Cat With EsophagostomyTube

Photo courtesy of Dr. Wendy Brooks

As most of us know, good nutrition and adequate fluid intake are crucial to good health.  When a pet is ill, this becomes even more important. Yet for various reasons, often because of the illness itself, a pet becomes unable or unwilling to meet those needs on his own.  Whether this problem is temporary or is expected to be permanent, feeding tubes can be of great assistance in restoring the pet to good health and a good quality of life. 

For a number of reasons, many pet owners are reluctant to consider the option of a temporary or permanent feeding tube and often decide too late to have one placed. Once unheard of, feeding tubes are being used more often as pet owners learn the ease of use and see their pets become healthier, regain strength, and enjoy life again.  Comments such as "The feeding tube gave me back my lively dog," and "If I'd known, I'd have done this sooner" are frequently heard.  A feeding tube is relatively easy to use yet there is often fear and reluctance about using one.

Cats are particularly sensitive to lack of nutrition. If a cat ‒ especially a fat cat ‒ doesn't eat for as few as 3 days, he can begin to develop hepatic lipidosis. Hepatic lipidosis in cats occurs when fat infiltrates into the liver and interferes with or prevents normal function. A cat goes into liver failure because he hasn’t been eating. This video, and this one, demonstrate how to feed a cat through a tube.

In this video, a dog receives one of his 3-4 daily feedings. When his tube was first inserted, his owner needed to draw back on the syringe before each feeding to check how much residual material was left in the stomach.

There are several types of feeding tubes, and your veterinarian will choose the most appropriate one. Which type to use depends on how long the tube needs to be in place and whether a permanent tube is needed.

Pets with permanent feeding tubes, such as those with otherwise unmanageable megaesophagus can lead normal lives. Some dogs with permanent PEG tubes hunt with their owners or perform in agility.

There are four types of feeding tubes used in veterinary medicine:

• Nasogastric tube: This is a narrow tube and can be used for only a few days to give watery material.
  
  
• Esophagostomy/pharyngostomy tube: This is a wider tube and can be used for days to a few weeks to give slightly thicker fluid and some liquid medications.
  
  
• PEG (percutaneous gastrostomy tube): This is to be used for several months or permanently. If the PEG tube is to be permanent it must be replaced every 6-8 months. Gruel and most crushed medications can be given through a PEG tube.
  
  
• Jejunostomy tube (J tube): This exits the right side of the abdomen and are usually only used in the hospital.

Nasogastric Tubes

Nasogastric Tube in a Dog

Photo by Dr. Val Fournier

Nasogastric tubes are usually used short term, such as with cats with severe upper respiratory infections. In general, these are placed with a local anesthetic in a nostril. A soft rubber tube is gently placed through the nose, past the back of the throat, and is inserted towards the end of the esophagus. The tube is then sutured to the skin, and an Elizabethan collar placed so that the pet cannot remove the tube. The tube is then used to flush thin, watery food and water into the tube, which will then pass from the esophagus into the stomach. Some medications can also be given through the tube. These tubes can often be placed with little or no sedation or anesthesia. The food and water will pass from the esophagus into the stomach.

To use the tube, remove the plug at the end to open it. The pet can move around freely, but cannot have unrestricted exercise because the tube is easily dislodged if it is caught on anything.

The tube is easily removed by taking out the sutures and pulling the tube out of the nose. These tubes are generally in place for a few days.

Esophagostomy/Pharyngostomy Tubes

Esophagostomy/pharyngostomy tubes can be left in place up to 4 weeks. The pet must be anesthetized for placement. A small incision is made on the left side of the neck and through the wall of the esophagus. The tube is inserted and sutured to the skin. A gauze and bandage wrap is placed around the neck to cover the insertion site. Thicker food and a greater variety of medications can be given with this type of tube than with a nasogastric tube. Some pets need to wear an Elizabethan collar so that they cannot accidently pull the tube out. Your pet can move around and interact with the family, as long as he is constantly supervised. Some pets should be confined when not under observation.  The dressing over the tube will need to be changed every few days to keep the insertion site clean. This tube is easily removed without anesthesia. The wound in the neck heals without additional treatment. 

