Eduovisual
Gastrointestinal
Nutritional support: enteral vs parenteral indications
— Nutritional support = provision of macronutrients, micronutrients, fluid, and electrolytes via enteral nutrition (EN) or parenteral nutrition (PN) when oral intake is inadequate, unsafe, or impossible
— Goal: prevent or reverse protein-calorie malnutrition, preserve lean body mass, support wound healing, modulate immune function, and reduce hospital morbidity
— Patients unable to meet ≥60% of estimated energy needs orally for >7–10 days
— Pre-existing malnutrition (weight loss >10% over 6 months, BMI <18.5, low prealbumin in context)
— Hypercatabolic states: sepsis, burns >20% BSA, major trauma, post-op major GI surgery
— Neurologic dysphagia (stroke, ALS, advanced dementia with reversible cause)
— Mechanical obstruction or dysfunction: head & neck cancer, esophageal stricture, gastroparesis, short bowel
— "If the gut works, use it." EN is preferred whenever the GI tract is functional and accessible
— PN reserved for true gut failure or when EN cannot meet >60% of needs within 7–10 days
— Well-nourished ICU patient: start EN within 24–48 h of admission; PN can wait 7 days
— Severely malnourished ICU patient unable to take EN: start PN earlier (within 3–7 days)
— Outpatient/chronic: home EN or home PN coordinated through nutrition support team
— NRS-2002, MUST, and Subjective Global Assessment (SGA) are validated; albumin/prealbumin reflect inflammation more than nutrition acutely
Board pearl: On Step 3, the stem describing a hemodynamically stable post-op ileus patient at day 5 with no PO intake should trigger EN via post-pyloric tube, not PN — gut function distal to the obstruction is the deciding factor, and starting PN prematurely is a classic wrong answer.
— Critically ill, intubated patient: NPO, on vasopressors weaning down → time to initiate EN
— Stroke with dysphagia: failed bedside swallow + SLP evaluation → NG tube initially, PEG if expected >4 weeks
— Head & neck cancer pre-radiation: prophylactic PEG before mucositis sets in
— Crohn disease with high-output enterocutaneous fistula: bowel rest + PN
— Short bowel syndrome (<200 cm remaining small bowel): often lifelong PN ± teduglutide
— Severe acute pancreatitis: early EN (within 72 h) via NJ tube; PN only if EN intolerant
— Hyperemesis gravidarum refractory to antiemetics + IV fluids: EN preferred, PN if EN fails
— Anorexia nervosa with BMI <14: cautious refeeding, often nasogastric EN
— Weight trajectory: usual weight, current weight, % loss, timeframe (>10% in 6 mo = severe)
— PO intake history: duration of inadequate intake, food aversions, early satiety, dysphagia, odynophagia
— GI symptom review: nausea/vomiting, distension, obstipation, diarrhea, stool output volume, ostomy output
— Surgical history: prior bowel resections (especially length and site — duodenum, ileum, colon), bariatric surgery, gastrostomy
— Functional status: ECOG, ability to feed self, caregiver availability (critical for home EN/PN feasibility)
— Medications: chronic steroids, chemotherapy, GLP-1 agonists (gastroparesis), opioids (ileus)
— Unintentional weight loss >5% in 1 month
— Visible muscle wasting (temporalis, interosseous)
— Pressure injury non-healing
— Pre-op albumin <3.0 g/dL before major elective surgery → consider 7–14 days pre-op nutrition
Step 3 management: When the vignette mentions an outpatient with progressive dysphagia from ALS losing >10% body weight, the next step is referral for PEG placement before FVC drops below 50% — delaying past that threshold increases procedural mortality.
