Best Evidence Summary for the Prevention and Management of Enteral Nutrition-Related Abdominal Distension in Stroke Patients
#These authors contributed equally to this work
Objective: This study aims to retrieve, select and consolidate the relevant evidence of enteral nutrition-related abdominal distension in stroke patients, providing a decision-making basis for healthcare professionals to carry out evidence based practice on abdominal distension in these patients.
Method: According to the “5S” model of the evidence pyramid, relevant evidence on the prevention and management of enteral nutrition-related abdominal distension in stroke patients was retrieved from domestic and foreign databases, including clinical decision-making studies, guidelines, evidence summaries, best practices, expert consensus, and systematic reviews. The search spanned from the establishment of the database to March 25, 2025. During the process of evaluation and data extraction, the retrieved guidelines were evaluated by four researchers who had received systematic training in evidence-based methodology, and the remaining literature was independently and rigorously evaluated by two researchers.
Result: A total of 12 articles were included in this review, consisting of 1 clinical decision making study, 1 guideline, 3 expert consensus documents, 1 summary of evidence, and 6 systematic reviews. From ten aspects, including forming a multidisciplinary team, risk assessment, management of enteral nutrition, feeding position, dietary adjustment, aerobic exercise, psychological support, drug management, Traditional Chinese Medicine therapy, and monitoring and recording, we extracted a total of 32 pieces of best evidence.
Conclusion: Given the results of this study, we suggest that future researchers conduct larger-scale, multi-center, longitudinal studies to verify our findings and further explore the association between increased abdominal circumference and the severity of abdominal distension in stroke patients, as well as the development of specific abdominal distension rating scales. Such research will provide high-quality evidence and contribute to the development of evidence-based management of enteral nutrition-related abdominal distension in stroke patients.
[1] Bath P. M., Lee H. S., & Everton L. F. (2018). Swallowing therapy for dysphagia in acute and subacute stroke. The Cochrane Database of Systematic Reviews, 10(10), CD000323. doi: 10.1002/14651858
[2] Branch of Gastrointestinal Diseases, China Association of Chinese Medicine. (2024). Expert consensus on Traditional Chinese Medicine diagnosis and treatment of abdominal distension (2023). Chinese Journal of Integrated Traditional Chinese and Western Medicine in Gastroenterology, 32(11), 939-944. doi: 10.3969/j.issn.1671-038X.2024.11.01
[3] Brouwers M. C., Kho M. E., Browman G. P., Burgers J. S., Cluzeau F., Feder G., ... & Zitzelsberger L., & AGREE Next Steps Consortium. (2010). AGREE II: Advancing guideline development, reporting and evaluation in health care. Canadian Medical Association Journal, 182(18), E839-E842. doi: 10.1503/cmaj.090449
[4] Chinese Society of Parenteral and Enteral Nutrition (CSPEN). (2023). Guideline for clinical application of parenteral and enteral nutrition in adults patients in China (2023 edition). Chinese Medical Journal, 103 (13), 946-974. doi: 10.3760/cma.j. cn112137-20221116-02407
[5] Cui Z., Wu Z. Z., Zhang J. H., & Liu Y. (2019). Effect of evodia rutaecarpa hot compression combined with ear point pressing bean nursing on abdominal distension and gastrointestinal function in elderly stroke constipation patients. Journal of North Sichuan Medical College, 34(3), 466-469. doi: 10.3969 /j. issn.1005-3697.2019.03.39
[6] Diane A., & Nicholas J.T. (2024). Overview of intestinal gas and bloating. Datebase: UPToDate. Retrieved from: https://kyuptodate.didavvis. cn/contents/overviewof-intestinal-gas-and-bloating?search=Overview%20of% 20intestinal% 20gas% 20and% 20bloating&source=search_result&selectedTitle=1~150&usage_type=de‐fault&display_rank=1
