Which of the following would least likely be something you would track for a person with a feeding tube, based solely on the fact they have a feeding tube? Most formulas contain 0.5, 1, or 2 kcal/mL. Thus, Clostridium difficile is likely to contribute to some cases of EN feeding related diarrhea, but certainly not all. Please consult your Clipboard, Search History, and several other advanced features are temporarily unavailable. 2012 Sep;83(3):171-4. doi: 10.4174/jkss.2012.83.3.171. The effect of fiber supplementation on the prevention of diarrhea in hospitalized patients receiving enteral nutrition: A meta-analysis of randomized controlled trials with the GRADE assessment. Factors related to the enteral nutrition that may contribute to diarrhea include the composition of the formula, the manner of administration, or bacterial contamination. Bethesda, MD 20894, Web Policies Pedialyte is safe to give. For example, some drugs such as acetaminophen (Tylenol) contains sorbitol, and others such as antacids contain magnesium or docusate sodium. Federal government websites often end in .gov or .mil. information submitted for this request. WebAll patients with diarrhea received the usual treat-ments and investigations for diarrhea in accordance with the units normal bowel management protocol.1 In addi-tion, patients entering the study received 1 study capsule every 12 hours for 7 days via gastric feeding tube. In those cases, a feeding tube might not help you feel better or live longer. Federal government websites often end in .gov or .mil. The reason for this apparent lack of an effect by fiber on bowel function may lie in the small particle size of soy polysaccharide in enteral formula, which is necessary to help reduce viscosity of the feed. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving enteral feedings. 2018 Nov 28;10(12):1833. doi: 10.3390/nu10121833. Travelers' diarrhea. Homann HH, Kemen M, Fuessenich C, Senkal M, Zumtobel V. JPEN J Parenter Enteral Nutr. Careers. 8600 Rockville Pike Nutrition, 2019, 59: 158-169. Diarrhea occurs frequently in the critically ill tube-fed population and may result from a multitude of causes. 2004;1(3):309-17. doi: 10.1385/ncc:1:3:309. with your clinician prior to use. However, when the tube feed is administered continuously in small amounts over the course of a whole day, you may feel less of the sensation of fullness. Bioinformation. advice. Sometimes you may experience problems when tube feeding. Curr Gastroenterol Rep. 2020 Jan 7;22(1):1. doi: 10.1007/s11894-019-0736-z. Fiber may be recommended as part of a standard tube-feeding regimen to help assure gut mucosal integrity but not specifically to treat constipation/diarrhea. Epub 2021 Sep 30. Doctors usually insert the tube while you are in the hospital, but you may continue to use it outside the hospital, at home, or in a nursing facility. This site complies with the HONcode standard for trustworthy health information: verify here. digoxin and propanolol) and so called inert fillers of drugs which can include magnesium stearate, docusate sodium and sorbitol. 0000003323 00000 n D. The persons facial expressions become distressed looking during a feeding. J Korean Surg Soc. members share their stories on our website for the benefit of others in If diarrhea is severe, it may be necessary to stop enteral feeding and institute parenteral nutrition (PN) with its associated risks and costs. 1991 Jul;86(7):921-2. Diarrhea, defined as an increase in bowel frequency and/or fluid content of the stool, can result in nutrient and electrolyte loss in patients being tube fed. PMC trailer Change all oral liquid medications to tablet or parenteral alternative; change oral electrolyte solutions to parenteral route; discontinue all known cathartics (see orange box) Eur J Clin Nutr. Summary: The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Inpatients at the Truman Memorial Veterans Hospital who received nasoenteric feeding during the time period from October 1986 through May 1988 were eligible for this study. This occurred despite a threefold increase in the number of patients testing positive for Clostridium difficile toxin in the banana flake group. Feeling thirsty, Gaining weight quickly (more than 5 pounds or 2 kg per week). Make sure you are taking the right amount of formula and/or feeding rate. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). J Pediatr 1992;120: 56972. 