— Cachexia, sarcopenia, loose-fitting clothing/dentures
— BMI categorization: <18.5 underweight; <16 severe; but BMI can be normal in sarcopenic obesity
— Temporal wasting (hollowing above zygoma) — sensitive sign of chronic malnutrition
— Angular cheilitis, glossitis (B vitamin/iron deficiency)
— Bitot spots, xerophthalmia (vitamin A)
— Bleeding gums (vitamin C); pale conjunctiva (iron, B12, folate)
— Flaky paint dermatosis (kwashiorkor)
— Follicular hyperkeratosis (vit A), perifollicular hemorrhage (vit C)
— Koilonychia (iron); brittle hair, easy pluckability
— Pressure injuries, poor wound healing
— Interosseous wasting (dorsum of hand), quadriceps and deltoid atrophy
— Hand-grip dynamometry: objective functional measure
— Distension, succussion splash (gastroparesis/obstruction — contraindication to gastric EN)
— Bowel sounds (not required to start EN — outdated dogma)
— Surgical scars, ostomies, fistula sites with output quantification
— Hepatomegaly (refeeding steatosis, PN-associated liver disease)
— Edema can mask weight loss; dependent edema in hypoalbuminemic states
— Orthostatic vitals — dehydration common in poor PO intake
— Inspect for central line sites (PN requires central access for osmolarity >900 mOsm/L)
— Nasal patency, gag reflex, dentition (impacts EN tube choice)
Key distinction: Marasmus (chronic energy deficit) = severe wasting, preserved albumin, no edema. Kwashiorkor (acute protein deficit + inflammation) = edema, hypoalbuminemia, fatty liver, relatively preserved fat stores. Modern terminology favors "malnutrition with/without inflammation" (GLIM criteria).
— CBC, CMP (Na, K, Cl, HCO3, BUN, Cr, glucose, Ca, total protein, albumin, LFTs)
— Phosphorus, magnesium, ionized calcium — critical baseline for refeeding risk
— Triglycerides (baseline; required before lipid emulsion in PN)
— Prealbumin (transthyretin): t½ ~2 days; useful for trending response but falsely low in inflammation (CRP up = prealbumin down regardless of nutrition)
— CRP to contextualize prealbumin
— TSH, HbA1c (glucose management on EN/PN)
— 25-OH vitamin D, B12, folate, iron studies, zinc — if clinical suspicion
— Weight-based: 25–30 kcal/kg/day for most adults; 20–25 in critical illness (permissive underfeeding in acute phase)
— Protein: 1.2–2.0 g/kg/day in critical illness; 1.0 g/kg/day in stable hospitalized; up to 2.5 g/kg in burns/CRRT
— Indirect calorimetry: gold standard in complex ICU patients (measures VO2/VCO2 → REE)
— Mifflin-St Jeor or Harris-Benedict equations as alternatives
— High risk if any: BMI <16, weight loss >15% in 3–6 mo, little/no intake >10 days, low pre-feed K/Mg/phos
— Or any two of: BMI <18.5, weight loss >10%, little/no intake >5 days, alcohol/insulin/chemo/diuretic history
— KUB/CT abdomen to exclude obstruction before gastric feeding
— Swallow study (modified barium swallow/FEES) for dysphagia
— Chest X-ray after NGT/NJT placement to confirm position before feeding — never skip this
CCS pearl: After ordering nasoenteric tube placement on CCS, the very next order should be "chest X-ray to confirm tube placement" — feeding through a misplaced tracheal tube is a never event and a classic CCS scoring trap.
— <4–6 weeks: nasogastric (NG), nasoduodenal (ND), or nasojejunal (NJ) tubes
— >4–6 weeks: surgical/endoscopic/radiologic gastrostomy (PEG, PRG) or jejunostomy (PEJ, surgical J-tube)
— Post-pyloric (NJ/J-tube) preferred when: high aspiration risk, gastroparesis, severe pancreatitis, recurrent gastric residuals, gastric outlet obstruction
— Peripheral PN (PPN): osmolarity ≤900 mOsm/L, short-term (<7–10 days), limited calories (~1500 kcal/day max)
— Central PN (TPN): via PICC, tunneled catheter (Hickman/Broviac), or implanted port; required for full nutritional support
— Tip should sit at cavoatrial junction; confirm with CXR
— Coags (INR, platelets) before PEG/PICC placement
— Endoscopy with transillumination for PEG
— Vascular ultrasound mapping for PICC if difficult access
— Gastric emptying scintigraphy if gastroparesis suspected as cause of EN intolerance
— D-xylose absorption test or fecal fat (rare on boards) for malabsorption assessment
— Citrulline level as surrogate for small bowel mass in short bowel syndrome
— Bone densitometry baseline in long-term PN (metabolic bone disease)
— Multidisciplinary: physician, RD, pharmacist, nurse — reduces complications, especially in PN
Board pearl: The vignette of a severe acute pancreatitis patient with persistent nausea on gastric EN should prompt the answer "advance the tube past the ligament of Treitz (NJ tube)" — not switching to PN. Post-pyloric EN bypasses the inflamed pancreas stimulation pattern and preserves gut barrier function.
