1108835 JFM Journal of Feline Medicine and SurgeryBrunet et al

Original Article

Journal of Feline Medicine and Surgery

Use of feeding tubes in 112 cats in 2022, Vol. 24(10) e338­–e346

© The Author(s) 2022
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DOI: 10.1177/1098612X221108835
https://doi.org/10.1177/1098612X221108835

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This paper was handled and processed
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Audrey Brunet1 , Tarek Bouzouraa1,2, Jean-Luc Cadore1

and Marine Hugonnard1

Abstract
Objectives The aims of this study were to describe diseases, complications and outcomes associated with the use
of feeding tubes in a population of sick cats with appetite disturbance managed at an internal medicine referral
service.
Methods Clinicopathological data from cats receiving nasoenteral (NE) or oesophagostomy (O) tubes were
studied. Cats were categorised according to their underlying disease and divided into subgroups (NE or O tube).
The following factors associated with survival were analysed: disease category, type of tube and return to appetite.
Results Included in the study were 112 cats, representing 118 cases. Of the 118 cases, 98 (83%) and 20 (17%)
received NE or O tubes, respectively. The most common underlying conditions were digestive (13.5%), hepatobiliary
(11%) and upper urinary tract (11%) disorders. Hepatobiliary (50%) and upper respiratory tract (30%) conditions
were predominant in the O tube group. Digestive (15%) and upper urinary tract (12%) diseases were more common
in the NE tube group. Complications following tube placement occurred in 22/118 cases (18.6%). The global
survival rate was 73% and did not differ between NE (71.4%) and O tube (80%) groups (P = 1.00) or disease
categories (P = 0.61). Return of appetite before feeding tube removal occurred in 56 cases (47%), within a median
of 3 days (range 1–30) and was not associated with mirtazapine administration (P = 1.00). Appetite returned earlier
for cats with NE tubes (3 days, range 1–17) than for those with O tubes (33 days, range 5–60; P <0.05). Voluntary
food intake was positively associated with survival (odds ratio 15.17). After discharge and feeding tube retrieval,
return of appetite was observed in 67% of cases.
Conclusions and relevance Feeding tubes were predominantly placed for the management of appetite disturbance
in cats with digestive, hepatobiliary and upper urinary tract diseases. While complications were frequent, they
were mostly mild, easily managed and did not preclude feeding tube use. Return to appetite occurred in a large
proportion of cats during or after assisted enteral feeding and was associated with survival.

Keywords: Appetite; anorexia; enteral nutrition; feeding tube

Accepted: 2 June 2022

Introduction
Anorexia, defined as a lack or loss of appetite, is a fre- high recovery rate (up to 88%) in the absence of an identi-
quent presenting complaint in cats and occurs in a large fied underlying primary condition.7
variety of diseases. Owing to their distinctive metabo-
lism, which requires high protein and essential amino
1Universityof Lyon, VetAgro Sup, Veterinary Campus of Lyon,
acid concentrations, cats are highly susceptible to the
Department of Companion Animals, Marcy L’Etoile, France
effects of starvation.1,2 Prolonged loss of appetite can lead 2VetAlpha, 1305 Route de Lozanne, ZA des Grandes Terres,

to severe systemic complications, including hepatic lipi- Dommartin 69380, France

