Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel?
Abstract
Although the enteral route of enteral feeding is the preferred method of nutrition support for critically ill patients, this important therapeutic strategy is not without risk. In human subjects, the digestion and absorption of nutrients induce typical hemodynamic changes, consisting of an increase in mesenteric blood flow at the expense of reduced systemic blood pressure. On rare occasion when providing aggressive enteral nutrition to critically ill patients, common symptoms of gastrointestinal intolerance may progress to a syndrome of abdominal distention, hypotension, and shock, with the development of small bowel ischemia or necrosis. Although the incidence of small bowel ischemia secondary to enteral feeding is low, the overall clinical outcome is still poor and carries a high mortality rate. Enteral feeding is well tolerated and is probably beneficial in most critically ill patients before and after a period of hypotension. Although enteral nutrition may be used with caution during the period of hypotension, evidence of poor gastrointestinal function (increased nasogastric tube output, unexplained abdominal pain, and abdominal distention), or development of dilated loops of bowel or intramural gas (pneumatosis intestinalis) on radiographic studies should be interpreted as potential indicators of gut ischemia. With progress in our understanding of the pathophysiology, diagnosis, and prevention of ischemic injury to the intestinal mucosa, the strategy of aggressive enteral feeding for critically ill patients may result in a reduction in this major complication and enhanced functional recovery from severe illness.
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In patients with heart failure or cardiogenic shock, initiation of enteral nutrition may prompt mesenteric ischemia due to increased metabolic demand of the intestinal mucosa.
“In these scenarios, the initiation of EN may prompt mesenteric ischemia due to increased metabolic demand of the intestinal mucosa.152,153”
From Malnutrition and Cachexia in Inpatients With Acute Cardiac Conditions: A Scientific Statement From the American Heart Association (2026) · cites this paper as [153]
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Self-citationZacharias, N., Blank, R., Bittner, E., Joyce, S., Kondili, D., Fisher, D. F., Eikermann, M., Velmahos, G., & Schmidt, U. H. (2011) · European Journal of Trauma and Emergency Surgery · doi:10.1007/s00068-011-0085-6 · Cited by 3
“Perceived barriers to the introduction of early enteral feeding in surgical patients seem to be anticipated anastomotic complications after bowel surgery [10], and increased risk of gut ischemia in hypotensive patients or patients on vasopressors [11].”
BackgroundHaseeb, M., Goiporia, M., Siddiqui, M. S., Sangle, A. L., Quadri, S. F., & Ravali, R. L. (2023) · Cureus · doi:10.7759/cureus.49285 · Cited by 2
“In addition, some physicians may be cautious about starting EN in critically ill patients due to concerns about potential mesenteric ischemia and non-occlusive bowel necrosis, particularly in hemodynamically unstable patients [15,16].”
BackgroundGastrointestinal Tract: A Neglected Guardian Angel?
Kothekar, A., & Kulkarni, A. (2020) · Indian Journal of Critical Care Medicine · doi:10.5005/jp-journals-10071-23616 · Cited by 2
Kim, S. H., Shin, Y., Rha, M. Y., Cho, Y., Yang, J., Cho, Y., Seo, J., Kang, B., & Kim, Y. (2016) · Journal of Clinical Nutrition · doi:10.15747/jcn.2016.8.3.77 · Cited by 2 · see citing works
Streefkerk, J., Beishuizen, A., & Groeneveld, A. J. J. (2016) · Clinical Nutrition · doi:10.1016/j.clnu.2015.05.015 · Cited by 2 · see citing works
Alpers, D. (2004) · Current Opinion in Gastroenterology · doi:10.1097/00001574-200403000-00009 · Cited by 2 · see citing works
Metabolism in the Trauma Patient
Gordy, S. D., & Kozar, R. A. (2014) · Springer eBooks · doi:10.1007/978-1-4939-1121-9_5 · Cited by 1 · see citing works
“The development of ischemic bowel is a rare but potentially fatal complication of enteral nutrition, occurring in <1 % of all patients [ 38 ].”
BackgroundEnterai Feeding during Circulatory Failure: Myths and Reality
Berger, M., & Chioléro, R. (2009) · Springer eBooks · doi:10.1007/978-3-540-92276-6_63 · Cited by 2 · see citing works
Enteral Access and Enteral Nutrition
Lynch, C. R., Fang, J., & McClave, S. (2008) · Clinical Gastroenterology · doi:10.1007/978-1-59745-320-2_10 · Cited by 2 · see citing works
Self-citationImproving the Outcome of Brain-Injured Patients by Non-Continuous Feeding to Prevent Dysbiosis
Corriero, A., Soloperto, R., Giglio, M., Taccone, F. S., Puntillo, F., & Preiser, J. (2026) · Nutrients · doi:10.3390/nu18172907
“Neurocritical care interventions, including sedation, vasoactive drugs, mechanical ventilation, and frequently reduced enteral nutrient delivery, may further amplify these disturbances by limiting mesenteric perfusion and slowing intestinal transit [9,16].”
How to Feed Critically Ill Patients
Hong, S.-K. (2015) · JOURNAL OF ACUTE CARE SURGERY · doi:10.17479/jacs.2015.5.1.1 · Cited by 1 · see citing works
“영양은 혈역학적 변화에 따라 신중하게 결정하여야 하며 고위험 환자에게 경장영양을 하는 경우 면밀하게 복부상태를 확인하여 야 한다[4,5].”
Splanchnic Hypoperfusion and Enteral Feeding
Sinaga, W., Sutanto, L. B., & Syam, A. F. (2013) · The Indonesian Journal of Gastroenterology Hepatology and Digestive Endoscopy · doi:10.24871/141201335-38
“Therefore, enteral feeding in patients with high risk of splanchnic ischemia need to consider many matters (Table 1).(23) in critically ill patients.”
Background„Early nutrition“ schon im Schockstadium?
Druml, W. (2011) · doi:10.1007/s00390-010-0232-z · Cited by 1
Total Parenteral Nutrition in the ICU: The Mount Sinai Hospital Experience
Neuman, T., Kohli-Seth, R., Wilson, S., & Bassily-Marcus, A. (2010) · doi:10.1177/1944451610378134 · Cited by 1
- Authors
- McClave, S. A., & Chang, W.
- Affiliations
- University of Louisville (US)
- Tri-Service General Hospital (TW)
- Corresponding author
- McClave, Stephen A.
- Venue
- Nutrition in Clinical Practice
- Publisher
- Wiley
- Published
- 2003-08
- Volume
- 18
- Issue
- 4
- Pages
- 279-284
- ISSN
- 0884-5336 (ISSN-L)
- 1941-2452
- OpenAlex
- W2131083917
- Cited by
- 130
- References
- 0
- Citations by year
- 2026: 3 · 2025: 2 · 2024: 2 · 2023: 4 · 2022: 3 · 2021: 5 · 2020: 7 · 2019: 7 · 2018: 1 · 2017: 10 · 2016: 8 · 2015: 6 · 2014: 10 · 2013: 4 · 2012: 6
- FWCI
- 3.21
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Nutrition in Clinical Practice (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
- Health Sciences › Medicine › Surgery › Abdominal vascular conditions and treatments
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Abdominal Surgery and Complications
- Keywords
- enteral nutrition, hypotension, small bowel ischemia, critically ill patients, mesenteric blood flow, gastrointestinal intolerance, pneumatosis intestinalis, intestinal necrosis
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