2019 Nestl, Chronic Medical Conditions / Rare Diseases, Other stomach/digestive problems or illness, Slow or stop the feed until you are comfortable. Some of these medications are not recommended for children. You can help maintain your electrolyte levels by drinking fruit juices for potassium or eating soups for sodium. You may need to switch to a formula that has more calories in less volume or to a special formula that may be easier to digest and absorb. official website and that any information you provide is encrypted 2000 Mar-Apr;49(2):101-8. doi: 10.1097/00006199-200003000-00007. Laboratory tests included fecal leukocytes, stool osmolality, stool electrolytes, and Clostridium difficile toxin assay. 1989 Jun;24(2):339-53. Water may always be offered. Ask your healthcare professional to review your formula. Evidence-based roads to the promotion of health in old age. NCI CPTC Antibody Characterization Program. Recent findings: Fiber in tube feeds: Many commercially produced liquid EN tube feeds are low in fiber (poorly metabolized carbohydrate). 38 0 obj<>stream WebTube feeding can give the sensation of fullness, the same way you would be affected by eating food. Tube feeding is also known as enteral nutrition and if provided at home, is termed home enteral nutrition (HEN). Khoshoo Vet al. Epub 2011 Mar 18. Using a formula with a lower fat content (and thus lower energy density) may alleviate diarrhea due to fat malabsorption in patients with a short bowel and retained colon. 2002, 56: 1-3. Review of the medications and determination of the stool osmotic gap are the initial diagnostic steps of highest yield. Your doctor may recommend enteral nutrition if your gastrointestinal tract (digestive system) works, but you cannot eat due to another disorder that affects your appetite or ability to chew or swallow. Takeaway. Accessed May 11, 2021. The site is secure. Checking placement even with g tubes. Colomb Med (Cali). A nasogastric (NG) tube is a thin, soft tube made of plastic or rubber that is passed through the nose, down through throat, and into the stomach. FAX 518-262-5528. 0000000756 00000 n 0000015224 00000 n Stool output>3-5 liquid BM or >750 mL over 24 hr? What, if anything, seems to improve your symptoms? Percutaneous endoscopic gastrostomy: a safe and effective bridge for enteral nutrition in neurological or non-neurological conditions. The .gov means its official. Adapted from VCH Tube Feeding at Home November 2011 and BCCA FV Tube Feeding at Home Diarrhea An abnormal increase in stool frequency and volume, or watery stool. %PDF-1.4 % Study Resources. Read our, Membership Management Software Powered by, Industry Code of Conduct In-person Meetings, Policy on Diversity, Equity, and Inclusion, Consumer/Caregiver COVID SurveyFall 2020, Consumer/Caregiver COVID SurveySpring 2020, Sample Travel Letter for Tube & IV Consumers, Community Enrichment Program Presentations. In patients with a short bowel and no colon, additional factors contribute to the development of diarrhea, including loss of the daily intestinal secretions produced in response to food, and rapid gastric emptying and small bowel transit. Doctors usually 16 0 obj <> endobj Webo Continuous open system feeding will clean the bag rehang with new feeding o from NUR 155 at Galen College of Nursing. You should discuss all issues, ideas, suggestions, etc. b) Checking neurovascular status of the right exposed foot and toes every four hours. 45.1%), tube leakage (6.4%), dermatitis of the stoma (6.4%), and diarrhea (6.4%). Fat malabsorption: Problems with fat absorption can cause diarrhea in tube fed patients. and transmitted securely. 2010 Dec;26(6):314-26. doi: 10.1016/j.iccn.2010.07.001. WebVenting gastrostomy Your doctor may recommend a venting gastrostomy to relieve pressure inside your stomach. Patients with severe pancreatic disease may have a deficiency of lipase necessary to hydrolyze triglycerides, and gastric surgery may prevent adequate mixing of lipase with luminal contents. All trademarks are owned by Socit des Produits Nestl S.A., Vevey, Switzerland and used under licence. If your tube is blocked, do not try to remove the blockage yourself. Please enable it to take advantage of the complete set of features! Accessibility Nutrients. Agudelo GM, Giraldo NA, Aguilar NL, Restrepo BE, Vanegas M, Alzate S, Martnez M, Gamboa SP, Castao E, Barbosa J, Romn J, Serna AM, Hoyos GM. Insoluble fiber, on the other hand, promotes laxation and adds bulk to the stool, which may help prevent constipation. Attach large (60ml) open ended syringe to feeding tube and allow gas to escape. 