dosis, intestinal impairment and immunosuppression.2,3
Early refeeding is strongly recommended for any ano-
rectic cat. It improves outcome and shortens hospitali-
sation in humans, dogs and cats.4–9 In cats with hepatic
lipidosis, early enteral feeding has been associated with
Corresponding author:
Audrey Brunet DMV, University of Lyon, VetAgro Sup, Veterinary
Campus of Lyon, Department of Companion Animals, 1 Avenue
Bourgelat, Marcy L’Etoile 69280, France
Email: audrey.brunet@vetagro-sup.fr
Brunet et al
After correction of fluid and electrolyte imbalances,
nausea and pain, several strategies can be implemented to
enhance food intake. Trying a different food or increasing
palatability of the meal is often attempted first.10–12 Some
drugs can be tried to stimulate appetite. Mirtazapine
and cyproheptadine are the two main medications rec-
ommended for cats owing to their proven efficacy and
safety.13 The efficacy and safety of mirtazapine has been
demonstrated in healthy cats and in cats with chronic kid-
ney disease, and is associated with a significant increase
in the amount of food ingested in 24–91% of cats, with few
side effects.14–17 Other drugs, such as benzodiazepines,
glucocorticoids, anabolic steroids, megestrol acetate and,
more recently, gabapentin have also been suggested.13,14
Capromorelin is another appetite stimulant currently
approved for use in dogs and was recently demonstrated
to be well tolerated in healthy cats in two randomised,
placebo-controlled studies.18
When appetite stimulants are not an option or fail to
resolve anorexia, feeding tubes are indicated to provide
enteral nutrition. Even if there is no consensus guide-
lines, three or more days of inappetence, meaning con-
sumption of less than the resting energy requirement
(RER = 70 × body weight [BW] 0.75), should prompt
assisted refeeding.11,19 In a cohort of hospitalised anorectic
dogs, a significant and positive relationship was docu-
mented between caloric intake and outcome.20 In another
study, outcome in hospitalised dogs and cats was better
for the animals that received food, regardless of the way
it was administered (forced feeding, enteral or parenteral
support).7 However, there was no comparison between
refeeding modalities, including nasoenteral (NE) and
oesophagostomy (O) tubes.7
NE and O tube placement is technically easy and
inexpensive, justifying their common use in feline
practice.3,21,22 The choice of using either an NE or an O
tube is generally based on the clinician’s estimation of
anticipated duration of feeding, type of food needed and
anaesthetic risk (for O tube placement). While NE tubes
are easy to place and do not necessitate general anaesthe-
sia, their small diameter (5–8 F) requires the exclusive use
of liquid diet. Medication through smaller tubes could
compromise their patency. Moreover, NE feeding tubes
only allow short-term nutritional support (<10 days),
while O tubes can be used for up to 8 weeks, with appro-
priate care.2,23,24
Complications associated with enteral feeding are not
rare and range from 13% to 71%.25–29 The two most com-
mon complications associated with the use of O tubes are
infections of the stoma site and tube dislodgement.29,30
Premature removal of the NE tube despite the use of an
Elizabethan collar, as well as diarrhoea, are also com-
monly reported with the use of NE tubes.27 Moreover,
one study demonstrated that the location of the tip of the
NE tube (either in the oesophagus or in the stomach) did
not influence complication rate.31
e339
Indications for enteral nutrition are highly variable but
have never been reported for cats with NE or O tubes.8,9,23–27,32
Therefore, the first aim of this study was to describe the
use of feeding tubes in a population of sick cats with
appetite disturbances. We recorded the underlying dis-
ease process, the type of tube used (NE or O tube) and the
associated complications. The second aim was to report
clinical outcomes (survival and return to voluntary food
intake) in this population.
Materials and methods
The medical records of cats hospitalised at the Internal
Medicine Service of the Veterinary Teaching Hospital of
VetAgro Sup Lyon, and managed with either NE or O
tubes, between January 2015 and January 2020, for at least
24 h, were retrospectively reviewed. Each new tube place-
ment was recorded as one case. The cases that received
NE tube followed by O tube during the same hospitalisa-
tion were included in the O group.
The following details were recorded for each case: sig-
nalment; duration of anorexia; BW; body condition score
(BCS) using a 9-point scale based on a previous publica-
tion;33 physical examination findings; blood work; diag-
nosis (if achieved); type of feeding tube (NE or O tube);
concurrent oral administration of mirtazapine; occur-
rence and nature of any complication; time from the onset
of anorexia/hyporexia to presentation at the university
(days); time from presentation at the university to feeding
tube placement (days); time from beginning of anorexia/
hyporexia to feeding tube placement (days); time from
feeding tube placement to spontaneous return of appe-
tite (days); and total duration of feeding tube utilisation
(days). Appetite disturbance was qualified as anorexia or
hyporexia. In this manuscript, ‘anorexia’ refers to com-
plete loss of appetite and ‘hyporexia’ to partial loss of
appetite. A cat could have presented first with hyporexia
and then anorexia. Return to voluntary food intake was
considered as being soon as the cat started to eat spon-
taneously even if the RER (RER = 70 × BW0.75) was not
achieved. Cats with voluntary food intake were subdi-
vided into two categories: spontaneous feeding either
resulting in <50% of RER or >50% of RER.
Clinical signs reported by owners or physical examina-
tion abnormalities were used to allocate each case to one
of the following disease groups: gastrointestinal; hepatic;
pancreatic; triaditis; neoplastic; respiratory; cardiac; uro-
genital; haematological; endocrine; and infectious disor-
ders. Cats entered the neoplastic category if they had a
tumour that could not be included in any aforementioned
category. Where there were multiple disorders, the condi-
tion that was most likely responsible for the clinical signs
prompting hospitalisation was retained. Diseases that
did not fit in any of the categories described above were
classified as ‘other’. If the diagnosis was not reached, cats
were classified in the category ‘unknown’. In this medi-
cine unit, traumatic conditions were not represented.
e340 Journal of Feline Medicine and Surgery 24(10)