[7] Dong H., & Lu D. W. (2022). Guidelines for chronic disease management of ischemic stroke in the elderly. Research of Integrated Traditional Chinese and Western Medicine, 14(6), 382-392. doi: 10.3969/j. issn. 1674-4616.2022.06.006
[8] Evidence-based Nursing Center, West China Hospital, Sichuan University, Nursing Management Professional Committee of Chinese Nursing Association, & Chinese Neurosurgical Society, Chinese Medical Association. (2021). Nursing practice guideline for enteral nutrition in patients with stroke. Chinese Journal of Evidence Based Medicine, 21(6), 628-641. doi: 10.7507/1672-2531.202101115
[9] Fekri Z., Aghebati N., Sadeghi T., & Farzadfard M. T. (2021). The effects of abdominal "I LOV U" massage along with lifestyle training on constipation and distension in the elderly with stroke. Complementary Therapies in Medicine, 57, 102665. doi: 10.1016/j.ctim.2021.102665
[10] Feigin V. L., Brainin M., Norrving B., Martins S. O., Pandian J., Lindsay P., F Grupper M., & Rautalin I. (2025). World Stroke Organization: Global Stroke Fact Sheet 2025. International Journal of Stroke, 20(2), 132-144. doi: 10.1177/17474930241308142
[11] Guo G. H., Xu X. M., Wang H. L., & Liu N. (2023). Summary of the best evidence of airway nursing management in patients with respiratory infection after stroke. Chinese Journal of Nursing, 58(1), 31-38. doi:10.3761/j.issn.0254-1769.2023.01.004
[12] Guo Y. B. (2019). Construction and evaluation of bundle care for postoperative abdominal distension in patients with liver cancer. Thesis. Xinxiang Medical College. doi: 10.27434/d.cnki.gxxyc.2019.000259
[13] Hu J., Chen T., Wang Z., Chen X., Lin K., Zhang G., ... & Wu J. (2022). Geriatric nutritional risk index and the prognosis of atients with stroke: A meta-analysis. Hormone and Metabolic Research, 54(11), 736-746. doi:10.1055/a-1886-4276
[14] Li M. L., Fan C. F., Duan L. J., Wang C., & Jiang Y. (2023). Effects of care bundles on reducing the enteral feed intolerance in patients with hemorrhagic stroke. Chinese Nursing Management, 23(12), 1774-1779. doi:10.3969/j.issn.1672-1756.2023.12.003
[15] Lin J. P., Li J., Chen S., Tang Y. Z., Wang M. H., Cao L. J., & Li Q. (2024). Application of bedside ultrasonography combined with enteral nutrition tolerance score in nutritional support for elderly patients with hemorrhagic stroke. Chinese Journal of Minimally Invasive Neurosurgery, 28(11), 682-686. doi: 10.11850/j. issn.1009-122X.2024.11.011
[16] Liu F., Gao L., Wang X. Y., Wang Y. J., Deng Q. X., Miao F. G., ... & Guo S. L. (2022). Expert consensus on enteral feeding nursing for patients with severe neurological disorders. Chinese Journal of Nursing, 57(3), 261-264. doi: 10.3761/j.issn.0254-1769.2022.03.001
[17] Liu N., Li Q., & Sun W. S. (2023). Application research of bedside ultrasound gastric residual volume monitoring in the implementation of enteral nutrition for critically ill stroke patients in ICU. Modern Diagnosis and Treatment, 34(9), 1355-1357. doi: 1001.8174(2023)09.1355.02
[18] Liu P., Tian H., Ji T., Zhong T., Gao L., & Chen L. (2023). Predictive value of malnutrition, identified via different nutritional screening or assessment tools, for functional outcomes in patients with stroke: A systematic review and meta-analysis. Nutrients, 15(14), 3280. doi: 10.3390/nu15143280
[19] Liu R. Y. (2020). Efficacy of press beans at points on prevention non-invasive ventilator-induced bloating in patients with chronic respiratory failure. Clinical Research of Traditional Chinese Medicine, 12(7), 126-128. doi: 10.3969/j.issn.1674-7860.2020.07.046
[20] Luo C. M., Zeng J. X., Liao Y. P., Yang Y., Ma H. X., & Zheng J. X. (2025). Observation on therapeutic effect of Yiqi Tongfu abdominal massage on constipation of Qi deficiency type in stroke patients. Nursing Research, 39 (2),279-284. doi:10.12102/j.issn.1009-6493.2025.02.016