— Yes → oral diet ± oral nutritional supplements (ONS) (e.g., Ensure, Boost); add between meals, not with meals
— No → proceed to step 2
— Functional gut = ability to absorb nutrients across ≥100 cm small bowel, no high-grade obstruction, no uncontrolled peritonitis, no severe shock requiring escalating pressors
— Yes → enteral nutrition
— No → parenteral nutrition
— <4 weeks of EN → nasoenteric tube
— ≥4 weeks of EN → gastrostomy/jejunostomy
— <2 weeks of PN with limited needs → PPN acceptable
— ≥2 weeks or full nutrition → central PN
— Short bowel syndrome (acute phase, before adaptation)
— Mechanical bowel obstruction not amenable to bypass tube
— Severe malabsorption/intestinal failure
— High-output proximal enterocutaneous fistula (>500 mL/day) without distal access
— Prolonged ileus >7 days with malnutrition
— Severe GI bleeding precluding EN
— Mesenteric ischemia (acute)
— Bone marrow transplant with severe mucositis (selected cases)
— Hemodynamic instability on escalating vasopressors (risk of non-occlusive mesenteric ischemia)
— Severe ileus, abdominal compartment syndrome
— Supplemental PN when EN provides <60% of needs after 7–10 days
— Wean PN as EN advances
Step 3 management: A post-op patient on stable low-dose norepinephrine (≤0.1 mcg/kg/min) with lactate trending down can — and should — be started on trophic EN (10–20 mL/h). Withholding EN simply because pressors are running is a wrong answer on modern boards.
— Standard polymeric (1.0–1.2 kcal/mL): intact protein, suitable for most patients with normal GI function (e.g., Jevity, Osmolite)
— Calorie-dense (1.5–2.0 kcal/mL): fluid-restricted (heart failure, CKD on dialysis)
— High-protein: wound healing, critical illness, pressure injuries
— Semi-elemental/elemental: malabsorption, short bowel, pancreatic insufficiency, severe IBD (peptides or free amino acids; e.g., Vivonex, Peptamen)
— Disease-specific: diabetic (lower carb, higher fat — limited evidence), pulmonary (lower carb — discredited), hepatic (BCAA-enriched in refractory encephalopathy only), renal (low K/phos/Mg for non-dialysis CKD)
— Fiber-containing for chronic constipation/diarrhea modulation
— Start continuous infusion at 10–20 mL/h in critically ill or high-aspiration-risk patients; advance by 10–20 mL/h every 4–8 h to goal
— Bolus feeds (250–400 mL over 15–30 min, 4–6×/day) appropriate for stable patients with gastric access — more physiologic, allows mobility
— Head of bed ≥30–45° during and 1 h after feeding to reduce aspiration
— Daily weights, strict I/O
— Electrolytes (especially K, Mg, Phos) daily × 3–5 days, then 2–3×/week
— Glucose checks q6h initially
— Gastric residual volumes (GRV): no longer routinely required; hold only if GRV >500 mL with intolerance signs (vomiting, distension)
— Bowel function, stool frequency/consistency
— Diarrhea → check meds (sorbitol in elixirs!), C. diff, formula osmolarity, infusion rate; rarely the formula itself
— Constipation → add fiber, hydration
— Tube clogging → flush 30 mL water q4h and pre/post meds; warm water + pancreatic enzymes for clog
Board pearl: Sorbitol-containing liquid medications (acetaminophen elixir, many cough syrups) are the most commonly missed cause of "tube-feed diarrhea." Switching to crushed tablets or sorbitol-free formulations resolves it without stopping EN.