Cats were categorised according to the disease cat-
egory leading to appetite disturbance and the type of
feeding tube used (NE or O tube). The feeding plan was
the same for all cats in this population. At admission,
the RER was estimated based on the following formula:
RER = 70 × BW(kg)0.75. When the appetite disturbance
lasted <5 days, the amount of food provided per day
was progressively increased to reach 100% of RER after
‘X’ days, with ‘X’ corresponding to the number of days of
anorexia. When the appetite disturbance lasted >5 days,
the amount of food provided per day was progressively
increased to reach 100% of RER over 5 days. Daily calorie
intake was divided into 4–5 meals per day. The amount
of food per day and the number of meals per day varied
depending on the cat’s tolerance (induction of vomiting,
abdominal discomfort, gastroesophageal reflux).
tube placed, 13 (65%) had been previously managed with
an NE tube and seven (35%) were only managed with an
O tube.
Clinicopathological findings
Clinical signs Clinical signs are presented in Table 1.
For the global population, the median time of appetite
disturbance before admission was 7 days (range 1–95).
Haematological and biochemical abnormalities Haemato-
logical and biochemical abnormalities are presented in
Table 2. The main biological abnormalities included
increased alanine aminotransferase (65%), hyperbiliru-
binaemia (59%), anaemia (49%), hypoalbuminaemia
(48%), hyperglobulinaemia (42%), hypokalaemia (41%)
and hyperglycaemia (41%).

Statistical analyses Disease categories Disease categories are presented in

The statistical analyses were performed using R statistical
software (Development Core Team 2008).34 The data were
generated for the general population, for cats with an NE
tube and for cats with an O tube. For continuous variables
(age, weight, BCS, temperature, time of anorexia, time
before feeding tube placement, time before feeding, time
before feeding tube retrieval), normality was assessed
using the Shapiro–Wilk test. The median and interquar-
tile ranges (IQRs; first and third quartiles) were reported
for all data, because some variables were not normally
distributed. For categorical variables (sex, vaccination,
deworming status, lifestyle, clinical signs, haematologi-
cal and biochemical abnormalities, use of mirtazapine,
survival and complications), the respective frequencies
were estimated using an exact binomial test. The cats in
each subgroup (NE vs O) were compared using the non-
parametric Wilcoxon Mann–Whitney test for continuous
variables, and the Fisher’s exact test (with subsequent
estimation of odds ratios [ORs]) for categorical variables.
For all data evaluated, a P value <0.05 was considered to
be statistically significant.
Table 3. The main diseases associated with feeding tube
placement were digestive (13.5%), hepatobiliary (11%)
and upper urinary tract (11%) diseases.
Comparison between NE and O tube groups
The subgroups (NE and O tube) were similar regarding age
(P = 0.31) and sex (P = 0.32). BW and BCS were significantly
lower in the NE group than in the O group (P = 0.03 and
P = 0.05, respectively). Time between admission and tube
placement in cats only managed with an NE or an O tube
did not differ (median 0.5 days and 0 days, respectively;
P = 0.70). For the 13 cats first managed with an NE tube
followed by an O tube, median time between admission
and O tube placement was 6 days (range 2–10). Median
time of appetite disturbance before tube placement was
similar between the NE and the O group (median 7 days
and 10 days, respectively; P = 0.85).
Table 1 Clinical signs of the 118 cases prior to
presentation

