Do you guys use NG or NJ for patients with severe pancreatitis not tolerating oral intake. Seems from uptodate you can use either. What are your thoughts?
NG vs NJ for pancreatitis
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NJ because of possible duodenal compression that can due to the enlarged pancreatic head
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NJ can be cumbersome. start with NG and if patient tolerates, great. if not, choose NJ.
D
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ICU doc here - NG.
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This is actually a common board question....there is extensive evidence that there is no difference.....in theory you would think NJ, but what we have learned that a jejunal tube needs to be placed at least 100 cm past the ligament of treitz to minimize pancreatic secretions and since we seldom ever float one that deep it makes sense clinically there is no difference. There are alternative clinical circumstances that require individualizing approach such as If there is groove pancreatitis or GOO from edema/mass effect etc
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@1Cor1557
I disagree that there is extensive evidence.
The data for this is from incredibly small non-blinded studies so it would have been very hard to show a difference. The largest study showed a trend towards higher infectious complications in the NG group but didn’t reach significance (either because of sample size of 30ish patients or because there is no real difference). There was one study of NG vs TPN that showed some adverse effects of NG feeds. So...the dogma now that NG and NJ are equivalent may not be true. The issue is one of logistics. Can you get a NJ placed readily? If so, go for it but don’t delay feeds to get it done.
The recent AGA guideline says NG or NJ and that safety concerns may be present for NG feeding.
I work in a place that can get a NJ same day. It’s hard to justify taking any extra risk with these patients since I can decide to get them fed in the morning and have it start by midafternoon nearly always. If they already have a NG, I’m also fine with just using it. I hope this isn’t really a board question because there really isn’t data to support an evidence based conclusion.
I disagree that there is extensive evidence.
The data for this is from incredibly small non-blinded studies so it would have been very hard to show a difference. The largest study showed a trend towards higher infectious complications in the NG group but didn’t reach significance (either because of sample size of 30ish patients or because there is no real difference). There was one study of NG vs TPN that showed some adverse effects of NG feeds. So...the dogma now that NG and NJ are equivalent may not be true. The issue is one of logistics. Can you get a NJ placed readily? If so, go for it but don’t delay feeds to get it done.
The recent AGA guideline says NG or NJ and that safety concerns may be present for NG feeding.
I work in a place that can get a NJ same day. It’s hard to justify taking any extra risk with these patients since I can decide to get them fed in the morning and have it start by midafternoon nearly always. If they already have a NG, I’m also fine with just using it. I hope this isn’t really a board question because there really isn’t data to support an evidence based conclusion.
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They are small but randomized and high quality and have been replicated several times, I think thats why the AGA has remained indiscriminate towards it, ACG SAT 2019 gave a preferential, or more accurately, non inferiority NGT answer from whoever the author of the hypothetical scenario is that year.....do you place NJT endoscopically, or protocol for nurses to float in bedside?
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I’m not sure why we’ve decided it’s high quality evidence with very small samples that aren’t powered to show a difference, limited randomization and non-blinded. Definitely is the dogma. We will see if we look silly in 10 years. The data hasn’t changed and in 2018, AGA said low quality evidence and a conditional recommendation.
IR places them for us when we ask. The endoscopic NJFT is too thin to be practical.
IR places them for us when we ask. The endoscopic NJFT is too thin to be practical.
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That is impressive rads support/response, we get into turf wars with them regretfully about this stuff.... you are definitely right about tribal customs, for all the heck I give the cardiologists we've turned into them when it comes to EBM justifying our favorite soup du jour
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our IR refuses to do NJ tube, they say its our responsibility. point being, there is clearly institutional variability
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Boards answer: Do either, equivalent, or rather non-inferior. TPN pretty much always wrong choice if offered.
Ivory Tower: NJ - most centers/ experts do it, including the Dutch. Stated benefits include concerns about GOO, patient tolerance etc, and studies are small and high bias risk. The only definitive trial was the Dutch group, early PO vs NJ in mild disease, which should PO was just fine.
Real-world: NJ if you can get it, NG if you can't, if patient doesn't tolerate NG then try NJ.
Ivory Tower: NJ - most centers/ experts do it, including the Dutch. Stated benefits include concerns about GOO, patient tolerance etc, and studies are small and high bias risk. The only definitive trial was the Dutch group, early PO vs NJ in mild disease, which should PO was just fine.
Real-world: NJ if you can get it, NG if you can't, if patient doesn't tolerate NG then try NJ.