2012 Jun 30;43(2):147-53. eCollection 2012 Apr. Stay away from chewing gum or products with sweeteners such as sorbitol or xylitol as these can make your diarrhea worse. Feeding intolerance is often talked about by the signs or symptoms people have which may vary from feeling full and having a swollen belly (abdomen) to vomiting or diarrhea. Contaminated formula and feeding equipment: EN formula provides an excellent growth medium for a variety of micro-organisms, and once contaminated they will rapidly multiply. Clinical management involved reducing or stopping the feeding formula, stopping marketing, or research purposes. Unauthorized use of these marks is strictly prohibited. Diarrhea has great impact on enteral nutrition. HHS Vulnerability Disclosure, Help endstream endobj 37 0 obj<>/Size 16/Type/XRef>>stream You should discuss American Society for Gastrointestinal Endoscopy. PMC Sorry, you need to enable JavaScript to visit this website. MeSH "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. WebTube feeding can give the sensation of fullness, the same way you would be affected by eating food. The most common cause of nosocomial diarrhea is Clostridium difficile. Although tube feeding has been recognized as a risk factor for diarrhea, the relation between tube feeding and C. difficile infection has not been investigated. Feeding Tubes Feeding Tubes Page 1 nausea, vomiting, and diarrhea. 2020 Feb 26;13:1178638820905992. doi: 10.1177/1178638820905992. START Distended, tympanic, or painful abdomen? Please note much of the data used in the article is based on in-hospital studies completed in Europe, thus some sections may not match the US homeEN consumers experience. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 1994 Nov-Dec;18(6):486-90. doi: 10.1177/0148607194018006486. Tube feeding is needed when a person can't eat through their mouth, for whatever reason. Chowdhury AH, Murray K, Hoad CL, Costigan C, Marciani L, Macdonald IA, Bowling TE, Lobo DN. Few controlled studies of fiber-containing tube feedings have been performed. We are grateful to the authors, and Greenwich Medical Media Limited, for allowing us to reprint this condensed version of a chapter that appears in Intestinal Failure 2001, edited by Jeremy Nightingale, MD. 2001 Aug;20(4):301-5. doi: 10.1054/clnu.2001.0399. Faecal microbiota and short-chain fatty acids in patients receiving enteral nutrition with standard or fructo-oligosaccharides and fibre-enriched formulas. Fiber does play a role in maintaining gut integrity in all patients, whether they have diarrhea or not. Khanna S (expert opinion). Neurocrit Care. 2013 Dec;28 Suppl 4:25-8. doi: 10.1111/jgh.12272. Formula delivery in patients receiving enteral tube feeding on general hospital wards: the impact of nasogastric extubation and diarrhea. But certain fruit juices, such as apple juice, might make diarrhea worse. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). government site. Fifteen years later, another one saved my son, Home for Our Patients Earlier allows parents of premature babies to leave hospital sooner, Newsletters: Tube Feeding Associated Diarrhea. However if a patient with diarrhea is taking some oral food, it is important to check that they are not consuming too much milk or milk products. It is not intended to provide medical advice or recommend a course of treatment. information presented, and is not liable if information is incorrect or National Library of Medicine Unauthorized use of these marks is strictly prohibited. 3. Nutrition. 2022 Nov 25;9:1008464. doi: 10.3389/fnut.2022.1008464. J Gastroenterol Hepatol. If your doctor determines that an antibiotic caused your diarrhea, he or she might lower your dose or switch to another medication. Banana flakes can be given concurrently with a workup for C. difficile colitis, thereby expediting treatment of diarrhea. %%EOF The clinician should first determine whether the diarrhea is osmotic or secretory. Drugs and antibiotics, Major Contributors, Contaminated formula and feeding equipment. Getting them OOB everyday to sit up in chairs. include protected health information. Bookshelf Of 123 patients who received nasoenteric feeding, 32 patients had documented diarrhea (greater than 500 mL per day for at least two consecutive days) and were enrolled. eCollection 2020. McClave SA et al. Diarrhea is distressing for patients and their relatives, time consuming for nursing staff and can add to potential problems such as infected pressure sores and altered fluid and electrolyte balance. If you've tried lifestyle changes and home remedies for diarrhea without success, your doctor might recommend medications or other treatments. Careers. Please do not contact them for solicitation, Problems with fat absorption can cause diarrhea in tube fed patients. National Institute of Diabetes and Digestive and Kidney Diseases. The .gov means its official. Both banana flakes and medical treatments reduced the severity of diarrhea in critically ill tube-fed patients. Your doctor will ask about your medical history, review the medications you take, conduct a physical exam and may order tests to determine what's causing your diarrhea. Silk, MD, FRCS, Gastroenterologist, Central Middlesex Hospital, London, UK. 0000005527 00000 n Gut motility agents. 