— Dextrose: 50–60% of non-protein calories; provides 3.4 kcal/g; max oxidation ~4–5 mg/kg/min
— Amino acids: 1.0–2.0 g/kg/day; 4 kcal/g
— Lipid emulsion (ILE): 20–30% of total calories; 9 kcal/g (10 kcal/g for 20% emulsion including glycerol)
— Newer formulations (SMOFlipid: soybean, MCT, olive, fish oil) reduce PN-associated liver disease vs pure soybean (Intralipid)
— Minimum 100 g/week of lipid to prevent essential fatty acid deficiency
— Na 60–150 mEq, K 40–80 mEq, Cl/acetate balanced, Ca 10–15 mEq, Mg 8–20 mEq, Phos 20–40 mmol
— Standard MVI and trace elements (Zn, Cu, Cr, Mn, Se) daily
— Vitamin K added separately if not in MVI; thiamine 100 mg added before/with PN start
— Day 1: provide ~50% of goal calories, especially dextrose-restricted to ~150–200 g (1.5–2 mg/kg/min) in refeeding-risk patients
— Advance over 2–3 days
— Cyclic PN (12–16 h overnight) for home patients — preserves liver function, allows daytime mobility
— Glucose q4–6h initially; target 140–180 mg/dL; add insulin to bag for stable needs
— Triglycerides at baseline, 1 week, then monthly; hold lipids if TG >400 mg/dL
— LFTs weekly; PN-associated cholestasis common after 2–4 weeks
— Electrolytes daily until stable
— Weekly: prealbumin, CRP, weight, 24-h urea nitrogen for nitrogen balance
— Do not infuse incompatible meds through PN line; dedicated lumen ideal
— Calcium-phosphate precipitation risk — pharmacy must verify
CCS pearl: On Day 1 of TPN, order fingerstick glucose q6h, BMP with Mg/Phos, and triglycerides. Forgetting Mg/Phos monitoring in a refeeding-risk patient is a high-yield Step 3 CCS deduction.
— Higher baseline sarcopenia → protein target 1.2–1.5 g/kg/day even when stable
— Higher aspiration risk → post-pyloric access often preferred; HOB elevation strict
— PEG in advanced dementia does NOT improve survival, prevent aspiration, or heal pressure ulcers — goals-of-care discussion mandatory; hand-feeding is preferred
— Polypharmacy: review for drug-nutrient interactions (warfarin + vitamin K in EN formulas)
— Non-dialysis CKD stage 4–5: protein 0.6–0.8 g/kg/day (renal formulas: Nepro, Suplena)
— On hemodialysis: 1.2 g/kg/day; on CRRT: up to 2.0–2.5 g/kg/day (significant amino acid losses across filter)
— Restrict K, Phos, Mg in PN/EN if hyperkalemia/hyperphosphatemia
— Volume-restricted formulas (2.0 kcal/mL) for HD patients
— Monitor for refeeding particularly post-HD initiation
— Do not protein-restrict routinely — worsens sarcopenia and outcomes
— Standard protein 1.2–1.5 g/kg/day; late-evening snack to reduce overnight catabolism
— BCAA-enriched formulas only for refractory hepatic encephalopathy not controlled by lactulose/rifaximin
— Watch for hypoglycemia (impaired gluconeogenesis), volume overload
— Reduce copper and manganese in PN with cholestasis (deposit in basal ganglia)
— Sodium and fluid restriction; calorie-dense formulas
— Cardiac cachexia confers poor prognosis — aggressive nutritional intervention warranted
— Hypocaloric, high-protein feeding: 11–14 kcal/kg actual body weight or 22–25 kcal/kg ideal body weight; protein 2.0–2.5 g/kg IBW
Key distinction: Routine protein restriction in cirrhosis is outdated and wrong on Step 3. The correct answer is normal-to-high protein intake with lactulose/rifaximin for encephalopathy control.
