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Enteral feeding has become an invaluable treatment in both the hospital and home setting. However, it is not without complications, the commonest of which is diarrhoea. This occurs in up to 25% of patients on general wards1-3 and 63% of patients on intensive care units.4 5 Diarrhoea not only limits the efficacy of enteral feeding, but also adds to potential complications, distresses both patients and staff, and increases costs.6Until recently, its pathogenesis has remained unknown, although a number of factors have been implicated, including infected diets,7 lactose intolerance,8 concomitant antibiotic therapy,9 10 osmotically active medications,11 12 and co-existing hypoalbuminaemia.13 14 However, despite attention to these factors, diarrhoea still occurs in up to 15% of patients.15 This would imply, therefore, that some other mechanism or mechanisms are involved.
Studies
In an attempt to unravel the pathophysiological mechanisms underlying enteral feeding related diarrhoea, a series of in vivo experiments in humans was undertaken examining the response of the small and large intestine to enteral feeding.16-20 In these studies two different strengths of a polymeric diet were infused either intragastrically or intraduodenally: a low load diet infused at 1.4 ml/min (1.4 kcal/min; 8.75 mgN/min) and a high load diet infused at 2.8 ml/min (4.2 kcal/min; 26.1 mgN/min). The low load diet corresponded clinically to the administration of 2 litres (2000 kcal) over 24 hours (equivalent to 2 litres/day), which is what most patients will receive on the wards. Catabolic patients or those being fed cyclically over 12–14 hours per day, a common situation especially in the home setting, require higher dietary loads—the high load diet in our studies corresponded to this type of feeding.
In the small intestinal studies intraduodenal feeding of the low load diet caused a normal …