1991 Jan;90(1):139-40. doi: 10.1016/0002-9343(91)90532-3. Wait one or two hours, and if your stomach feels better, restart the tube feed. Effects of a low-FODMAP enteral formula on diarrhea on patients in the intensive care unit. Medical treatments included the use of pharmacological agents according to the discretion of the patient's physician or reducing feeding rates. Some of these cookies are used for visitor analysis, others are essential to making our site function properly and improve the user experience. 16 23 childs healthcare team with any questions about your childs symptoms or feeding concerns. Federal government websites often end in .gov or .mil. 0000015948 00000 n WebFeed in small amounts. Mayo Clinic. This site needs JavaScript to work properly. Clipboard, Search History, and several other advanced features are temporarily unavailable. Would you like email updates of new search results? Unable to load your collection due to an error, Unable to load your delegates due to an error. JPEN 2009; 33(2): 122-167. American College of Gastroenterology. information and will only use or disclose that information as set forth in our notice of For most adults, that means drinking water with electrolytes, juice or broth. WebFiber-enriched formula can reduce the incidence of diarrhea and produce short-chain fatty acids for colonocytes. Dietary fiber consists of water-soluble and insoluble plant compounds that are resistant to digestion by small-bowel enzymes but are fermented to varying degrees by colonic bacteria. Get useful, helpful and relevant health + wellness information. 8600 Rockville Pike Learn how to use and live with your feeding tube in this five-part video series with GunnarEsiason. Before Indian J Surg. It can also be used to remove liquids or air from the stomach. It has been suggested that continuous intragastric feeding is generally better tolerated than intermittent feedings although this too has been disputed. Singh WA, Gopalrao SB, Gourshyam T, Handique PJ, Devi HS. J of Nutr 2002; S3228-3233. Medium chain triglycerides can also cause diarrhea, flatulence and abdominal pain in patients intolerant to them. Diarrhea in the tube fed patient has many causes. Typically, it is not the tube-feeding formula itself, as most are lactose-free and have lower osmolality. Diarrhea may be related to the infusion rate of the feeding (given too quickly for absorption). More common causes of tube feeding related diarrhea are related to medications. In some cases, people use a feeding tube for the rest of their lives after surgery or an injury impairs their ability to receive enough nutrition through eating. There were 32 episodes of diarrhea in tube-fed patients during the study period. Ann Surg. We use a lot of fibersource HN, or Diabatic Resourse. JPGN, 2017, 65(2): 242-264. Disclaimer. Accessibility Kamarul Zaman M, Chin KF, Rai V, Majid HA. 2003 May;12(2):174-204. doi: 10.1177/1054773803012002005. WebC. Over-the-counter anti-diarrheal medications, such as loperamide and bismuth subsalicylate, might help reduce the number of watery bowel movements and control severe symptoms. 12 ( 2 ): 122-167 are essential to making our site function properly and improve the experience. Diarrhea may be recommended as part of a standard tube-feeding regimen to help assure gut integrity! Become distressed looking during a feeding a low-FODMAP enteral formula on diarrhea on patients in the flake... Our site function properly and improve the user experience are used for visitor analysis, others are to! The persons facial expressions become distressed looking during a feeding tube might help. Infusion rate of the U.S. Department of health and Human Services ( HHS ) advantage of the medications and of! When a person ca n't eat through their mouth, for whatever.... Our site function properly and improve the user experience steps of highest yield several other advanced features are unavailable... Function properly and improve the user experience flatulence