— Hyperemesis gravidarum refractory to IV fluids, antiemetics (ondansetron, doxylamine/B6, metoclopramide), and thiamine repletion → next step is NG/NJ enteral feeding, not PN
— PN reserved for failed EN, with strict glycemic control (target similar to gestational diabetes)
— Additional ~340 kcal/day in 2nd trimester, ~450 kcal/day in 3rd
— Folate 400–800 mcg/day continued; iron, calcium, DHA in PN
— Always give thiamine before dextrose in pregnancy to prevent Wernicke (multiple case reports in hyperemesis)
— Energy needs vary by age: infants 90–120 kcal/kg/day, decreasing with age
— Protein: 2–3 g/kg/day infants, 1.5–2 g/kg/day older children
— NEC prevention: trophic enteral feeds + human milk in preterm infants
— PN-associated cholestasis common in neonates — use SMOF or Omegaven (fish oil) when bilirubin rises
— Glucose infusion rate (GIR) more relevant than g/kg in neonates
— Routine PN in chemotherapy patients not recommended — increases infection without survival benefit
— Indications: severe mucositis, prolonged ileus, GVHD with gut involvement, bowel obstruction
— Cancer cachexia: multimodal approach (nutrition + exercise + anti-inflammatory) — single-agent nutrition rarely reverses it
— Avoid PN in actively dying patients — palliative oral comfort feeding preferred
— ART is the most effective "nutritional" intervention; appetite stimulants (megestrol, dronabinol) adjunctive
— Lifelong micronutrient supplementation (B12, iron, Ca, vit D, thiamine); annual labs
— Acute thiamine deficiency post-RYGB with persistent vomiting is a Step 3 favorite
Board pearl: For a 24-week pregnant patient with hyperemesis losing 8% body weight despite optimal antiemetics, the next step is NG tube enteral feeding, not TPN — EN is safer, cheaper, and preserves gut integrity for both mother and fetus.
— Pathophysiology: carbohydrate load → insulin surge → intracellular shift of phosphate, potassium, magnesium, plus thiamine consumption
— Manifests within 72 h: hypophosphatemia (rhabdo, respiratory failure, arrhythmia), hypokalemia, hypomagnesemia, Wernicke encephalopathy, CHF, hemolysis
— Prevention: identify high-risk patients; start at 10 kcal/kg/day (5 in extreme cases); replete electrolytes BEFORE and DURING; thiamine 100–300 mg IV daily × 5–7 days before any feed; advance over 4–7 days
— Aspiration pneumonia — HOB elevation, post-pyloric placement, prokinetics if needed
— Tube dislodgement, occlusion, nasal pressure injury
— Diarrhea (most common; usually not the formula)
— PEG site: peristomal infection, buried bumper syndrome, leakage, gastrocolic fistula
— Tube misplacement into airway — confirm with CXR before first feed
— Central line-associated bloodstream infection (CLABSI) — leading cause of PN morbidity; chlorhexidine bundle, ethanol/taurolidine locks for home PN
— Catheter occlusion, thrombosis (SVC thrombus, PE)
— Hyperglycemia — insulin in bag; goal 140–180
— Hypertriglyceridemia, pancreatitis if TG >1000
— PN-associated liver disease (PNALD/IFALD): steatosis, cholestasis, fibrosis; risk factors are continuous (not cyclic) infusion, soybean-only lipids, overfeeding, sepsis, lack of EN
— Metabolic bone disease: osteoporosis, fractures with long-term PN
— Trace element abnormalities: manganese toxicity (basal ganglia), copper deficiency (cytopenias, myelopathy after gastric bypass), selenium deficiency (cardiomyopathy)
— Acalculous cholecystitis from gut disuse → biliary sludge
Step 3 management: Patient on TPN × 3 weeks develops fever and rigors during infusion — draw paired peripheral and central line blood cultures, remove or exchange the line if cultures positive, and start empiric vancomycin + antipseudomonal coverage. Don't just "stop the TPN."
