089. Gastrointestinal Procedures and Devices

Feeding Tubes

Tube Nomenclature

Categorized by location of the tip of the tube.

Gastrostomy or PEG tube – terminates in the stomach

Jejunostomy – terminates in the stomach

PEG-J tube or GJ tube – terminates in both the stomach and the small intestine

PEG (Gastrostomy tubes)

Placed endoscopically, no surgical incision

Can temporarily keep stoma patent with a foley catheter. Need bolster to prevent further migration (can use 3 cm segment of another foley with hole in the middle to act as temporarily bolster if one is not available).

Replacing blindly must only be done on a mature stoma track (2-3 weeks) for possible complication of placing tube into peritoneal cavity. Stomach most likely adhered to abdominal wall by that time.

For clogged or leaking G-tubes without balloon that need to be removed, traction/countertraction should be enough force to squeeze the mushroom out of the stomach. Will likely hear or feel a pop.

Tintinalli recommends consulting the GI or surgeon initially before applying traction depending on the internal bolster.

If still unable to remove, can pull out the tube as much as possible and cut it at the skin to allow rectal passage. Have been reported cases of obstruction, though rare. Still better to consult surgeon prior to doing this.

Can verify placement with Gastrograffin (water-soluble, diatrizoate meglumine-diatrizoate sodium). Barium is contraindicated due to potential peritoneal contamination. Inject 20-30mL, take supine abdominal film 1-2 minutes after dye instillation to optimize gut visualization.

Irregular or rounded blotch with wispy edges or streamers suggests peritoneal leakage.

Entry site irritation: common, can be treated with silver nitrate at time of dressing change to prevent granuloma.

Large stomas: can cause leak. Though insertion of larger tube or firmer traction can be temporarily effect, this often results in further stoma enlargement. Need to replace to pliant soft tube or just remove to allow stoma to shrink. Large amounts of drainage can also be due to high residual volumes – consider checking for residuals after feeds and holding anything further until residual is < 100 mL.

Clogged tubes: can use roter-rooter type wire to drill the clog out. Using guidewire or needle is contraindicated. If unsuccessful, should inject with contrast with imaging to check tube integrity.

Jejunosotomy tubes

Placed surgically under general anesthesia, require a surgical incision and have surgical scar at insertion site.

Less likely to cause aspiration or reflux compared to PEG tubes.

If foley catheter used to replace dislodged J-tube stoma, DO NOT INFLATE BALLOON. Advance 20cm and keep in place.

Does not have balloon on end of it. Generally, jejunum is sutured to abdominal wall. If patient pulls it out, can just place tube back in place and then adhere it to the skin by suture or tape until surgeon sees it again. Needs to have been in place for at least 2-6 weeks though.

Roberts and Hedges, Expert Consult, 2013.

Tintinalli, Chapter 89, 2011.

089. Gastrointestinal Procedures and Devices

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