Although the techniques for the initial placement of transabdominal feeding tubes (gastrostomy [G-tube], jejunostomy [J-tube], and gastrojejunostomy) are beyond the scope of emergency physicians, complications related to these tubes need to be recognized (Table 86-5). These tubes can be placed by a surgeon using open technique, by a gastroenterologist using endoscopic technique (percutaneous endoscopic gastrostomy), or by a radiologist with percutaneous techniques. The radiographic technique has been associated with fewer complications than has open or endoscopically assisted placement.18
TABLE 86-5Complications Seen with Transabdominal Feeding Tubes ||Download (.pdf) TABLE 86-5 Complications Seen with Transabdominal Feeding Tubes
|Complication ||Initial Considerations |
|Purulent drainage from stoma ||Local care with hydrogen peroxide unless cellulitis is present. |
|Leakage from stoma ||Carefully replace with larger tube. |
|Tube occlusion ||Attempt irrigation; most often, just replace. |
|Dislodged tubes ||Gently replace; confirm placement with x-rays. |
|Pneumothorax ||High index of suspicion; consider needle aspiration. |
|Bacteremia ||Consider as potential source in septic patient. |
|Bleeding from tract ||If recently inserted, consider local injection, consult. |
|Bleeding from granuloma buildup ||Local therapy with silver nitrate. |
|Infection of surrounding skin ||Consultation, pull tube, IV antibiotics. |
|Necrotizing fasciitis ||Consider MRI to help confirm; surgical debridement. |
|Peritonitis ||Determine if fistula exists; consultation, IV antibiotics. |
|Pulmonary aspiration of feedings ||Reduce flow rate, half-strength feeds, consider J-tube. |
|Vomiting or diarrhea ||Reduce flow rate, half-strength feeds, stop feeds. |
|Gastroesophageal reflux ||Reduce flow rate, half-strength feeds, consider J-tube. |
|Intestinal obstruction ||Step feedings, NPO, admit, and observe. |
|Gastric outlet obstruction ||Reposition tube. |
|Gastric volvulus ||Surgical consult. |
|Gastric perforation ||Surgical consult. |
|Esophageal perforation ||Surgical consult. |
|Colonic perforation ||Surgical consult. |
|Colocutaneous fistula ||Surgical consult. |
|Electrolyte abnormalities ||Change feedings or increase free water. |
|GI bleeding ||Endoscopy and therapy directed at cause. |
|Bolster buried in abdominal wall ||Surgical consult. |
Frequent minor complications are associated with the use of these tubes, including purulent drainage and leakage around the stomal site, clogging, dislodgement, and vomiting and diarrhea.
Drainage from the stomal site is a common finding and represents a foreign-body reaction due to the catheter. As long as there is no evidence of cellulitis or necrotizing fasciitis, local skin care with hydrogen peroxide and warm water usually will clear up the problem. If there is granuloma formation with localized bleeding from friable skin, local treatment with silver nitrate usually will help.
Leakage of gastric contents can become a problem. This is managed by careful insertion of a larger tube. Care should be used not to force too large a tube into the stoma, because this can cause separation of the stomach wall from the abdominal wall.
Prevention is the best treatment for clogging of gastrostomy and jejunostomy tubes. Frequent flushing with water and careful crushing of pills usually can prevent this problem. Vomiting and diarrhea can be relieved by decreasing the amount of the feedings and/or diluting the feedings. To unclog the tube, instill warm water or carbonated beverage (cola is most often used) and let it remain for 20 minutes. Then attempt flushing.19 Alkalinized pancreatic enzymes (12,000 lipase units dissolved in 650 mL bicarbonate) have also proven effective in about 50% of cases.20
If the tube cannot be unclogged or if it has fallen out, replacement will be necessary. If the tube was placed by a surgeon or gastroenterologist and has not been replaced, it probably will have a bolster (also called a mushroom or bumper) holding the tube in place (Figure 86-4). This will prevent the tube from being removed. The bolster must be removed endoscopically, or the tube may be cut off and the bolster allowed to pass through the GI tract.21 The latter technique is generally safe in adults, but passage in children has complications,22 and tube removal should be done by the endoscopist or surgeon. Tube removal should be done by the endoscopist or surgeon. Endoscopic removal in adults is advisable when there is suspected or potential obstructive disease of the GI tract, such as pyloric stenosis, intestinal pseudo-obstruction, and intestinal stricture (e.g., due to radiation, ischemia, or inflammatory bowel disease). If the tube is cut, an abdominal radiograph should be obtained 1 week later to confirm passage of the internal component. Most reported complications from a retained internal bolster have occurred when the bolster did not pass within 1 to 2 weeks.23 If the bolster or bumper becomes buried in the abdominal wall, consult with the endoscopist or surgeon who placed the device. Do not attempt removal by traction. Some specially designed tubes have internal bumpers that can be removed by external traction, but consultation with the endoscopist or surgeon who placed the device is necessary before any traction is applied to verify the type of tube and the appropriate method of removal24 (Figure 86-4).
Percutaneous endoscopic gastrostomy tube (G-tube) with a mushroom bolster in place.
If the tube has become dislodged or has fallen out, replace it as quickly as possible (within a few hours) to prevent closure of the tract. Most tracts mature after 2 to 3 weeks. Do not attempt to replace a tube with an immature tract.19 First determine, if possible, which type of tube is being used. If the tube is available, replacement with the same size is usually possible. If the tube is not available, it can be difficult to determine whether the tract is for a jejunostomy or gastrostomy tube. Location site on the abdominal wall is not helpful to differentiate the two. A tract for a gastrostomy tube is usually larger. Old records may be useful and should be obtained, if possible. After determining the type of tract and size of tube used previously, insert the tube using a water-soluble lubricant. If the size of the tube being replaced is not known, it is reasonable to start with a 16- or 18-F replacement gastrostomy tube or Foley catheter. The lubricated tube should pass easily into the stoma without additional equipment. If resistance is met, abandon the attempt. A smaller tube can be tried to keep the tract open. After replacing the tube, instill a 20- to 30-mL bolus of a water-soluble contrast material (e.g., diatrizoate meglumine and diatrizoate sodium solution [Gastrografin]) through the tube, and obtain a supine abdominal x-ray within 1 to 2 minutes. The x-ray should demonstrate rugae of the stomach for a gastrostomy tube and flow into the small bowel for a jejunostomy tube. US can also be used to verify gastric placement. The tip of the tube can be visualized within the stomach, and confirmation of placement can be done by injecting 10 cc of normal saline into the tube and observing the fluid entering the stomach, using real-time US. Another way of determining placement is to withdraw gastric fluid and check pH to make sure it is acidic. If there is any question of improper placement, obtain immediate consultation.
A special caution regarding jejunostomy tubes should be noted. Jejunostomy tracts are smaller, and smaller tubes are used (8- to 14-F). These tubes usually are not sutured in place and frequently become dislodged. They can be replaced with catheters made specifically for jejunostomies or with Foley catheters. If a Foley catheter is used to replace a lost jejunostomy catheter, the balloon should never be inflated because it can cause a bowel obstruction or damage the jejunum. The tube is lubricated, inserted into the stoma, and advanced 20 cm. These tubes are easily replaced if the tract is mature; however, if resistance is met, referral to a radiologist for fluoroscopic placement using guidewires is recommended.