REVIEW

CURRENT
OPINION Role of gastric ultrasound to guide enteral
nutrition in the critically ill
Ángel Augusto Pérez-Calatayud a and Raul Carillo-Esper b
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Purpose of review
Early initiation of enteral nutrition (EN) is often not feasible due to the high prevalence of gastrointestinal
dysfunction that constitutes one of the leading nonavoidable causes for discontinuing or delaying enteral
feeding in critically ill. This review summarizes current evidence on the role of gastric ultrasound as a
management and monitoring tool for enteral nutrition in critically ill patients.
Recent findings
The ultrasound meal accommodation test, the gastrointestinal and urinary track sonography (GUTS), and
other gastric ultrasound protocols used to diagnose and treat gastrointestinal dysfunction in critically ill
patients have not changed the outcome. However, this intervention could help clinicians with accurate daily
clinical decisions. The dynamic changes in the cross-sectional area (CSA) diameter could help to access
gastrointestinal dynamics results immediately, provide a valuable guide to initiate EN, predict feeding
intolerance (FI), and aid in following treatment response. More studies are necessary to determine the
complete scope and true added clinical value of these tests in critically ill patients.
Summary
Using gastric point of care ultrasound (POCUS) is a noninvasive, radiation-free, and inexpensive method.
Implementing the ultrasound meal accommodation test in ICU patients might become a step forward to
ensure safe early enteral nutrition in critically ill patients.
Keywords
enteral nutrition, feeding intolerance, point of care ultrasound

INTRODUCTION ventilation support of complications during EN.

Enteral nutrition (EN) is essential for patients in
the intensive care unit (ICU), and is considered a
standard of care [1]. The benefits of enteral nutrition
include preserving the gastrointestinal mucosa’s
structure and function, decreasing catabolic
response to injury, and reducing risk of bacterial
translocation [1]. Early initiation of EN is often not
feasible due to the high incidence of gastrointestinal
complications and a high prevalence of gastrointes-
tinal dysfunction that constitutes one of the leading
nonavoidable causes for discontinuing or delaying
enteral feeding in critically ill patients [1].
Several methods are available to measure gastric
emptying, broadly categorized as direct or indirect
tests and surrogate assessments. However, these
methods are invasive, time-consuming, compli-
cated, or not feasible at the bedside. Gastric residual
volumes (GRVs) are used in gastric emptying during
nasogastric feeding; however, these measurements
are often inaccurate, and there is a lack of robust
evidence that GRV monitoring does not avoid
complications at least in patients on mechanical
The best protocol for GRV monitoring is currently
unknown; thus, the precise efficacy and safety pro-
files of GRV monitoring remain to be ascertained [2].
A validated tool with high sensitivity and
specificity to evaluate gastric volume and content
noninvasively is gastric ultrasound. Enteral feeding
can lead to high-volume aspiration, especially when
associated with gastric dysmotility, poor cough,
and altered mental status. Its implementation in
preoperative emergency surgery evaluation has
been proven cost-effective, decreasing patients’
morbidity [3]. Currently, it is accepted that the
volume necessary to cause risk of pulmonary
a
Hospital General de México Dr. Eduardo Liceaga and bAcademia
Nacional de Medicina de México, México City, México
Correspondence to Ángel Augusto Pérez-Calatayud, Head of División
Critical Áreas, Hospital General de México Dr Eduardo Liceaga, Dr Luis
Balmis 148, Cuahutemoc, México City, México.
Tel: +55 27892000 (Ext 1473); e-mail: admin@siapbm.com
Curr Opin Clin Nutr Metab Care 2023, 26:114–119
DOI:10.1097/MCO.0000000000000911

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 Role of gastric ultrasound to guide enteral nutrition in the critically ill Pérez-Calatayud and Carillo-Esper
KEY POINTS

Gastric point of care ultrasound could become a tool
for management and monitoring enteral nutrition in
critically ill patients.

Gastrointestinal dynamics provide a valuable guide to
initiate enteral nutrition, predict feeding intolerance,
and aid in following treatment response.

