal tube or fecal management device where stool can be quantified Boullata et al., eds. 2010 DIARRHEA

7. Gastrointestinal Complications ★ Osmotic Diarrhea ○ Caused by osmotically active substances in intestines ○ The osmotic force pulls fluid into the intestinal lumen ○ Examples: Lactulose, sorbitol, magnesium, phosphate, hyperosmolar enteral formula ★ Secretory Diarrhea ○ Imbalance between absorption and secretion of electrolytes with a net water secretion in bowel lumen ○ Examples: C. difficile infection, enteroviruses, laxatives such as senna, colchicine Btaiche et al. 2010 DIARRHEA

8. Gastrointestinal Complications ★ Common Causes: ○ Medication ■ Antibiotic therapy ■ Hyperosmolar medications ■ Sorbitol: containing medications ■ Other (ex.: colchicine) ○ Infection ■ C. difficile ■ CMV: cytomegalovirus in post transplant or immunosuppressed pts DIARRHEA

9. Gastrointestinal Complications ★ Common Causes: ○ Enteral formula contamination ○ Maldigestion or malabsorption ■ Steatorrhea ○ Bacterial overgrowth ○ Overflow diarrhea ○ Lactose intolerance ○ Severe hypoalbuminemia DIARRHEA

10. Gastrointestinal Complications ★ Common causes medication-induced: ○ Antibiotic therapy ■ Non-infectious ● Commonly cause diarrhea without causing CDAD (C. difficile associated diarrhea) ■ Infectious ● C. difficile associated diarrhea (Ex.: Clindamycin, Ampicillin) ○ Oral electrolyte supplements (Ex.: Magnesium) DIARRHEA

11. Gastrointestinal Complications ★ Common causes medication-induced: ○ Laxatives ■ Lactulose: Osmotic type diarrhea ■ Senna: Secretory type diarrhea ○ Prokinetics (Ex.: Maxeran, Erythromycin) ○ Hyperosmolar medications (Ex.: Liquid multivitamins, nystatin suspension, docusate syrup, kayexalate) ■ Can cause osmotic diarrhea, nausea, abdominal cramping if undiluted on administration via SB ● Ex.: Cimetidine solution (Tagamet), furosemide (Lasix), doxycycline (Vibramycin), hydroxyzine (Vistaril), isoniazid, nortriptyline DIARRHEA

12. Gastrointestinal Complications ★ Common causes medication-induced: ○ Sorbitol: Containing medications ■ Sorbitol: a sugar alcohol used as a sweetener in oral medications ■ May cause osmotic diarrhea and abdominal cramps or bloating ■ Inactive ingredient in liquid medications, amounts often not listed on label or package insert ○ Acid-suppressive medications (Ex.: Proton-pump inhibitor ) ○ Chemotherapeutic drugs ○ Other: colchicine Boullata J et al. 2010, Btaiche IF, et al. 2010, Malone A, et al. 2007 DIARRHEA

13. Gastrointestinal Complications ★ Common causes: ○ Infection ■ Need stool assay to rule out C. difficile associated diarrhea ■ Enteroviruses: Rotavirus, norwalk ■ CMV colitis in immunosuppressed ○ Contamination of enteral feeding solution ■ Needs to ensure gloves are clean when handling enteral spike sets/ tubing for open tube feeding formulas ■ All equipment to prepare enteral feeding must be clean ■ Open tube feeding formula needs to be refrigerated and formula discarded after 24hr. Label with date and time opened DIARRHEA

14. Gastrointestinal Complications ★ Common causes: ○ Contamination of enteral feeding solution ■ Only 4hr of feeding should be hung at one time for open feeding systems ■ Feeding bags and tubing should be washed after each intermittent feeding and discarded after 24hr ■ Closed feeding systems need to be labelled with date and time when bag spiked and discarded after 48hr DIARRHEA

15. Gastrointestinal Complications ★ Common causes: ○ Maldigestion / Malabsorption ■ Definition Maldigestion: Impaired breakdown at nutrients Malabsorption: Defective mucosal uptake and absorption from bowel ■ Diarrhea, weight loss, steatorrhea (fat malabsorption) DIARRHEA