Clinical signs n (%)

Results
Population Lethargy 92 (77.9)
One hundred and twelve cats were included in the Anorexia 76 (64.4)
study, representing 118 cases of feeding tube placements, Vomiting 60 (50.8)
with six cats included twice at two different visits. Of Hyporexia 60 (50.8)
the 112 cats, there were two intact females, one intact Cardiovascular signs 51 (43.2)
male, 60 neutered females and 49 neutered males. Eight Jaundice 26 (22.0)
breeds were represented, including 91 domestic short- Pallor 25 (21.2)
hairs, eight Birmans, six Siamese, two Chartreux, two Lower respiratory signs 11 (9.3)
Maine Coons and one each of British Shorthair, Bengal Neurological signs 11 (9.3)
and Norwegian. Median age was 9 years (range 1–18). Diarrhoea 10 (8.5)
Upper urinary signs 9 (7.6)
Median BW was 3.8 kg (range 1.7–10) and median BCS
Upper respiratory signs 9 (7.6)
was 4/9 (range 1–9).
Lower urinary signs 4 (3.4)
Ninety-eight cases (83%) had an NE tube placed and
Osteoarticular signs 2 (1.7)
20 (17%) an O tube. Among the 20 cases that had an O
Brunet et al e341

Table 2 Haematological and biochemical data of the general population at admission

RI Median Range No. of No. (%) of cases No. (%) of cases

cases below the RI over the RI

RBCs (×1012/l) 6.6–12.4 7 1.9–10.7 89 37 (42) 0 (0)

Haemoglobin (g/l) 9.5–16.4 11 3.5–25 90 39 (43) 1 (1)
Haematocrit (%) 29–48 35 9.2–51.1 92 45 (49) 1 (1)
WBCs (×109/l) 3.7–18.6 14 4.8–40.2 90 4 (4) 17 (19)
Platelets (×109/l) 230–680 241 23–756 89 41 (46) 1 (1)
BUN (mmol/l) 4–11 40.5 2.3–145 105 0 (0) 40 (38)
Creatinine (μmol/l) 50–140 110 33–1948 96 3 (3) 33 (34)
Glycaemia (mmol/l) 3–8 8 1.3–24.6 99 2 (2) 41 (41)
ALT (U/l) 16–60 81 9–1604 101 3 (3) 66 (65)
ALP (U/l) 1–100 30.5 6–1274 99 0 (0) 21 (21)
GGT (U/l) 0–2 1 0–36 36 0 (0) 10 (28)
Bilirubinaemia (μmol/l) 1.0–6.0 62.5 0.3–240 49 0 (0) 29 (59)
Total proteins (g/l) 54–79 72 39–125 102 10 (10) 33 (32)
Albumin (g/l) 29–39 29 19–42 101 48 (48) 1 (1)
Globulins (g/l) 29–47 42 17–103 100 0 (0) 37 (37)
Thyroxine (nmol/l) 15–65 76 2–197 13 2 (2) 4 (31)
DGGR lipase (U/l) 0–40 24 1.5–343 36 0 (0) 10 (28)
Sodium (mmol/l) 150–165 151 114–174 99 39 (39) 9 (9)
Potassium (mmol/l) 3.7–5.8 4 3–6.2 99 41 (41) 1 (1)
Chloride (mmol/l) 112–129 116 82–137 99 31 (31) 3 (3)
iCa (mmol/l) 1.0–1.3 1.05 0.42–2.1 52 20 (38) 3 (6)
Phosphate (mmol/l) 1.37–2.58 1.6 0.7–9.9 48 12 (25) 14 (29)

RI = reference interval; RBCs = red blood cells; WBCs = white blood cells; BUN = blood urea nitrogen; ALT = alanine transaminase;
ALP = alkaline phosphatase; GGT = gamma-glutamyl transferase; DGGR = 1,2-o-dilaurylrac-glycero-3-glutaric acid-(6’methylresorufin) ester;
iCa = ionised calcium