To date, the use of gastric ultrasound protocols to
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diagnose and treat gastrointestinal dysfunction in
critically ill patients has not impacted outcomes.
aspiration is 0.8 ml/kg and it has been used as a
definition of risk stomach aspiration pneumonia
or chemical pneumonitis in anesthesia settings
[4]. However, in critical care settings associations
with adverse outcomes had not been confirmed in a
few randomized clinical trials investigating different
cutoff or abandoning GRV measurements. More-
over, omitting monitoring of GRV resulted in sig-
nificantly increased provision of early EN during the
ICU stay, with reduced use of prokinetic drugs and
less gastrointestinal (GI) complications [5]. but with
this statement there are also several issues to resolve
for enteral nutrition and feeding intolerance in ICU
settings: monitoring, associations between GI func-
tion and outcome, GI function and nutrition, man-
agement of GI dysfunction, and pathophysiological
mechanisms. Current evidence on GI dysfunction is
scarce, partially due to the lack of precise definitions
[6]. The use of core sets of monitoring and outcomes
are required to improve the consistency of future
studies.
This review summarizes current evidence on the
role of gastric ultrasound as a decision-making and
monitoring tool for enteral nutrition in critically
ill patients.
GASTRIC ULTRASOUND
POCUS assessment of gastric content and solutes has
been described in preoperative surgical and critically
ill patients. The origins of gastric ultrasound date
back to the 1980s [3] to study gastric motility. Other
researchers utilized gastric ultrasound to assess gastric
emptying following the ingestion of liquids [3].
Van de Putte et al. [7,8] published the applica-
tion of a point-of-care (POC) gastric ultrasound to
evaluate aspiration risk assessment by providing
bedside information on the type of gastric content
and the volume. This examination can differentiate
an empty stomach from one that contains clear
fluid, thick fluid, or solid particulate content based
on qualitative findings.
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The calculated gastric volume according to the
Perla’s model is calculated by the following formula
[4,7,8]:
GV (ml) ¼ 27.0 þ 14.6  right-lateral CSA (cm2)
 1.28age (years)
Perlas’ approach can predict volumes from 0 to
500 ml and be applied to adult patients with
<40 kg/m2 of body mass index [4]. The concept
of ‘risk stomach’ by gastric ultrasound is defined
when the gastric volume exceeds 1.5 ml/kg of body
weight, measured at the level of the gastric antrum.
The margin of error of the measurement was 6 ml
[8].
Kruisselbrink et al. [9] in a simulated scenario for
gastric ultrasound in 40 healthy volunteers after a
fasting period of 8 h, the subjects were randomized
to either remain fasted or ingest a standardized
quantity of fluid or solid. The pretest probability
of 50% a sensitivity of 100% and a specificity of
97.5% with a positive predictive value of 97.6% and
a negative predictive value of 100%. Tan et al. [10]
with 117 patients, reported for a gastric volume of
>0.8 ml/kg, cut-off values for functional dyspepsia
and organic dyspepsia were 6.7 cm2 and 10.0 cm2,
respectively. The cut-off value for patients with FD
to predict gastric volume of >0.8 ml/kg was 6.7 cm2,
with a sensitivity of 100% and a specificity of 48.7%.
The cut-off value for patients with organic dyspepsia
to predict gastric volume >0.8 ml/kg was 10.0 cm2,
with a sensitivity of 92. 7% and a specificity of 82.4%
[10]. However, it does not access gastrointestinal
dynamics.
BACKGROUND FOR MEASURING
ULTRASOUND-BASED GASTRIC DYNAMICS
In 1988, a publication described the method for
evaluating gastric emptying by measuring the gas-
tric antrum’s cross-sectional area (CSA) at regular
intervals following a meal [3].
In perioperative settings, studies demonstrate
that the mean gastric antral CSA after ingestion of
carbohydrate drinks is noninferior to that of fasted
patients undergoing elective surgery. These studies
showed that carbohydrate drinks ingested up to 2 h
before anesthetic induction do not delay gastric
emptying compared to midnight fasting, as eval-
uated by gastric ultrasound. Hence, gastric ultra-
sound is valuable for assessing gastric emptying
when minimal fasting time is preferred. However,
in these studies, gastric content evaluation was
made qualitatively by classifying the presence or
absence of gastric volume content measured by
the Perla’s method, and quantitative measures only
evidence the presence of ‘risk stomach’ also meas-
ured by Perla’s GV formula [4,7].
www.co-clinicalnutrition.com 115
 Nutrition and the intensive care unit