16. Gastrointestinal Complications ★ Common causes: ○ Maldigestion / Malabsorption ■ Celiac disease ■ Short bowel syndrome ■ Resection of terminal ileum ■ Human immunodeficiency virus ■ Pancreatic insufficiency ■ Inflammatory bowel disease ■ Protein-losing gastroenteropathies ■ GVHD of gut DIARRHEA

17. Gastrointestinal Complications ★ Common causes: ○ Maldigestion / Malabsorption ■ Past medical history part of nutrition assessment When interviewing patient / family ask regarding usual bowel habits Medications which affect bowel movements. Lactulose, Imodium, herbal teas ■ Tests Look at stool - fat floating on top? Steatocrit to assess fecal fat content Check B12, folate, vitamin A level Malone et al. 2007 DIARRHEA

18. Gastrointestinal Complications ★ Common causes: ○ Bacterial overgrowth ■ Diagnosed by distal duodenal or jejunal aspirates, high serum folate (de novo synthesis) or hydrogen-methane breath tests ■ Chronic diarrhea with minimal steatorrhea ■ Associated with achlorhydria, bile acid deficiency, dysmotility (pseudo obstruction, diabetic neuropathy, narcotics) ○ Overflow diarrhea ■ Occurs in chronic-care immobilized patients ■ Liquid flowing around hard feces ■ Volume of stool not large usually DIARRHEA

19. Gastrointestinal Complications ★ Common causes: ○ Lactose intolerance ■ Majority of commercial tube feeding formulas are lactose free ■ Patient on food and tube feeding may be receiving lactose in diet ○ Severe hypoalbuminemia ■ Decreases oncotic gradient across bowel wall ■ May be due to malnutrition, stress, fluid overload ○ Edematous bowel ■ Patient with anasarca likely has edema of the bowel also ■ Diarrhea often improves with fluid removal such as continuous dialysis DIARRHEA

20. Gastrointestinal Complications ★ Treatment ○ Rule out C. difficile associated diarrhea ○ Medication review with pharmacist ■ Discontinue medications suspected of causing diarrhea if possible ■ Sorbitol-containing oral liquid medications should be discontinued and replaced with tablets ■ Mg or K-elixir given via tube should be given IV to see if it makes a difference ■ Review antibiotic use ■ Dilute drugs introduced into jejunum to avoid dumping-like syndrome Btaiche IF, et al. 2010 DIARRHEA

21. Gastrointestinal Complications ★ Treatment ○ Review medical / surgical history ■ Is patient with pancreatic insufficiency on a high fat formula (ex.: renal formula) without pancreatic enzymes? ■ Use a lower fat formula or a formula with 50%-70% of fat as MCT ■ Steatorrhea Use lower fat formula ■ Severe GVHD of gut: consider parenteral nutrition until diarrhea decreases, use trophic feeding at low rate if tolerated ■ Extensive SB resection Trial of elemental formula (low fat) or semi-elemental formula (protein in peptides, at least 50% fat in form of MCT) DIARRHEA

23. Gastrointestinal Complications ★ Treatment ○ Review medical / surgical history ■ Irritable bowel syndrome (IBS) High fructose corn syrup, fructooligosaccharides (FOS), galactooligosaccharides and inulin can cause diarrhea, pain and bloating in IBS patients Barrett, et al. 2009 DIARRHEA

24. Gastrointestinal Complications ★ Treatment ○ Enteral Formula ■ Trial of formula with fibre ■ In ICU patients: use soluble fibre but only when hemodynamically stable and fully resuscitated ■ Soluble fibre is fermented to SCFA ■ SCFA are absorbed in the colon pulling water and electrolytes with them McClave et al. 2009; Btaiche, et al. 2010 DIARRHEA

25. Gastrointestinal Complications ★ Treatment ○ If feeding with a hypertonic formula consider trial with an isotonic formula ○ Decrease rate temporarily ○ Avoid intermittent feeds DIARRHEA