If you don't want to deal with bandages, there's a commercial neck wrap designed for use with e-tubes in dogs and cats that can be used instead.

Percutaneous Endoscopic Gastrostomy (PEG)

Bassett Hound with PEG Tube

Photo courtesy of Diane Shelton, DVM, PhD, DACVIM, and the Comparative Neuromuscular Laboratory at UC San Diego.

PEG tubes are usually larger in diameter than the esophagostomy/pharyngostomy tubes, and thus can be used for pets who require longer term or permanent feeding tubes. The pet is anesthetized and a PEG tube is placed through the side of the abdomen into the stomach. Usually a temporary tube is placed first. If a permanent tube is required, it can be placed after a permanent stoma/fistula has developed from the stomach to the skin. (The temporary tube must remain for at least 2 weeks before removal or replacement with a "permanent" tube.)  Formation of the stoma is important in allowing the stomach to adhere to the inside of the abdomen. This prevents leakage of stomach contents into the abdomen. The temporary tubes usually last for several months, but does need to be replaced after about 6 months as the plastic will deteriorate. This can be performed under light sedation.

You must wait at least 24 hours after placement before giving the first meal through a PEG tube to allow the stoma to form and seal.

Permanent PEG tubes do not have the long tube attached, making the device more low-profile and less likely to be accidentally damaged or removed by the pet.

The dog or cat should not be left alone for several days after the tube is placed, and the tube should be protected by clothing to prevent access by the pet or other pets. Both the temporary and permanent feeding tubes are easily removed without anesthesia.

Several companies manufacture permanent PEG tubes for humans, and these tubes can be used in dogs and cats.

Dog with Muscle Shirt

This feeding tube is covered with a mesh stockinette muscle shirt and a Button Buddy. Photo by Donna Koch.

Your veterinarian will choose the tube that is best for your pet.

A cover over the feeding tube should be used as the tube can be either be damaged or removed by the pet. K9 Topcoats, Thundershirts, and medical stockinettes can be used. It is best not to allow your pet to be left alone until you are certain that he cannot get to the tube. Eventually most pets accept these as inconveniences and won't be bothered by them.

If medically appropriate, the pet can eat and drink normally as the PEG tube does not interfere with eating by mouth.

Jejunostomy Tubes

Jejunostomy tubes (J-tube) are usually placed surgically through the right side of the abdomen. The tube diameter is smaller that the PEG tube, and feedings need to be given much more slowly. Typically a J tube is used in hospitalized pets as the feedings are best administered using a constant rate infusion; a pump feeds the nutrition through the tube slowly. They are particularly helpful for the patient who is vomiting, as the J tube bypasses the stomach. J tubes should only be removed after an adequate stoma is formed. This varies from 10 to 14 days although it may be longer in patients with delayed healing.

Tube Care

Check the tube position every day. Also check the insertion site for redness, swelling, discharge, or pain. It is normal for a thin rim of pink or red tissue to grow outward to the skin of the insertion site. It’s a good idea to wash your hands before and after cleaning around the tube. Clean the insertion site with an antiseptic solution or gentle, non-drying cleanser recommended by your veterinarian. Clean debris on the tube with a warm, moist cotton ball, gauze, or cloth. After cleaning the tube, place gauze or a Button Buddy over the insertion site.

Excessive, foul-smelling material at the insertion site can quickly become a pus-filled localized infection, so report it immediately to your veterinarian to help prevent an infection.

Feeding through the Tube

• A pet can be fed immediately through nasogastric and esophagostomy/pharyngostomy tubes, but feeding through a PEG tube must wait for 24 hours to allow the stoma to form and seal.
  
  
• Push food twice through a fine sieve to remove all tiny "bits" that can obstruct the tube. The food can be refrigerated for 2 days.
  
  
• If the tube becomes plugged, or it is difficult to push the gruel through the tube, see Clogged Feeding Tubes below.
  
  
• Your veterinarian will calculate the amount of food to be given and how often. Keeping a record of everything (type and amount) that goes through the tube is important.

Clogged Feeding Tubes

• Check for kinks in the external tube, and if there is a tube clamp make sure it is open.
  