— Severe refeeding syndrome with cardiac arrhythmia or respiratory failure
— Septic shock from CLABSI requiring vasopressors
— Massive aspiration event with hypoxemic respiratory failure
— Hyperosmolar hyperglycemic state from PN with glucose >600 and altered mental status
— Severe electrolyte derangements (K <2.5, Phos <1.0, Mg <1.0 symptomatic)
— Registered Dietitian/Nutrition Support Team: should be involved in every patient receiving EN >7 days or any PN
— GI/Interventional Endoscopy: PEG/PEJ placement, dislodged tubes, refractory clog
— Interventional Radiology: PRG when endoscopy contraindicated (e.g., esophageal obstruction)
— Surgery: open or laparoscopic jejunostomy when endoscopic access not feasible; short-bowel evaluation
— Infectious Disease: complex CLABSI, fungemia, persistent bacteremia
— Endocrinology: refractory hyperglycemia on PN
— Palliative care: goals-of-care for advanced dementia, end-stage cancer, persistent vegetative state
— Hospital to home EN: confirm caregiver training, durable medical equipment (pump, formula delivery), insurance authorization (Medicare Part B covers if expected >90 days), follow-up RD visit within 1–2 weeks
— Hospital to home PN: requires tunneled catheter or port, home infusion company, weekly labs initially, 24/7 on-call support; nutrition support team follows monthly
— Always reconcile EN/PN orders at every level-of-care change — formula errors at handoff cause harm
— Pre-discharge: ensure 48 h of stable feeds at goal before discharge
CCS pearl: When advancing the clock on a CCS case with EN running, intermittently order "reposition patient HOB ≥30°," "check residuals/symptoms," and "BMP with Mg/Phos" — these process orders earn points and prevent silent complications.
— Esophageal: stricture (peptic, caustic, radiation), Schatzki ring, achalasia, cancer (squamous, adenocarcinoma) → endoscopy ± dilation; bypass with NJ tube or PEG distal to obstruction
— Gastric outlet: pyloric stenosis, malignancy, peptic stricture → post-pyloric feeding or PN
— Small bowel: adhesions (most common), hernia, Crohn stricture, malignancy, intussusception → surgical evaluation; PN if prolonged
— Large bowel: colon cancer, volvulus, stricture → less commonly affects nutrition acutely
— Gastroparesis: diabetic, post-surgical, idiopathic, medication-induced (GLP-1 agonists, opioids, anticholinergics) → post-pyloric EN, prokinetics (metoclopramide, erythromycin)
— Chronic intestinal pseudo-obstruction: scleroderma, amyloid, paraneoplastic → often requires PN
— Postoperative ileus: usually self-limited; if >7 days, supplement nutritionally
— Short bowel syndrome: <200 cm remaining; depends on ileocecal valve preservation and colon-in-continuity → PN initially, EN advancement, teduglutide
— Pancreatic insufficiency: chronic pancreatitis, cystic fibrosis, post-Whipple → enzyme replacement; elemental formulas if needed
— Bile acid deficiency: ileal resection >100 cm → fat malabsorption, fat-soluble vitamin deficiencies
— Celiac, Whipple, tropical sprue, SIBO
— Crohn flare with fistula → bowel rest + PN often needed
— Severe ulcerative colitis → EN preferred unless toxic megacolon
— Radiation enteritis, chemotherapy mucositis
Key distinction: Gastroparesis vs mechanical gastric outlet obstruction: both cause vomiting and early satiety, but gastric emptying scintigraphy diagnoses gastroparesis while EGD/CT identifies mechanical lesion. Management diverges: prokinetics + post-pyloric EN vs surgical/endoscopic intervention.