26. Gastrointestinal Complications ★ Treatment ○ Fiber supplements may help ■ Pectin (Certo): for diarrhea every 4-8 hr ● Mix 30mL pectin with 100 mL warm water, syringe into feeding tube and flush well with 60mL water ■ Benefiber (Novartis) (Inulin) ● Rounded 1 tsp (312g) provides 3g fibre, mix 1-2 tsp benefiber with ½ cup (125mL) water ■ Clearly fibre (Inulin) ● 3.2g sachet provides 3g fibre DIARRHEA

27. Gastrointestinal Complications ★ Treatment ○ Antimotility agents (loperamide, lomotil) ■ Loperamide: lower risk of central nervous system adverse effects ■ Slows intestinal motility ■ Contraindicated in C. difficile diarrhea and may aggravate toxic megacolon ■ Use only when all other causes of diarrhea have been addressed ○ Cholestyramine ■ An insoluble ion exchange resin that binds bile acids in intestines ■ May be beneficial in diarrhea due to bile acid malabsorption, Ex.: cholestasis, short bowel syndrome, terminal ileum resection DIARRHEA

28. Gastrointestinal Complications ★ Treatment ○ Fluid and electrolyte replacement to replace GI losses ○ Chronic diarrhea can lead to micronutrient deficiencies especially selenium and zinc, may require supplements DIARRHEA

29. Gastrointestinal Complications ★ Clinical definition: accumulation of excess waste in colon ★ Can identify this with abdominal X-ray, able to rule out ileus or obstruction ★ Causes of constipation ○ Immobility ○ Neurological disorders ○ Dehydration ○ Inadequate fibre in enteral nutrition ○ Excessive fibre in enteral nutrition ○ Some medications (Ex.: sedatives, analgesics, opioids)  gut motility ○ Acute colonic pseudo obstruction (Ex.: Ogilvie’s syndrome) ○ GI motility disorders CONSTIPATION

30. Gastrointestinal Complications ★ Consequences ○ Delayed transit time ○ Vomiting ○ Abdo. distension ○ Risk of perforation ○ Bacterial overgrowth ○ Prolonged ventilator dependence in ICU patients ★ Electrolyte disturbances ○ Severe hypokalemia and hypomagnesemia may result in  bowel motility ○ Severe hypokalemia may result in paralytic ileus CONSTIPATION

31. Gastrointestinal Complications ★ Treatment and Prevention ○ Use a bowel regimen when you start enteral feedings ○ Calculate the fluid requirement for a patient that is on enteral feeding: ■ 30-40 mL/kg OR 1 mL/Kcal (minimum for adults) ○ Use fibre-containing enteral feeding with adequate fluid. Avoid formula with fibre if fluid restricted ○ Medication review: Medication-induced dysmotility? CONSTIPATION

32. Gastrointestinal Complications ★ Treatment and Prevention ○ Laxatives ■ Emollients (Ex.: Sodium docusate) Maintain soft fecal texture Onset of action: 1-3 days Not likely beneficial after stools harden ■ Osmotics (Ex.: Lactulose) Non absorbable sugar Onset of action: 1-3 days ■ Stimulants (Ex.: Senna, bisacodyl) Increase lower GI motility and anal sphincter tone Onset of action: 6-12 hr after oral dose CONSTIPATION

33. Gastrointestinal Complications ★ Causes of delayed gastric emptying ○ Hypotension ○ Hypokalemia ○ Sepsis ○ Medication(anesthesia, opioids, anti-cholinergics) ○ Diabetes mellitus (gastroparesis) ○ Rapid infusion of formula or cold formula ○ Formula infusion ○ High fat feeding formula ○ Hyperglycemia CAUSES OF DELAYED GASTRIC EMPTYING

34. Gastrointestinal Complications ★ Treatment ○ Duodenal or jejunal feeding ○ Prokinetic agents (Ex.: Maxeran, erythromycin) ○ Low fat feeding formula ○ Check residual volume every 4hr and assess tolerance ■ Follow feeding algorithm CAUSES OF DELAYED GASTRIC EMPTYING