  
• Massage the external tube to loosen any material in the tube.  Use your fingers to squish the tube along its full length to break up any material.
  
  
• If the tube flushes but food does not go through, check the tip of the feeding syringe; it’s possible the syringe tip is obstructed rather than the feeding tube.
  
  
• If water flushing does not relieve the obstruction, leave water in the tube and attempt to flush again in 20 minutes.
  
  
• Flushing the tube with 1-2 teaspoons of any brand of cola (other effervescent sodas do not work as well as colas) may help unblock the tube.
  
  
• Flushing the tube with 1-2 teaspoons of fresh (not frozen, jarred or canned) pineapple juice may help unblock the tube.

Tips

• Flush tube with water before and after giving medication or food.
  
  
• Start feedings at 33-50% of the calculated volume for the first day. If it is tolerated, go to 50 - 67% for day 2, 75-80% for day 3, and 100% thereafter.
  
  
• Give food at room temperature. If using refrigerated food, add a little water and microwave it to warm it. Make sure it is not too hot and mix well to assure there are no hot "pockets."
  
  
• Gruel can be pulled up in the syringe either by placing the syringe tip into the food and pulling back on the plunger, or by removing the plunger and pouring food into the syringe and then replacing the plunger. The size of the pet will depend on how much food and water can be given at each meal. Food should be given slowly and injected over a 3-4 minute period. If the pet acts nauseated or restless, slow down the administration.

When to Call The Veterinarian or go to the Emergency Veterinary Service

• Call the veterinarian or an emergency veterinary service immediately if the tube position has changed, the tube is no longer secure, or if it falls out. With a PEG tube, it is a good idea to obtain an equal diameter red rubber catheter for an emergency replacement at home in case the PEG tube comes out. The temporary replacement tube can safely be inserted 1 to 2 inches into the stoma and attached using adhesive tape while you get to the emergency service or your veterinarian. The stoma can begin closing immediately, making replacement difficult or impossible without anesthesia and/or surgery, so it is important not to delay.
  
  
• The insertion site or sutured skin is excessively irritated, swollen, painful, or infected.
  
  
• Excessive, foul-smelling material is found at the site.
  
  
• The tube cracks or rips, or its attachments (feeding port, external stent) become detached.
  
  
• Your pet coughs or develops breathing problems.
  
  
• Your pet vomits, develops a fever, or becomes lethargic.
  
  
• If the tube clogs, even if you can clear it, the veterinarian may want to change the feeding formulation.

What the Veterinarian Should Tell You

Ask your veterinarian to provide the following information.

To accomplish fulfilling the pet’s water requirement, flush with  ____cc  prior to feeding, and ______cc after feeding
Remove or open end piece and flush with  _____ cc warm water. Aspirate the fluid that remains in the stomach. Record the amount flushed, and the residual amount.

If there is ever more than _____cc of residual fluid, wait 2-3 hours and recheck and feed. The total amount can be given over a 5-minute period. If your pet acts nauseated (a lot of swallowing, restlessness, regurgitating/vomiting) stop and flush with  _____warm water, and wait a few hours.

On day 1, feed _______cc every _______hours after flushing with  _______cc of warm water.
On day 2, feed _______cc every _______hours after flushing with  _______cc of warm water.
On day 3, feed _______cc every _______hours after flushing with  _______cc of warm water.
On day 4, feed _______cc every _______hours after flushing with  _______cc of warm water.

Usually the total calculated amount can be given in three feedings by day 3 or 4. Totals are added up at the end of 24 hours to make sure the pet is receiving adequate nutrition and fluids.

Use a chart like the following one to record the residual/ amount of food and water:

Quality of Life

Pets can lead happy lives with feeding tubes. Dogs with PEG tubes have been known to go hunting or participate in agility, as well as other normal activities. Cats can also have wonderful lives, whether the PEG tube is needed for only a few months or permanently. My own cat had a tube for 3 months due to a severe infection. Maddie slept with me, and she pranced around the house when I was watching her. She cleaned herself and acted like a normal cat while recovering. She lived for 6 years after the tube was removed.