Table 3 Underlying disease processes that had required Table 4 Underlying disease processes according to the
placement of a feeding tube in 118 cases type of feeding tubes

Disease category n (%) Disease category Nasoenteral Oesophagostomy

group (n = 98) group (n = 20)
Digestive 16 (13.5)
Hepatic 13 (11.0) Digestive 15 (15.3) 1 (5.0)
Upper urinary tract 13 (11.0) Upper urinary tract 12 (12.2) 1 (5.0)
Pancreatic 11 (9.3) Pancreatic 10 (10.2) 1 (5.0)
Neoplastic 11 (9.3) Neoplastic 11 (11.2) 0 (0)
Upper respiratory tract 9 (7.6) Hepatic 9 (9.2) 10 (50.0)
Endocrine 8 (6.8) Endocrine 8 (8.2) 0 (0)
Unknown 8 (6.8) Lower urinary tract 6 (6.1) 0 (0)
Lower urinary tract 6 (5.1) Other 5 (5.1) 0 (0)
Other 6 (5.1) Infectious 5 (5.1) 0 (0)
Infectious 5 (4.2) Lower respiratory 4 (4.1) 0 (0)
Lower respiratory tract 4 (3.4) tract
Haematological 4 (3.4) Haematological 4 (4.1) 0 (0)
Triaditis 3 (2.5) Upper respiratory tract 3 (3.1) 6 (30.0)
Cardiovascular 1 (0.8) Triaditis 2 (2.0) 1 (5.0)
Cardiovascular 1 (1.0) 0 (0)

Data are n (%)

The distribution of disease categories within the NE
and O groups is presented in Table 4. Digestive (15.3%)
and upper urinary tract (12.2%) diseases were the most
frequent categories for the cats with an NE tube. Hepatic
(50%) and upper respiratory tract (30%) categories were
the most frequent categories for the cats with O tube.
Complications
For the global population, complications following tube
placement occurred in 22/118 cases (18.6%), and are
summarised in Table 5. For the cases only managed with
e342 Journal of Feline Medicine and Surgery 24(10)

Table 5 Complications associated with feeding tubes

Complication type NE tube (n = 98) NE tube before O tube (n = 13) O tube (n = 7)

None 83 (84.7) 13 (65) NA

Removed by cat, replaced by an NE tube 7 (7.1) 0 (0) 0 (0)
Removed by cat, replaced by an O tube NA 3 (23.1) 0 (0)
Removed by cat, not replaced 7 (7.1) 0 (0) 1 (14.3)
Partial dislodgment by cat, repositioned 0 (0) 0 (0) 1 (14.3)
Infection of stoma site NA 0 (0) 1 (14.3)
Mispositioning of the tube in airway (removed) 1 (1) 0 (0) NA
Vomiting of the tube, replaced by an O tube 0 (0) 1 (7.7) 0 (0)

Data are n (%)