35. Gastrointestinal Complications ★ Nausea may be caused by high enteral feeding rate or volume or medications ○ Treat with antiemetics ○ Decrease rate or volume ○ Review medications ★ Vomiting may be caused by GI obstructions, medications, delayed gastric emptying ○ Hold enteral nutrition if GI obstruction ○ Use antiemetics ○ Hold feeds x 1hr then reassess NAUSEA and VOMITING

36. Gastrointestinal Complications ★ Abdominal Distention ○ Causes ■ GI ileus ■ Obstruction ■ Obstipation ■ Ascites ■ Lactose intolerance ■ Rapid infusion of enteral formula ■ Infusion of cold formula ○ Rule out ileus or obstruction, do abdominal Xray ABDOMINAL DISTENTION

37. Metabolic Complications Problem Possible Causes Prevention / Treatment Overhydration ● Excessive fluid intake ● Heart Failure, renal failure ● Limit fluid intake ● Use calorie dense formula ● Use diuretic if appropriate ● Monitor intake and output (I/O) ● Weight patient Dehydration ● Excessive fluid loss: Vomiting, Diarrhea, Ileostomy output ● Inadequate fluid intake ● Hypertonic fluid intake ● Hypertonic feeding formula ● High protein feeding formula ● Hyperglycemia ● Monitor I/O ● Check skin turgor ● Monitor wt ● Monitor urea: Cr (normal 1:10) ● Increase enteral fluid flush ● Use less concentrated formula Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

38. Metabolic Complications Problem Possible Causes Prevention / Treatment Hyponatremia ● Dilution,  ADH levels ● Hepatic, renal or cardiac failure ● Excessive losses ● Monitor Na level ● Assess fluid status ● Limit fluid intake ● Na depletion, add Na ● Diuretic, if appropriate Hypernatremia ● Dehydration ● Increased Na intake ● Monitor I/O ● Provide adequate fluid ● Reassess IV fluid Hypokalemia ● Refeeding syndrome ● Excess losses ● Use of diuretics (Ex.: Lasix) ● Monitor serum K + ● Replete K + before starting enteral feedings ● Use a K + supplement Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

39. Metabolic Complications Problem Possible Causes Prevention / Treatment Hyperkalemia ● Excessive K + intake ● Renal Failure ● Use of spironolactone ● Metabolic acidosis ● Remove K + form IV ● Use kayexalate ● Use low K + TF formula ● Correct acidosis Hypophosphatemia ● Refeeding syndrome ● Binding by drugs (epinephrine, phosphate binders, insulin) ● Replete phosphorus before starting TF ● Monitor phosphorus ● Reassess drugs Hypomagnesemia ● Refeeding syndrome ● Increased losses (diarrhea) ● Drugs (Ex.: Cyclosporine) ● Monitor Mg ● Supplement Mg before starting feeding if possible Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

40. Metabolic Complications Problem Possible Causes Prevention / Treatment Hypoglycemia ● Sudden cessation of TF in a patient on insulin therapy without adjustment of insulin ● Severe liver failure ● Use an insulin protocol ● Use D10W IV until TF provides adequate carbohydrate Hyperglycemia ● Diabetes ● Steroid therapy ● Stress, sepsis ● Pancreatic insufficiency ● Insulin resistance ● Adequate insulin ● Low carbohydrate formula ● Correct serum glucose before feeding Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

41. Metabolic Complications Problem Possible Causes Prevention / Treatment Vitamin deficiencies  Vitamin A, D, E, K ● Fat malabsorption ● Pancreatic insufficiency ● Use water soluble supplement ● Use pancreatic enzymes Vitamin deficiencies  Vitamin D ● Lack of sunlight ● Inadequate vitamin D in enteral formula ● Vitamin D supplement Vitamin deficiencies  Zn, Se ● Excessive losses in diarrhea, ostomy, wound ● Supplement Zn,Se Boulatta et al, eds 2010, Malone et al. 2007, St-Laurent 2009

