Does gastro-oesophageal reflux following PEG placement in stroke patients predict a poorer outcome?

SIR—We read with interest the article by Clayton et al. on tracheal pH monitoring and aspiration in acute stroke [1] and agree with their suggestion that research into this area is much needed. We have been concerned about the risk of aspiration in patients with dysphagic stroke who are fed by percutaneous endoscopic gastrostomy (PEG) tube. The median survival of PEG-fed stroke patients is 10 months, with aspiration pneumonia being the commonest complication [2]. Oesophageal manometry in patients following dysphagic stroke has shown that many have oesophageal sphincter dysfunction [3], which may lead to regurgitation of gastric contents. We performed oesophageal manometry and 24-h oesophageal pH studies on five patients with recent onset dysphagic stroke, within 1 week of PEG placement. Patients were fed via the PEG tube for 16 of the 24 monitored hours and were nursed according to standard protocols. In keeping with previous reports [3], we confirmed lower oesophageal sphincter (LOS) dysfunction in four of the five patients. In two patients, we also demonstrated significant gastro-oesophageal reflux (GOR). One patient with significant GOR made a good neurological recovery, so that the PEG feeds were stopped after 6 weeks, whereas the other had three episodes of aspiration pneumonia and died 4 months after PEG insertion. The three patients with minimal GOR had better survival (all >8 months) and had no documented episodes of aspiration pneumonia. In these PEG-fed patients, GOR was greatly influenced by patient position. There were significantly more reflux events whilst the patients were in either the right lateral or the supine positions than in either the left lateral or the sitting positions. GOR events are known to be more common in the right than in the left lateral position [4], but this has not previously been documented in stroke patients. In total, there were 205 reflux events. Fifty-one per cent of these occurred in the right lateral position, 2% in the left lateral position, 30% whilst supine and 17% when the patients were sitting (or at >45° head up). This difference occurred despite roughly equivalent times in each position (overall proportion of time spent in right, left, supine and sitting positions was 22, 23, 25 and 30%, respectively). In conclusion, we agree with Clayton et al. [1] that better identification of patients who aspirate post stroke is important. Our small data series on PEG-fed stroke patients indicates that LOS dysfunction and GOR are common and that GOR is influenced by patient position. It may be prudent to nurse patients in the left lateral, rather than the right lateral, position during PEG feeding. Furthermore, significant GOR during PEG feeding may predict a poorer outcome and may be an indication for a jejunal feeding tube.