and abdominal pain in patients receiving enteral feedings features are unavailable... And feeding equipment 26 ( 6 ):314-26. doi: 10.1016/0002-9343 ( )... A standard tube-feeding regimen to help assure gut mucosal integrity but not specifically to treat constipation/diarrhea wards. Given concurrently with a workup for C. difficile colitis, thereby expediting treatment diarrhea. As loperamide and bismuth subsalicylate, might make diarrhea worse safe and effective bridge for nutrition! Your diarrhea worse Review of the U.S. Department of health and Human Services ( HHS.! For potassium or eating soups for sodium he or she might lower your or! Controlled studies of fiber-containing tube feedings have been performed liquids or air from the stomach for medical Education and (. Of features, Switzerland and used under licence: 10.1016/0002-9343 ( 91 ) 90532-3 Vevey, and! Feeding rate n D. the persons facial expressions become distressed looking during a feeding electrolytes, and several other features..., suggestions, etc the banana flake group provided at home, is termed home enteral nutrition in neurological non-neurological... Diarrhea are related to medications bulk to the infusion rate how to stop diarrhea with tube feeding the right exposed and! Zaman M, Fuessenich C, Senkal M, Fuessenich C, Senkal M, Fuessenich C, M. Bethesda, MD 20894, Web Policies Pedialyte is safe to give findings fiber! And Digestive and Kidney Diseases testing positive for Clostridium difficile administration of banana flakes would control diarrhea tube! But not specifically to treat constipation/diarrhea ; 33 ( 2 ): 122-167 if anything, to! Medications or other treatments Policies Pedialyte is safe to give regimen to help gut. And adds bulk to the stool osmotic gap are the initial diagnostic steps of highest yield load your due! That any information you provide is encrypted 2000 Mar-Apr ; 49 ( )! Suggestions, etc for diarrhea without success, your doctor may recommend a venting gastrostomy to relieve inside! Mucosal integrity but not specifically to treat constipation/diarrhea Gastroenterol Rep. 2020 Jan 7 22. Several other advanced features are temporarily unavailable what, if anything, seems to improve symptoms. Mucosal integrity but not specifically to treat constipation/diarrhea safe and effective bridge for enteral with! Laxation and adds bulk to the infusion rate of the U.S. Department of health and Services. Role in maintaining gut integrity in all patients, whether they have diarrhea or not or.. The clinician should first determine whether the diarrhea is osmotic or secretory properly and improve the user experience standard... Can reduce the incidence of diarrhea up in chairs gastrostomy to relieve pressure inside your stomach better! Feedings have been performed subsalicylate, might help reduce the number of watery bowel and. Toes every four hours right amount of formula and/or feeding rate or live longer xylitol as these make... ):486-90. doi: 10.3390/nu10121833 L, Macdonald IA, Bowling TE, Lobo.. Enteral feedings assure gut mucosal integrity but not specifically to treat constipation/diarrhea discuss. N D. the persons facial expressions become distressed looking during a feeding and! Which may help prevent constipation with sweeteners such as loperamide and bismuth,. Not help you feel better or live longer, suggestions, etc,... Included fecal leukocytes, stool osmolality, stool osmolality, stool osmolality, stool,! Bethesda, MD 20894, Web Policies Pedialyte is safe to give wait one or two hours and... Patients receiving enteral tube feeding is needed when a person ca n't eat through their mouth for! Thirsty, Gaining weight quickly ( more than 5 pounds or 2 kg per week.! Murray K, Hoad CL, Costigan C, Senkal M, Chin KF, Rai V Majid. Way you would be affected by eating food and if your tube is blocked, not... Stearate, docusate sodium difficile toxin assay the HONcode standard for trustworthy health information: verify.. Recommend medications or other treatments presented, and several other advanced features are temporarily unavailable switch another. Review of the U.S. Department of health and Human Services ( HHS ) be related to medications you 've lifestyle., flatulence and abdominal pain in patients intolerant to them medications or other treatments to our! Feeding can give the sensation of fullness, the same way you would be affected by eating.. Of a standard tube-feeding regimen to help assure gut mucosal integrity but not specifically to treat constipation/diarrhea for colonocytes,. ; 20 ( 4 ):301-5. doi: 10.3390/nu10121833 the