42. Refeeding Syndrome ★ Occurs when severely malnourished patients are refed ★ Acute intracellular shifts of electrolytes as cell anabolism is stimulated ★ Results in decreased circulating levels of K +, Mg, phos ★ Can cause hematologic, neuromuscular, cardiac and respiratory dysfunction ★ Prevention / Treatment: ○ Identify patients at risk ○ Correct electrolytes before starting EN ○ For the first day limit energy provided to 25% of requirements and progress gradually over 3-5 days to 100% of energy requirement ○ Supplement with thiamine 100mg/day X 3-5 days ○ Monitor for signs of fluid retention ○ Monitor electrolytes daily until at mantenenace and replete low levels

43. Administrative Complications ★ Tube feeding, gastric secretions, or oral secretion enter the lungs ★ A severe complication of enteral feeding ★ Risk factors ○ supine position ○ regurgitation ○ vomiting ○ delayed gastric emptying ○ decreased level of consciousness ○ patient pulling out nasoduodenal tube while feeding is running ○ poor oral hygiene ○ mechanical ventilation ○ neurological disease ASPIRATION

44. Administrative Complications ★ Progression from aspiration of tube feeding formula to pneumonia depends on the amount, acidity of formula, and the microbial content and the health of the patient ★ To decrease aspiration risk ○ HoB 30-45 o if not contraindicated ○ Small bowel feeding tubes ○ Motility agents ■ Ex.: Metoclopramide: ineffective in head-injured patients, Erythromycin ○ Oral Hygiene ■ Chlorhexidine mouthwash should be used twice daily to  VAP risk in mechanically ventilated patients ASPIRATION

45. Case Study 66 year old male, post liver transplant 2009 with recurrent HCV on liver bx admitted to hospital due to cholangitis due to stones and needs surgery to remove one of the stones. Transferred to ICU with respiratory failure, anasarca, hyponatremia, hyperkalemia, C. difficile diarrhea and AKI with anuria and  Cr. Intubated, ventilated, bronchoscopy performed. Found gastric fluid in lungs, vocal cords which didn’t close. Aspiration pneumonia diagnosed. Continuous veno-venous hemodialysis will be started. The patient had a PEG inserted 2 weeks before ICU admission due to inadequate food intake. (He had pulled out 3-4 nasoduodenal tubes) He was also eating some food. (200-300Kcal per day)

46. Case Study ➔ Abdomen: ◆ Non-tender ◆ CT scan of abdo: nothing acute ◆ Diarrhea but not copious amounts ➔ GU: ◆ High potassium treated with kayexalate ◆ On CVVHDF, urea, Cr, K, phos decreasing ◆ Still anasarca Case Study

47. Problems: ➔ Aspiration: ◆ Gastric contents seen on bronchoscopy ◆ Vocal cords not closing ➔ Diarrhea ◆ C. Difficile ➔ Electrolyte abnormalities ◆ Acute kidney injury (AKI) ◆ Likely not related to tube feeds ➔ Overhydration ◆ Treated with continous dialysis Case Study

48. Should you use PEG for feeding? Case Study

49. ➔ Decision at morning rounds to use PEG until PEG/J can be arranged through radiology ◆ Promotility drug initially (despite diarrhea) ◆ Check residuals every 4hr Case Study

50. On continuous dialysis with DNFL 100 If anasarca likely has gut edema and may have decreased absorption History of C. difficile diarrhea diagnosed and treated X 5 days Case Study Which formula?

