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Lipodystrophy and WastingLipodystrophy and Wasting
           
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Wasting, TPN or FM Tube?
Apr 8, 2003

A friend is in severe wasting having gone from about 125 lbs to 85 lbs. He is 5'4" tall. He has been on TPN for about a month now and has not gained weight but hasn't lost either. His blood work vis a vis HIV seems to be improving but I am not privy to the exact CD4 or VL numbers. I have talked with his doctor about the possibility of putting him on FM Tube (my understanding is that the tube actually passes through the stomach and into the large intesting) in addition to the TPN. The doctor indicated that the FM Tube ended in the stomach. Is this correct? And what about the type of feeding tube that passes through the abdominal wall? Doesn't that type also bypass the stomach and go directly to the intestines? (The J-Tube?). My friend has also had a complete GI workup and there doesn't seem to be any CMV or any other reason for his GI problems. He also complains of gas and cramps (sometimes severe). I really don't want to see my friend leave the hospital feet first but am in a bind trying to find the appropriate treatment for him. I do trust his doctor (since he is my doctor too) but the question about the FM Tube has me wondering. My friend is, for the most part, alert and has been trying to eat small amounts of bland foods. Sometimes the food stays down other times, he vomits it up. He has been in the hospital since March 5, at which time he weighed 85 lbs and today is April 4, and he still weighs 85 lbs. Any suggestions?

Response from Ms. Fields-Gardner

The first question I have is why your friend may have been placed on TPN rather than enteral nutrition in the first place. TPN is not equivalent to enteral nutrition and generally the reasons for choosing TPN can preclude or limit the use of enteral nutrition. Fast weight gain is not always a good thing, but no weight gain suggests that something else may be going on.

The second question I have is about his prognosis and goal for therapy. Before becoming too invasive and aggressive it will be worth talking with the doctor and nurse about your friend's situation and his wishes. It sounds like your friend has GI problems that may or may not allow for adequate tube feeding without causing additional distress.

The jejunal placement of the tube means that it is placed directly into the jejunum. I apologize that I am not familiar with the term "FM tube" and so cannot verify the placement of this tube. Jejunal placement requires experience and skill as well as testing to determine that the placement is correct. It is more typical to place the tube into the stomach where such testing for placement is less likely to be required. Placement of a tube surgically may be risky in your friend's case with such severe malnutrition.

Assuming that the goal of therapy is rehabilitation, there are several things to look into. You can look into the level of nutrient provision (often a cautious approach to providing nutrients via TPN is advised because of the potential for complications related to overfeeding). It may be worth checking to see if there is a need for some additional therapy to assist the TPN in being better utilized. If there is a considerable infection, the body may not allow nutritional rehabilitation to take place effectively until the beginning of a resolution to the infection is seen. Treatment for infections can be a very important part of the body's ability to use nutrients well. Beyond that there is normalization of the body's hormonal balance and sensitivity.

Overall, I would recommend talking with the doctor and nurse about the reasoning behind the choice of TPN, his prognosis and wishes, what "outcomes" are expected by using TPN, and any plans to adjust therapies based on achieving or not achieving those goals. There is a lot that is considered in determining therapy and it is good that he has a friend like you to help him ferret out the best path.

Best wishes!


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