The ultrasound meal accommodation test was
developed as part of the evaluation protocol for
ambulatory patients with dyspepsia. The ultra-
sound meal accommodation test is a clinical
meal-provoking test used to assess gastric accom-
modation, gastric emptying, and visceral sensitiv-
&&
ity [11 ]. In critically ill patients, where gastric
emptying dynamics are objectively measured. Sig-
nificant changes are found in the ultrasound meal
accommodation test CSA measurements between
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monitor the gastrointestinal function in critically ill
patients. The GUTS protocol focuses on four gastro-
intestinal endpoints: gastrointestinal diameter,
mucosal thickness, peristalsis, and blood flow (the
SMA ultrasound aids in the analysis of the superior
and inferior mesenteric flow and provides several
quantifiable parameters, such as pulsatility index,
resistive index, systolic and diastolic velocities, and
blood flow volume, to assess the signal from visceral
vessels) (Fig. 1). This POCUS imaging technique

&&
subjects with FI and those without FI [11 ].
GASTRIC ULTRASOUND IN CRITICAL CARE
In recent years, POCUS has been used to confirm the
provides anatomical and functional information
on the gastrointestinal tract. Recent research has
shown the utility of GUTS with other parameters,
such as gastrointestinal biomarkers, AGI class, and
clinical outcomes [12].
&&

position of nasogastric and gastrointestinal tubes. It
also provides a noninvasive assessment of the calcu-
lated gastric volume, gastrointestinal motility, and
patient’s muscle status, thus allowing comprehen-
sive evaluation of the nutritional status and EN
efficacy and guiding the development of further
nutritional support treatment plans [2].
GASTROINTESTINAL ULTRASOUND
PROTOCOL FOR ENTERAL NUTRITION IN
CRITICAL CARE
Evaluating gastrointestinal integrity
Using the GUTS protocol (gastrointestinal and uri-
nary tract sonography) (Fig. 1) [12] is relevant to
Lai et al. [13 ] used a combined assessment of
gastrointestinal function by CSA colonic diameter,
peristaltic frequency, and other indicators to predict
recovery of intestinal function. They found that
individually CSA 9 cm2 had an area under the
curve (AUC) of 0.896; colonic diameter 2.9 cm,
AUC of 0.92; and peristaltic frequency >3 bowel
peristaltic movement (BPM), AUC of 0.845. More-
over, they reported that integrating the three
indexes could reflect the recovery of gastrointestinal
function. When CSA, colonic diameter, and peri-
staltic frequency were combined, the positive pre-
dictive value and AUC were higher than those
of a single indicator. Moreover, the difference
was statistically significant (P < 0.001), except
for colonic diameter þ peristaltic frequency

FIGURE 1. Ultrasound meal accommodation test: pretest use of GUTs protocol to evaluate gastrointestinal integrity, gCSA --
gastric cross-sectional area (note: acute gastrointestinal injury grade IV is an absolute contraindication for EN according to
ESCIM AKI group). Patient with a calculated gastric residual volume >400 ml EN should be avoided for safety reasons until a
treatment plan is established. Post-test a DCSA >50% enteral nutrition is safe with a 96% probability of EN tolerance. EN,
enteral nutrition; GUT, gastrointestinal and urinary track.