51. ➔ Vivonex plus and protein powder ◆ Elemental: easier to absorb ◆ Low fat Case Study

52. ➔ Estimated calorie requirement: Ht = 170 cmTmax = 36.9 0 C Wt = 66.5 kgVe = 9:44 ➔ Mifflin St. Jeor: REE Kcal / day Male: 10 (wt) + 6.25 (ht) - S (age) + 5 Female: 10 (wt) + 6.25 (ht) - S (age) - 161 ➔ Mifflin St. Jeor: 10 (66.5) + 6.25 (170) - 5 (66) + 5 = 1402 ➔ Penn state(mifflin) = Mifflin (.96) + Tmax (167) + Ve (31) - 6212 = 1402 (.96) + 26.9 (167) + 9.44 (31) - 6212 = 1589 ➔ Estimated protein requirements on CVVHDF: 133 - 166 g (2-2.5 g/kg) Case Study

53. ➔ Vivonex plus: 1000 Kcal / mL 45 g protein / litre ➔ Beneprotein powder: 6 g protein / scoop ➔ No need to calculate Na, K, phosphorus because pt on CVVH (continuous dialysis) Case Study

54. ➔ Start Vivonex plus slowly at 20 mL/hr and advance by 15 mL/hr every 8hr to 50 mL/hr with 13 scoops protein powder daily Case Study 1200 mL Vivonex Plus BeneproteinTotal Kcal12003251525 Protein (g)54 g78 g (13 scoops)132 g

55. ➔ Good tolerance ➔ No residuals ➔ Pasty and loose stools approx 3 times per day ➔ Good glycemic control ➔ Electrolytes monitored Case Study

56. ➔ 1 week later, PEG/J inserted ➔ Extubated on HHM ➔ Continuous dialysis stopped ➔ U/O: 150-200 mL / 8 hr Case Study Which formula should I use?

57. Case Study ➔ Formula ◆ Renal formula: high in fat so did not want to use this in patient with diarrhea ◆ Vivonex plus: 1 Kcal / mL, not calorie dense. Need to limit fluid volume ◆ No hemodialysis at present time ◆ Used semi-elemental formula 1.5 Kcal / mL ◆ Able to keep protein in recommended range, potassium less than 60 mmol, phosphorus a little high at 1350 mg, fluid approximately 1200 mL ◆ Monitor: electrolytes, diarrhea Case Study

58. Can this patient eat? Case Study

59. ➔ ENT service says pt has voice so vocal cords not paralyzed ➔ Swallowing assessment by OT ➔ OT will do modified barium swallow Case Study

60. ➔ Patient stable and transferred to transplant ward. Case Study

61. Conclusion ➔ It is important to be aware of the various complications which can occur with enteral feeding. ➔ All members of the medical team should monitor the patient to try to prevent these problems from occurring and should be aware of how to treat them ➔ The gastrointestinal complications often lead to enteral feeding being held and if feedings are held too often this compromises the nutritional status of patients. ➔ Often takes trial and error to solve problems with diarrhea and constipation.

62. References Barrett JS, Sheperd SJ, Gibson PR. Strategies to manage gastrointestinal symptoms complicating enteral feeding. JPEN 2009; 33: 21-26. Bliss DZ et al. Defining and reporting diarrhea in tube-fed patients – what a mess! Am J Clin Nutr. 1992; 55: 753-759. Boullata J, Nieman Carney L, Guenter P, eds. A.S.P.E.N. Enteral Nutrition handbook. Silver Spring, MD: American Society for Parenteral and Enteral nutrition; 2010: 267-307. Btaiche IF, et al. Critical illness, gastrointestinal complications and medical therapy during enteral feeding in critically ill adult patients. Nutr Clin Pract 2010; 25: 32-49. Malone A, Serres DS, Lord L. Complications of enteral nutrition. In Gottschlich M, ed. in chief. The A.S.P.E.N. Nutrition Support Care Curriculum, Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2007: 246-263.

63. References McClave SA, Martindale RG, Vanek VW, et al; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine, Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically I ll Patient: Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) JPEN 2009; 33: 277-316. Mobarhan S, DeMeo M. Diarrhea induced by enteral feeding. Nutr. Rev. 1995; 53: 67-70. Williams MS, et al. Diarrhea management in enterally fed patients. Nutr Clin Pract. 1998; 13: 225-229. St-Laurent L. Nutrition entérale: guide practique pour le clinicien. Montréal: McGill University Health Centre, 2009: 12.1-12.6.