— Stroke (cortical or brainstem): bedside swallow screen + SLP evaluation; NG initially, PEG if dysphagia persists >2–4 weeks
— ALS, Parkinson, MS, myasthenia gravis: progressive — anticipate decline and place PEG before respiratory decline (ALS: before FVC <50%)
— Dementia: late-stage Alzheimer or other → comfort feeding preferred over PEG (no mortality benefit, may increase agitation/restraints)
— Anorexia nervosa: severe — admit if BMI <14, bradycardia <40, hypotension, electrolyte derangement, or rapid weight loss; refeed cautiously starting at 1200–1500 kcal/day, advance slowly; NG feeds if refusing PO; PN almost never indicated
— Severe depression with food refusal: treat underlying depression; may need temporary NG feeds
— Burns (Curreri formula), polytrauma, sepsis, hyperthyroidism — increased caloric demand, not decreased intake
— Chemotherapy mucositis, radiation, opioid-induced constipation/ileus, GLP-1 agonist–induced satiety, SSRIs, stimulants
— Repeated NPO orders for procedures — the "NPO creep" hospital phenomenon; address with proactive scheduling
— Food insecurity, poverty, isolation — major in geriatrics
— Substance use disorder (alcohol use disorder → thiamine, folate, B12 deficiencies)
— Domestic violence, elder neglect — mandatory reporting if suspected
— Uncontrolled diabetes (osmotic diuresis, weight loss), adrenal insufficiency (anorexia, weight loss), hypercalcemia
Board pearl: Elderly patient with weight loss, no GI symptoms, and a normal exam — screen for depression and food insecurity before launching expensive workup. Cancer is on the differential but treatable social/psychiatric causes are more common and missed.
— As oral intake improves, transition from continuous to nocturnal-only feeds, then to oral supplements alone
— Discontinue EN when patient consistently meets ≥60–75% of needs orally for several days and weight is stable
— Remove PEG after at least 4–6 weeks of mature tract and confirmed unnecessary; deflate balloon or endoscopic removal
— Advance EN/PO gradually; reduce PN proportionally
— In short bowel syndrome: intestinal adaptation occurs over 1–2 years; some achieve PN independence
— Adjuncts: teduglutide (GLP-2 analog) reduces PN dependence in short bowel
— Cycle PN (12–16 h overnight) to preserve liver and improve quality of life before full discontinuation
— Coordinate with home infusion pharmacy, DME provider
— Caregiver training: line care, pump operation, sterile technique, troubleshooting alarms
— Insurance: Medicare requires documented need >90 days and failed less-invasive options
— Weekly labs initially → monthly when stable; quarterly trace elements and vitamins on home PN
— Address underlying cause: optimize diabetes control for gastroparesis, treat IBD aggressively, swallow rehab post-stroke
— Continue oral nutritional supplements between meals after discharge in malnourished patients — reduces readmission
— Vitamin D, B12 supplementation common after bariatric surgery, ileal resection
— Bone density screening every 1–2 years on home PN
— Home PN patients have meaningful QoL despite line burden; psychosocial support essential
Step 3 management: A post-discharge patient on home EN should have an RD follow-up within 2 weeks, weight check in primary care at 1 week, and explicit caregiver instructions on tube site care — fragmented discharge causes 30-day readmission for tube complications.
— Home EN: weight weekly, BMP monthly, prealbumin/CRP every 1–3 months, RD visit every 1–3 months
— Home PN: weight 2–3×/week, BMP weekly initially then biweekly, LFTs and triglycerides monthly, CBC monthly, trace elements (Zn, Cu, Se, Mn) every 3–6 months, vitamins (A, D, E, B12, folate) every 6–12 months, DXA scan annually–biennially
— Glucose monitoring: home glucometer for diabetic patients on EN/PN
— Weight stable or gaining 0.5–1 kg/week if rebuilding
— Prealbumin rising (when CRP normalizing) — suggests anabolic state
— Wound healing progress for those started for that indication
— Functional measures: handgrip strength, 6-minute walk
— Physical therapy to combat sarcopenia; resistance training augments protein synthesis
— Swallow rehabilitation with SLP for dysphagia (Mendelsohn maneuver, effortful swallow, etc.); repeat instrumental swallow studies before liberalizing diet
— Occupational therapy for adaptive feeding equipment in stroke, Parkinson, arthritis
— Sorbitol-free medications when on EN
— Avoid grapefruit juice through tubes (some interactions), don't mix meds with formula directly
— Signs of CLABSI: fevers, chills, redness at exit site — call immediately
— Sick day rules: when to hold PN (sepsis, hyperglycemia >300, fever workup)
— Travel planning for home PN — coordinate with infusion company
— Routine vaccines including annual influenza, pneumococcal, COVID — chronic malnutrition impairs immunity
CCS pearl: Always order "social work consult" when initiating home EN or PN — insurance navigation, caregiver assessment, and home safety evaluation are essential and earn CCS points for comprehensive care.