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 Role of gastric ultrasound to guide enteral nutrition in the critically ill Pérez-Calatayud and Carillo-Esper
combination (P > 0.05), indicating that only Diam
and Peri could not reflect the complete gastroin-
testinal function. For patients with CSA 9 cm,
colonic diameter 2.9 cm, and peristaltic fre-
quency >3 BPM, enteral nutrition therapy was
initiated with an AUC of 90.95, and tolerance of
enteral nutrition therapy was 93.7%. The authors
concluded that with these findings, enteral nutri-
tion therapy could be initiated earlier without
complications after a complete evaluation of gas-
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trointestinal function. Gastrointestinal POCUS can
better evaluate the damaged state of gastrointesti-
nal track, and enteral nutrition therapy can be
&&
carried out earlier [13 ].
Ultrasound meal accommodation test
This protocol helps differentiate among patients
who will develop FI and can provide indications
for adequate therapy (Fig. 1). The ultrasound meal
accommodation test is a feasible tool for monitoring
&&
the gastric response to meal stimulation [11 ].
The ultrasound meal accommodation test is
done with the patient at a head elevation of 308.
For gastric scanning, a 2–5 Hz curved transducer is
recommended. The parasagittal plane of the epigas-
tric area is obtained using the left lobe of the liver
and the abdominal aorta as anatomic reference
points. Ultrasound measurements are performed
at the subxiphoid window, and the basal CSA is
determined. This measure is done for safety; if a risk
stomach is found, the test should be suspended.
Changes in the CSA of the gastric antrum are meas-
ured after administration of 500 ml of a liquid meal
with low protein (10 g) for contrast [14] given in
2 min. The second measure is done after 60 min. In
an observational study of 61 patients, 52 patients
(85%) in group A and 9 (15%) in group B. we found
that a DCSA (difference between after-meal CSA
measure and 60 min after) of 52% had a sensitivity
of 50%, specificity of 88.9%, a positive likelihood
ratio of 4.50, and a negative likelihood ratio of 0.56.
The pretest probability was 85% for feeding toler-
ance in ICU patients, and the posttest probability
&&
was 96% [11 ].
Gastric point of care ultrasound value to
guide enteral nutrition in critically ill patients
FI definitions are inconsistently described in the
literature but are a common finding among crit-
ically ill adults [15]. FI is most frequently defined
as the presence of gastrointestinal symptoms and
raised GRV. A standardized definition of FI is essen-
tial for future research and clinical practice. How-
ever, studies show GRV to correlate poorly with
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delayed gastric emptying, and this systematic review
that included eight studies with 1585 patients, dem-
onstrated no correlation between GRV threshold
and the prevalence of FI [15]. Other attempts to
predict GID and FI in critical care settings have failed
to predict FI, such as intra-abdominal pressure
value. Although a higher intra-abdominal pressure
(cut-off value >14 mmHg) was associated with EN
intolerance, intra-abdominal pressure alone did not
emerge as a good predictor of EN intolerance in
critically ill patients [16]. GRV has been widely used
in clinical practice as an essential indicator of gastro-
intestinal motility and enteral nutrition tolerance.
Recent studies have questioned the rationality of
monitoring GRV routinely in critically ill patients
[15]. With the widespread clinical application of
harmless monitoring technologies such as ultra-
sound, gastric suctioning may be used less and less
[16]. Early use of enteral nutrition in critically ill is
necessary for maintaining gastrointestinal function.
Gastrointestinal dysfunction has accumulating evi-
dence of a negative impact on outcomes. However,
despite several efforts to integrate gastrointestinal
function into scores or the development of moni-
toring instruments for these settings, nothing
appeared to integrate the complexity of the gastro-
intestinal tract [16–19]. A ‘one size fits all’ principle
is not an optimal solution in the clinical practice of
enteral nutrition in critically ill patients because of
the considerable heterogeneity of the ICU popula-
tion and the many risk factors for gastrointestinal
dysfunction [15]. Each method of monitoring GRV
has advantages and disadvantages. The manage-
ment of enteral nutrition focuses on identifying
the factors and triggers of gastric retention. Attempt-
ing to solve this from the perspective of prevention
and elimination of high-risk factors for aspiration
and analysis of pathophysiological mechanisms,
eliminating all negative hindering factors, and
actively creating conditions for enteral nutrition.
It is necessary to pay attention to the continuous