[21] Ma R., Wang T. T., Liu H. H., & Qu Y. (2020). Research progress on the assessment of non-verbal anxiety in patients with aphasia and cognitive impairment after stroke. Chinese Journal of Rehabilitation Medicine, 35 (4), 502-507. doi: 10.3969/j.issn.1001-1242.2020.04.023
[22] Mi Y. Y., Huang P. P., Wu B.N., Bao L., Xiang C. L., Lu S. W., & Huang H. Y. (2022). Prevention and management of enteral nutrition associated abdominal distention in ICU patients: Best evidence summary. Journal of Nursing Science, 37(2), 91-95. doi: 10.3870/j.issn.1001-4152.2022.02.091
[23] Moon H. J., Noh S. E., Kim J. H., & Joo M. C. (2015). Diagnostic value of plain abdominal radiography in stroke patients with bowel dysfunction. Annals of Rehabilitation Medicine, 39(2), 243-252. doi: 10.5535/arm.2015.39.2.243
[24] Moshiree B., Drossman D., & Shaukat A. (2023). AGA clinical practice update on evaluation and management of belching, abdominal bloating, and distention: Expert review. Gastroenterology, 165(3), 791-800. e3. doi:10.1053/j.gastro.2023.04.039
[25] Neri L., Iovino P., & Laxative Inadequate Relief Survey (LIRS) Group. (2016). Bloating is associated with worse quality of life, treatment satisfaction, and treatment responsiveness among patients with constipation predominant irritable bowel syndrome and functional constipation. Neurogastroenterology and Motility, 28 (4), 581-591. doi: 10.1111/nmo.12758
[26] Neurology Branch of the Chinese Medical Association. (2017). Guidelines for early rehabilitation treatment of stroke in China. Chinese Journal of Neurology, 50(6), 405-412. doi: 10.3760/cma. j. issn. 1006-7876.2017.06.002
[27] Nishioka S., Yamasaki K., Ogawa K., Oishi K., Yano Y., Okazaki Y., ... & Kurihara M. (2020). Impact of nutritional status, muscle mass and oral status on recovery of full oral intake among stroke patients receiving enteral nutrition: A retrospective cohort study. Nutrition & Dietetics, 77(4), 456-466. doi: 10.1111/1747-0080.12579
[28] Page M. J., McKenzie J. E., Bossuyt P. M., Boutron I., Hoffmann T. C., Mulrow C. D., ... & Moher D. (2021). Updating guidance for reporting systematic reviews: Development of the PRISMA 2020 statement. Journal of Clinical Epidemiology, 134, 103-112. doi: 10.1016/j.jclinepi.2021.02.003
[29] Pasin Neto. H., & Borges R. A. (2020). Visceral mobilization and functional constipation in stroke survivors: A randomized, controlled, double-blind, clinical trial. Cureus, 12(5), e8058. doi: 10.7759/cureus.8058
[30] Shi H., Du Y. Y., Ren Y., Liu L., & Zhang J. J. (2022). Effects of intermittent oro-esophageal tube feeding on stroke patients with dysphagia: A meta-analysis. Xinjiang Medical Journal, 52(8), 875-880. doi: 1001.5183(2022)08.875.06
[31] Shimizu A., Maeda K., Koyanagi Y., Kayashita J., Fujishima I., & Mori N. (2019). The global leadership initiative on malnutrition-defined malnutrition predicts prognosis in persons with stroke-related dysphagia. Journal of the American Medical Directors Association, 20(12), 1628-1633. doi: 10.1016/j.jamda.2019.07.008
[32] Sun T., Wang K., Li L., Yan M., Zou L., Zhang M., ... & Liu J. (2023). Efficacy and safety of acupuncture in post-stroke constipation: A systematic review and meta analysis. Frontiers in Neuroscience, 17, 1275452. doi:10.3389/fnins.2023.1275452
[33] Tan J. P., Liu H., Deng G. M., & Tan D. C. (2018). Meta analysis of occurrence of gastrointestinal complications in patients with cerebral apoplexy under different tube feeding methods. Nursing Research, 32(2), 247-252. doi: 10.3969/j.issn.1009-6493.2018.02.02
[34] Tuz A. A., Hasenberg A., Hermann D. M., Gunzer M., & Singh V. (2022). Ischemic stroke and concomitant gastrointestinal complications-a fatal combination for patient recovery. Frontiers in Immunology, 13, 1037330. doi: 10.3389/fimmu.2022.1037330