NE = nasoenteral; O = oesophagostomy; NA = not applicable

NE tubes, the complication rate was 15% (n = 15/98). Thirty-nine cases (33%), including 31 in the NE tube
Complications in cases only managed with O tubes were group and eight in the O tube group, received mirtazap-
reported in 43% of cases (n = 3/7). For cats managed with ine during hospitalisation. Mirtazapine was not associ-
an NE tube followed by an O tube, the complication rate ated with return to voluntary food intake (P = 1.00) or
was 31% (n = 4/13). amount of food consumed when reported (P = 0.53)
Refeeding syndrome was suspected in one cat after 10 (Table 7).
days of enteral feeding, including 7 days with an NE tube The decision to remove the tube occurred in 88/118
followed by 3 days with an O tube. The cat had appetite cases (75%), including the 56/88 cases previously
disturbance for 75 days before admission and a hepatic reported with spontaneous return of appetite and 32/88
lipidosis was diagnosed. On day 10, the cat became that did not recover appetite. The 30 cases for which the
severely lethargic and presented vomiting. Blood work tube was not removed died or were euthanased. For the
revealed hypokalaemia (2.7 mmol/l), hypophospha- global population, median time before removal was 5
taemia (1.06 mmol/l), hypomagnesaemia (0.4 mmol/l), days (range 1–61). It was 4 days (range 1–17) for the NE
hyperglycaemia (11.7 mmol/l) and anaemia (haematocrit
10.6%). The cat was managed by intravenous (IV) and
oral potassium, IV magnesium supplementation, oral Table 6 Amount of food ingested according to the type of
phosphorus supplementation, IV B1 and B6 vitamin sup- feeding tube
plementation, constant rate infusion of metoclopramide,
Consumption Consumption
IV maropitant citrate and fluid therapy. Enteral feed-
of <50% of of >50% of
ing via the O tube was continued. Anaemia required a RER RER
whole-blood transfusion. The cat survived to discharge,
and spontaneous food intake was observed on day 29. Cats with an NE tube that 19 22
had voluntary food intake
(n = 41)
Outcomes
Cats with an O tube that had 3 4
For the global population, spontaneous return to appe-
voluntary food intake (n = 7)
tite before feeding tube removal occurred in 56/118 cases
(47%), including 49/98 (50%) cases in the NE group and RER = resting energy requirement; NE = nasoenteral;
7/20 (35%) in the O group (P = 0.33). Median time before O = oesophagostomy
return to voluntary food intake was reported in 52/118
cases (44%) and was 3 days (range 1–30 days) for the whole
population. Return to voluntary food intake occurred in a Table 7 Amount of food consumed with or without oral
administration of mirtazapine
median time of 3 days (range 1–16) for the NE group and
14 days (range 7–30) for the O group (P <0.05).
Consumption Consumption
The amount of food ingested when the tube was of <50% of of >50% of
retrieved was reported in 48 cases for which return to vol- RER RER
untary intake occurred. The percentage of RER covered
was estimated as <50% in 22 cases (46%) and >50% in 26 With mirtazapine 9 8
(n = 17)
cases (54%). A comparison in the RER coverage between
Without mirtazapine 13 18
cats with NE and O tubes is presented in Table 6. These (n = 31)
results were not statistically different between groups
(P = 0.1). RER = resting energy requirement
Brunet et al
group and 33 days (range 5–61) for the O group (P <0.05).
Of those 88 cases, 86 survived to discharge (98%). The
survival rate was 72.9% for the 112 cats included in this
study and did not differ between the NE (71.4%) and O
groups (80%; P = 1.00). Survival was also similar among
disease categories (P = 0.61). Resolution of anorexia was
positively correlated with survival (OR 15.17, 95% confi-
dence interval 4.21–83.94).
Of the 32 cases that survived to discharge and did not
experience voluntary food intake before tube removal,
follow-up was available for 12 (37.5%). Return of appetite
was observed in 8/12 cases (66.7%) in a median time of
2 days (range 1–12). The last 4/12 cases remained ano-
rexic (33.3%). Two were euthanased and two underwent
another tube placement within 72 h after initial discharge.
Discussion
Few studies have documented the use of feeding tubes in
cats. Therefore, the first aim of this study was to describe
the use of NE and O feeding tubes, including underly-
ing disease processes and complications of feeding tube
placement in a large population of cats. Complications
were common and occurred in 18.6% of cases.
The second aim of this study was to evaluate survival
and return to voluntary food intake in this population.
Spontaneous food intake occurred in half of the cases
before removal of the tube, and a large proportion of the
global population survived to discharge (72.9%). When
return to voluntary eating was observed, 54% of cats ate
>50% of their RER. Time before spontaneous food intake
was significantly shorter when an NE tube was used (4
days) compared with when an O tube was used (14 days).
Survival did not depend on the type of feeding tube cho-
sen or disease category, and was positively correlated
with resolution of anorexia.
In this study, 118 cases with feeding tube placement