— PEG placement and central line insertion are procedures requiring written informed consent including risks (bleeding, infection, perforation, dislodgement, death) and alternatives (NG tube, comfort feeding, no nutrition)
— In advanced dementia, document the discussion that PEG does not prolong life or prevent aspiration, and explore the patient's prior wishes and surrogate decision-maker preferences
— Artificial nutrition and hydration are medical treatments legally and ethically — they can be refused or withdrawn like any other treatment
— Withdrawal of EN/PN in end-of-life care is ethically equivalent to withholding; provide mouth care and comfort measures
— Patient autonomy: a competent patient may refuse a feeding tube even if death will result
— Advance directives and POLST forms should specifically address tube feeding
— Use substituted judgment when patient lacks capacity and has expressed prior preferences
— Best interest standard when no prior preferences known
— Ethics committee consultation for irresolvable conflict
— Severe malnutrition in an elderly or dependent adult living with caregivers → consider elder neglect and report to Adult Protective Services
— Pediatric failure to thrive with concern for neglect → Child Protective Services
— Misplaced feeding tube into airway with feeding initiated — confirm position with CXR (gold standard) before first feeding; auscultation alone is insufficient
— Wrong-route administration: enteral formula given IV (fatal) — ENFit connectors mandated to prevent
— PN compounding errors (wrong electrolyte concentration) — pharmacy double-check protocols
— Hypoglycemia from abrupt PN discontinuation — taper over 1–2 h or run D10W
— Home PN access varies by insurance — advocate for coverage
Board pearl: A daughter requests "everything be done" for her father with end-stage Alzheimer's including PEG placement. The correct Step 3 answer is structured goals-of-care conversation explaining that PEG does not improve survival or aspiration risk in advanced dementia, not immediate consent for the procedure.
Key distinction: Albumin (t½ 21 days) reflects chronic illness/inflammation; prealbumin (t½ 2 days) reflects acute changes but is dropped by inflammation independent of nutrition. Use both with CRP to interpret.
— Post-op ileus day 5, no malnutrition → continue IV fluids, no PN yet (most overcall PN)
— Functional gut + NPO >7–10 days → EN via NG/NJ
— Bowel obstruction not bypassable → PN
— Severe acute pancreatitis → EN (NJ if NG intolerant), never "bowel rest with PN" anymore
— Anorexia nervosa or chronic alcohol use, started on regular diet/TPN, day 2–3 with weakness, arrhythmia, low phos → diagnosis is refeeding; answer is slow advancement, replete electrolytes, thiamine
— Advanced dementia, family wants PEG → goals-of-care discussion; comfort feeding preferred (NOT place PEG)
— ALS with FVC 55% and dysphagia → place PEG now (before FVC <50%)
— Stroke with dysphagia at 2 weeks, no improvement → convert NG to PEG
— Patient on TPN × 4 weeks, fever, rigors during infusion → CLABSI; cultures + empiric vanc/pip-tazo; consider line removal
— TPN × 3 weeks, rising bilirubin → PNALD; cycle PN, advance EN, switch lipid emulsion
— Glucose 350 on TPN → insulin in bag, reduce dextrose
— TG 500 → hold lipids
— Next step is NG feeding, not TPN
— Stable low-dose norepi, day 2 → start trophic EN
— Check medication elixirs (sorbitol) and C. difficile before blaming formula
— Always thiamine before dextrose in malnourished alcohol user
— Encephalopathic patient → do not protein restrict; lactulose/rifaximin + normal protein
— Myeloneuropathy with normal B12 → check copper
Step 3 management: When in doubt between EN and PN — choose EN unless the stem explicitly describes mechanical obstruction, gut ischemia, or true intestinal failure. Defaulting to PN is the most common wrong answer pattern.
Nutritional support follows one cardinal rule: if the gut works, use it — enteral nutrition is preferred whenever the GI tract is functional, accessible, and safe, with parenteral nutrition reserved for true intestinal failure or when EN cannot meet >60% of needs within 7–10 days.
Board pearl: When the answer feels obvious toward PN, re-read the stem for a functional gut — the right answer on Step 3 is usually EN.