[35] Wang C., Liu S., Jia S., Yan C., Zhang X., Liu Y., ... & Jiang Y. (2024). Care bundles to improve enteral nutrition management in stroke patients: Study protocol for a stepped wedge cluster randomised trial. Trials, 25(1), 795. doi: 10.1186/s13063-024-08645-1
[36] Wang C. Q., & Hu Y. (2015). JBI evidence pre-grading and evidence recommendation level system (2014 edition). Journal of Nurse Training. Journal of advanced nursing, 30(11), 964-967. doi: 10.16821/j. cnki. hsjx.2015.11.002
[37] Wang Y. J., Zhao X. Q., Wang S. S., Ji R. J., & Wang C. X. (2020). Expert consensus on standardized management of stroke nutrition in China. Chinese Journal of Stroke, 15(6), 681-689. doi: 10.3969/j. issn. 1673-5765.2020.06.019
[38] Wang Y. Q. (2018). Nutritional support nursing for a patient with cerebral hemorrhage complicated with intra abdominal hypertension. Journal of Nursing of the People’s Liberation Army, 35(7), 69-71. doi: 10.3969/j.issn.1008-9993.2018.07.017
[39] Wang Y. X., Wang L. T., Huang Z. W., Li T. L., & Ouyang X. F. (2021). Effectiveness of traditional Chinese medicine in treating gastrointestinal dysfunction in patients with acute stroke: A systematic review and meta analysis of 16 randomized controlled trials. Annals of Palliative Medicine, 10(11), 11808-11820. doi: 10.21037/apm-21-2915
[40] Wang Z. Z., Li W. R., Zhang Z. G., Han X. Y., Ma X. J., & Zhang C. Y. (2022). Effects of probiotics combined with early enteral nutrition on intestinal function in patients with severe stroke: A meta-analysis. Chinese Journal of Stroke, 17(10), 1071-1081. doi: 10.3969/j. issn.1673-5765.2022.10.006
[41] Wu Y. P., Tian Y. J., Shen M. F., Feng L. M., Shen Q. Y., Shen L. Y., ... & Jiao W. (2021). The role of intestinal noise monitoring in the assessment of enteral nutrition tolerance in patients with acute hemorrhagic stroke. Journal of Advanced Nursing, 36(20), 1835-1838. doi:10.16821/j.cnki.hsjx.2021.20.003
[42] Xing J., Zhang Z. H., Ke L., Zhou J., Qin B. Y., & Liang H. K. (2019). A cross-sectional study on nutritional status of ICU patients in the mainland China. Medical Journal of the People’s Liberation Army, 44(5), 388-393. doi: 10.11855/j.issn.0577-7402.2019.05.05
[43] Xing W. J., Zhou Y. F., Zhu Z., Chen Y., Gu Y., & Zhang X. J. (2025). The evolution of the evidence pyramid: from the "6S" model to the "5S" model. Journal of Advanced Nursing, 40(13), 1345-1348. doi: 10.16821/j.cnki.hsjx.2025.13.001
[44] Yang C. C., Ji X. F., Ma H. L., Li Y. L., & Zheng L. W. (2016). Effects of feeding position on the incidence of complications for patients with dysphagia pos-stroke: A meta analysis. Journal of Advanced Nursing, 31(24), 2223-2227. doi: 10.16821/j.cnki.hsjx.2016.24.006
[45] Yi J. H., Chun M. H., Kim B. R., Han E. Y., & Park J. Y. (2011). Bowel function in acute stroke patients. Annals of Rehabilitation Medicine, 35(3), 337-343. doi:10.5535/arm.2011.35.3.337
[46] Yue M., Zhang Y. H., Geng X. J., Zhou Y., Wang L. Y., & Feng J. (2023) Summary of the best evidence for non pharmacological prevention and management of constipation in stroke patients. Nursing Practice and Research, 20(13), 1961-1967. doi: 10.3969/j. issn.1672-9676.2023.13.013
[47] Zhao X. (2023). Study on the evolution law of TCM syndromes in acute gastrointestinal injury after acute phase of ischemic stroke. Thesis. Shandong University of Traditional Chinese Medicine. doi: 10.27282/d. cnki.gsdzu.2023.000952
[48] Zhang F. Y., Shen A. M., Zeng X. T., Qiang W. M., & Jin Y. H. (2018). An Introduction to AMSTAR 2: A critical appraisal tool for systematic reviews. Chinese Journal of Evidence-Based Cardiovascular Medicine, 10(1), 14-18. doi: 10.3969/j.issn.1674-4055.2018.01.03
[49] Zhu J. (2023). Clinical study of tiankuang decoction on treating spleen deficiency and dampness obstruction of functional abdominal bloating with somnipathy on "stomach disharmony leads to restlessness". Thesis. Shandong University of Traditional Chinese Medicine. doi: 10.27282/d.cnki.gsdzu.2023.000980