[What are the means of alimentary function supply and their indications in amyotrophic lateral sclerosis?]

Artificial nutrition is necessary when oral feeding becomes insufficient to cover protein and energetic needs and becomes dangerous (risk of malnutrition, dehydration and aspiration). In ALS patients, enteral nutrition is the method of choice and gastrostomy is preferable to nasogastric tube which must be limited for a short term enteral nutrition or if gastrostomy is at risk (because of pulmonary function) or refused by the patient. The percutaneous gastrostomy can be placed endoscopically (PEG) or radiologically (RIG), surgical gastrostomy has to be avoided because of general anaesthesia. Advantages of RIG are a success rate of about 100 percent and a placement feasible without sedation but its superiority on PEG in ALS patients especially if pulmonary functions are altered is not demonstrated. No objective criterion permits to define the exact moment of enteral nutrition. However, enteral nutrition is recommended when dysphagia becomes symptomatic (insufficient caloric intake with weight loss, dehydration, frequent choking and aspiration). Swallowing disorders must be detected early to give to patients and their family information about enteral nutrition and gastrostomy as soon as possible and to help them to decide. It is desirable to propose gastrostomy when forced vital capacity is yet above 50 percent and nutritional state not altered (body mass index>18kg/m2 and/or weight loss<10 percent). Enteral nutrition is not desirable in ALS patients with dementia or in the preterminal phase. Suitable enteral nutrition with regular nutritional evaluation can improve nutritional status. Currently, improvement of quality of life and survival due to enteral nutrition has not been proved in ALS patients.