were documented, with 83% being NE tubes and 17%
being O tubes. Sixty-five percent of cats with an O tube
were previously managed with an NE tube. Interestingly,
median BW and median BCS were significantly higher
for cats with an O tube compared with those with an NE
tube. One explanation could be that overweight cats seem
to be more susceptible to hepatic lipidosis and so a longer,
more aggressive nutrition plan could be preferred.9,35–37
Moreover, the duration of appetite disturbance before
tube placement did not vary between cats only managed
by NE and O tubes. This might suggest that the type of
tube chosen is not only influenced by the duration of ano-
rexia, but rather by other parameters, including the sever-
ity of the condition encountered or the BCS of the patient.
Interestingly, time of appetite disturbance (7 days for NE
tube and 10 days for O tube) was longer than the period
of anorexia (3 days) generally accepted as an indication
for tube placement. This result seems to be primarily due
to the fact that, as a referral service, cats were seen in the
first instance by their primary care veterinarian.
e343
In our population, the most common underlying dis-
ease processes were digestive, hepatobiliary and upper
urinary tract diseases (13.5%, 11% and 11% of cases,
respectively). Interestingly, hepatobiliary and respira-
tory conditions were predominant (50% and 30%, respec-
tively) in the O tube group, and digestive and upper
urinary tract diseases were the most common categories
(15.3% and 12.2%, respectively) in the NE tube group.
To our knowledge, this is the first study to compare dis-
ease conditions associated both with O tube and NE tube
placement. In a recent study on O tube placement in cats,
the repartition of disease categories was slightly differ-
ent.26 Indeed, traumatic, neoplastic, pancreatic and gas-
trointestinal diseases were most common, representing
16.1%, 16.1%, 14.1% and 11.3% of cats, respectively. The
differences with our findings could be explained by dif-
ferent populations and definitions of disease categories.
Indeed, cats with trauma were not represented in our
study, as it was conducted in an internal medicine service.
Moreover, only cats with a neoplastic condition that could
not fit a previously defined category were classified in the
neoplastic subgroup in the present study, which was not
the case in the previous study.
We observed that voluntary eating occurred in 48% of
cats while the feeding tube was still in place. This result
agrees with previous studies that reported spontaneous
feeding ranges from 44% to 50%.27,32 The quantity of food
ingested at the time of removal of the tubes represented
<50% of RER in 46% of cats and >50% of RER in 54%.
To our knowledge, this study is the first to document a
quantitative evaluation of voluntary food intake during
utilisation of feeding tubes in cats. Almost half of the cats
ate <50% of RER when their tube was retrieved. For cats
remaining anorexic despite assisted nutrition with an NE
tube, appetite at home is often tested to rule out appetite
disorders related to stress within the hospital areas before
drawing any conclusions and considering other means of
feeding. Considering the small number of cats managed
with an O tube alone, it remains difficult to draw clear
conclusions regarding food intake. Median time before
tube removal was significantly shorter in the NE group
compared with the O group. Obviously, NE tubes are
retrieved earlier than O tubes, as they are a more short-
term option due to their use and discomfort caused to
the patient. An earlier return to voluntary eating for cats
within the NE group is also logically expected. Moreover,
in our hospital, cats are never discharged with their NE
tube.
Mirtazapine is a serotonin and presynaptic alpha2-
receptor antagonist that acts as an appetite stimulant. In
our study, the use of mirtazapine did not appear to act
on qualitative (return to voluntary food intake or not) or
quantitative (<50% of RER or >50% of RER) food intake.
This finding is unexpected as an appetite-stimulating
effect of oral or transdermal mirtazapine has been dem-
onstrated in several studies comparing sick and healthy
e344
cats.13,14–17,38 However, to our knowledge, the effect of mir-
tazapine in cats managed with enteral feeding has never
been previously evaluated. It cannot be excluded that
the tube in place might alter the response to mirtazapine.
The survival rate in this population of cats managed
by NE and O tubes was 72.9%, which is comparable to
those registered in previous canine and feline case series
with enteral feeding, ranging from 65.3% to 83%.7,26,27
Moreover, the mortality rate did not significantly differ
according to the type of tube or among disease catego-
ries. In a previous study assessing the effect of nutritional
support including enteral and parenteral nutrition and
forced feeding on hospital outcome, outcome was mainly
related to disease severity.7 Indeed, survival might rather
be influenced by the severity of the disease process itself
rather than the type of tube chosen. However, disease
severity was not assessed in our population of cats, and
it precludes further conclusions regarding factors influ-