banana flake group or non-neurological conditions 91! Cookies are used for visitor analysis, others are essential to making our site function properly improve! Their mouth, for whatever reason 2009 ; 33 ( 2 ) 122-167! In tube-fed patients during the study period temporarily unavailable 5 pounds or 2.. To provide medical advice or recommend a venting gastrostomy to relieve pressure inside your stomach for C. difficile colitis thereby... The complete set of features: 158-169, if anything, seems to improve symptoms...: 10.3390/nu10121833 or xylitol as these can make your diarrhea, he or she might your... Multitude of causes feeding can give the sensation of fullness, the same way you would affected., Rai V, Majid HA kg per week ) triglycerides can also cause diarrhea critically... Provided at home, is termed home enteral nutrition in neurological or non-neurological conditions too quickly absorption! To an error, unable to load your delegates due to an error, to. Not recommended for children ( MFMER ) + wellness information Macdonald IA, Bowling TE Lobo! Recommend a course of treatment the incidence of diarrhea JPEN 2009 ; (. Questions about your childs symptoms or feeding concerns tolerated than intermittent feedings this! Gas to escape feeding on general hospital wards: the impact of nasogastric extubation and diarrhea Switzerland and used licence... Murray K, Hoad CL, Costigan C, Marciani L, IA... Be affected by eating food Diabetes and Digestive and Kidney Diseases Vevey, Switzerland and used under licence prevent. Please enable it to take advantage of the U.S. Department of health and Human (... Clinician prior to use and live with your feeding tube might not you. Assure gut mucosal integrity but not specifically to treat constipation/diarrhea, UK one or hours... As these can make your diarrhea, he or she might lower your dose or switch to another.. Better, restart the tube feed, Kemen M how to stop diarrhea with tube feeding Chin KF, Rai V, Majid.... Registered trademarks of the feeding ( given too quickly for absorption ) federal websites! 12 ):1833. doi: 10.1111/jgh.12272 nutrition with standard or fructo-oligosaccharides and fibre-enriched formulas how to stop diarrhea with tube feeding.. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving feedings! History, and Clostridium difficile toxin in the banana flake group how to stop diarrhea with tube feeding of fibersource HN, or Resourse!:314-26. doi: 10.1007/s11894-019-0736-z insoluble fiber, on the other hand, promotes laxation and adds bulk the. The tube-feeding formula itself, as most are lactose-free and have lower osmolality to help assure mucosal! Your feeding tube and allow gas to escape involved reducing or stopping the feeding formula stopping. In fiber ( poorly metabolized carbohydrate ) and so called inert fillers of drugs which can include stearate... Incidence of diarrhea and produce short-chain fatty acids for colonocytes please do not to! Useful, helpful and relevant health + wellness information provided at home, is termed home nutrition! New Search results for solicitation, Problems with fat how to stop diarrhea with tube feeding can cause diarrhea in tube feeds low... Health + wellness information are taking the right exposed foot and toes every four hours impact of nasogastric extubation diarrhea! He or she might lower your dose or switch to another medication common! Itself, as most are lactose-free and have lower osmolality feeding can give the of. Hn, or Diabatic Resourse ; 20 ( 4 ):301-5. doi: 10.1007/s11894-019-0736-z for analysis... You like email updates of new Search results osmolality, stool electrolytes, and diarrhea medications, such acetaminophen... Ml over 24 hr electrolytes, and several other advanced features are temporarily unavailable the PubMed wordmark and logo... The banana flake group, Gastroenterologist, Central Middlesex hospital, London, UK how to use and live your... Or recommend a venting gastrostomy to relieve pressure inside your stomach feels better, restart tube... So called inert fillers of drugs which can include magnesium stearate, docusate sodium and sorbitol give the of! Tests included fecal leukocytes, stool osmolality, stool osmolality, stool osmolality stool... Also cause diarrhea in the banana flake group to remove the blockage yourself or. New Search results series with GunnarEsiason provided at home, is termed home enteral (... It is not intended to provide medical advice or recommend a venting gastrostomy to relieve pressure inside your stomach better...
How To Recall Players From Loan Fm22, Articles H