It is stated that enteral nutrition is safer than parenteral nutrition. Which of the following may be complications of enteral nutrition?

A. Hyperosmolar, nonketotic coma.

B. Vomiting and aspiration.

C. Pneumatosis cystoides intestinalis.

D. Perforation and peritonitis.

 DISCUSSION: It is not necessarily true that enteral nutrition is safer than parenteral nutrition, and it may in fact be associated with a higher risk of death than parenteral nutrition. Specifically, a well-run parenteral nutrition service should not be associated with significant mortality, except for the occasional death due to undetected yeast infection. On the other hand, enteral nutrition, especially if not carried out safely, can result in significant mortality. The most common of the severe complications of enteral nutrition result from the gastrostomy, or tube feedings into the stomach. Sudden changes in gastric motility, such as those associated with sepsis, may result in aspiration. Nasoenteric or nasoduodenal tubes help prevent this complication, as does shutting off enteral feedings between the hours of 11 P.M. and 7 A.M. It is also essential to keep the patient's head elevated 30 degrees. Also necessary is the use of extreme care when initiating enteral nutrition. If hypertonic material is given into the stomach, one can increase osmolality followed by an increase in volume. If, however, the material is given into the small bowel, volume must be increased first and then tonicity, with the expectation that osmolality greater than 400 or 500 mOsm per liter may never be achieved without provoking severe diarrhea. If care is not taken with the initiation of enteral nutrition, massive diarrhea may result, including fluid loss, the absorption of enormous amounts of carbohydrate into the circulation with inadequate fluid to support it, and the development of hyperosmolar, nonketotic coma. Alternatively, severe unremitting diarrhea may result in necrosis of the intestinal wall, the appearance of pneumatosis cystoides intestinalis, and, finally, perforation and death. All of these complications may be prevented by judicious use of enteral nutrition with the same care one uses for parenteral nutrition.