encing survival. Resolution of anorexia was significantly
and positively associated with survival in our study. This
result is in accordance with previous studies, which have
demonstrated that persistent anorexia can lead to nega-
tive effects on wound healing, immune function, skeletal
and respiratory strength and overall prognosis.13,39,40
Complications associated with enteral feeding were
common and occurred in 18.6% of cases. In our study,
the complication rate associated with the use of NE tubes
was 15%, with self-removal of the NE tube being the
most common (14.2%). This complication rate appears
to be lower than previously reported with NE tubes (42–
71%).27,32 However, the prevalence of NE tube removal
is similar to that documented in other studies (11–18%),
and diarrhoea, which was the main complication pre-
viously reported with feeding tubes (25–27%), was not
noted in this study. In our study, complications associated
with the use of O tubes occurred in 43% of cases, which
is in the range of frequencies reported in the literature
(13–71%).25,26,28–30 As in two recent studies, infection of
the stoma site (14.3%) and partial tube dislodgement or
complete removal (28.6%) were the two most common
complications associated with the use of O tubes.26,30
Interestingly, refeeding syndrome was diagnosed in
one cat in our study, which led to an overall prevalence
of 0.8%. In our case, duration of appetite disturbance
before tube placement was 11 weeks, which was simi-
lar to the results of a recent study (range 3–104).41 This
cat presented electrolyte disturbances (hypokalaemia,
hypophosphataemia and hypomagnesaemia), hypergly-
caemia and anaemia, which is in accordance with previ-
ously reported biological abnormalities.41,42
The main limitation of our study was its retrospective
design, which led to missing information. The percent-
age weight loss since the beginning of appetite distur-
bance was not documented. It would have been a more
interesting parameter to assess than BW or BCS, as this
Journal of Feline Medicine and Surgery 24(10)
parameter is dynamic and could reflect disease evolution.
Moreover, disease severity, usually determined by clini-
cal scores, was not evaluated. It was an important con-
founding factor, as disease severity could have influenced
the choice for a specific feeding option and global prog-
nosis. Furthermore, owing to the retrospective design,
the occurrence of diarrhoea as a complication of enteral
feeding could not be included, as it was inconsistently
reported in the medical database. Another limitation is
that many cats (18.6%) were lost to follow-up after tube
removal, which affected precise evaluation of outcomes
associated with the use of NE tubes and O tubes. Then,
even if the effect of mirtazapine was quantitatively inves-
tigated by evaluation of RER coverage, a slight improve-
ment of food intake (+10–20%) could have been missed.
Finally, our study was conducted in the internal medicine
service of a tertiary veterinary teaching hospital, which
led to selection bias, with the exclusion of traumatic dis-
eases, for instance. Therefore, the results cannot be gener-
alised to all anorectic cats with enteral feeding.
Conclusions
Enteral feeding was well tolerated in cats, and diseases
associated with the use of feeding tubes were highly vari-
able. Minor complications were not infrequent, but were
easily managed. Even if return to voluntary food intake
occurred in less than half of the cases before tube removal,
it was reported in a larger proportion of cases thereafter.
This suggests that spontaneous food recovery can be
attempted at home in some cases. Mirtazapine appeared
safe in cats with feeding tubes but was not associated
with resolution of anorexia.
Author note This original study was presented as a poster at
the 2020 ECVIM-CA congress, using preliminary data collected
from January 2015 and July 2018.
Conflict of interest The authors declared no potential
conflicts of interest with respect to the research, authorship,
and/or publication of this article.
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Ethical approval The work described in this manuscript
involved the use of non-experimental (owned or unowned)
animals. Established internationally recognised high standards
(‘best practice’) of veterinary clinical care for the individual
patient were always followed and/or this work involved the
use of cadavers. Ethical approval from a committee was there-
fore not specifically required for publication in JFMS. Although
not required, where ethical approval was still obtained, it is
stated in the manuscript.
Informed consent Informed consent (verbal or written)
was obtained from the owner or legal custodian of all animal(s)
Brunet et al
described in this work (experimental or non-experimental
animals, including cadavers) for all procedure(s) undertaken
(prospective or retrospective studies). No animals or people are
identifiable within this publication, and therefore additional
informed consent for publication was not required.
ORCID iD Audrey Brunet https://orcid.org/0000-0002-
1469-327X
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