improvement of enteral nutrition management cul-
ture and rationally use diversified management
strategies, which may be more important than mon-
itoring GRV [16]. Recent studies have introduced
gastric POCUS in evaluating and monitoring GRV
and gastrointestinal function in anesthesia and crit-
ical care. POCUS could help clinicians measure
the stomach’s ability to accommodate a liquid
meal, observe gastric emptying, and the patient’s
&&
symptom response [11 ]. The potential utility of
ultrasonography for monitoring gastrointestinal
function and dysfunction in critical care settings
may lead to appropriate therapeutic interventions.
Together, they offer a sound basis for dynamic imag-
ing of the gastrointestinal patient’s condition and
www.co-clinicalnutrition.com 117
 Nutrition and the intensive care unit
can obtain valuable and better information than
&&
subjective clinical evaluations [12,13 ].
During EN, the primary goals to achieve include
accurate confirmation of the feeding tube position,
monitoring the gastric residual volume, assessing
gastrointestinal motility, and monitoring the nutri-
tional status of patients. With rapid technological
development, gastric POCUS has become a more
convenient and effective technical tool for monitor-
ing critically ill patients receiving EN [2]. FI patients
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have fewer ventilator-free days and longer ICU
lengths of stay, and the daily mortality hazard rate
increased by 1.5 once enteral feed intolerance
occurred [20]. Gastrointestinal pocus could signifi-
cantly contribute to integrating protocols and help
clinicians make accurate daily clinical decisions. The
dynamic changes in the CSA diameter could help to
access gastrointestinal dynamics results immediately,
provide a valuable guide to initiate EN, predict FI, aid
in following treatment response in critically ill
&&
patients and avoid known complications [11 ,12].
Using the ultrasound meal accommodation test
at the patient’s bedside may reduce the risk of bron-
choaspiration and malnutrition. With the ultrasound
meal accommodation test, the three pillars of gastric
evaluation, including accommodation, emptying,
and stimulus sensitivity, are performed in a single
test. The clinicians can measure the stomach’s ability
to accommodate a liquid meal, observe gastric emp-
&&
tying, and the patient’s symptom response [11 ].
Other resent studies have found a correlation
between gastric POCUS and FI. Wang et al. [21]
reported the measurement of gastric antrum echo-
density was associated with greater severity of
AGI and that patients with higher gastric antrum
echodensity upon enteral nutrition initiation via a
nasogastric tube were more likely to develop FI.
There are also some
LIMITATIONS
To date, the use of the ultrasound meal accommo-
dation test, GUTS, and other gastric ultrasound
protocols to diagnose and treat gastrointestinal dys-
function in critically ill patients has not changed the
outcome. Gastric POCUS is user dependent. Obese
patients are challenging to examine due to fatty
tissue’s attenuation of the sound waves of the ultra-
sound. Abdominal intraluminal gas also impairs the
&&
visualization of the gastric compartment [11 ,12].
CONCLUSION
Using POCUS gastric ultrasound is a noninvasive,
radiation-free, and inexpensive method. Imple-
menting the ultrasound meal accommodation test
118 www.co-clinicalnutrition.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
in ICU patients might proof to be a step forward to
ensure safe early enteral nutrition in critically ill
patients. More studies are necessary to determine
the complete scope and true clinical value of this
test in the critically ill patient from a patient
centered perspective
Acknowledgements
Ethics approval and consent to participate: No ethics and
research committee approval needed for this review.
Consent for publication: All Authors consent for publi-
cation if the manuscript is accepted.
All authors confirm that the content of the manuscript
has not been published or submitted for publication
elsewhere.
Availability of data and materials: The data of this study
are available from the corresponding author upon rea-
sonable request.
Authors contributions: Guarantor Angel Augusto Pérez-
Calatayud Hospital General de Mexico Dr Eduardo
Liceaga, Mexico City Mexico. gmemiinv@gmail.com
Author contributions. Raul Carrillo-Esper drafting the
work or revising it critically for important intellectual
content Academia Nacional de Medicina de Mexico,
Mexico City, Mexico. cmx@revistacomexane.com.mx
Financial support and sponsorship
The funders had no role in study design, data collection
and analysis, decision to publish, or preparation of the
manuscript.
Conflicts of interest
There are no conflicts of interest.
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