Enterostomy

Aka: Enterostomy, Enterostomy Tube, G-Tube, Gastrostomy Tube, Gastrojejunostomy, Gastric Tube, Gastrostomy, Gastrostomy Button, GJ-Tube, J-Tube, Jejunostomy, Jejunal Tube, Percutaneous Endoscopic Gastrostomy Tube, PEG Tube

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II. Indications

  1. Anticipated enteral feeding beyond 4 weeks
  2. Nutrition in Advanced Dementia
    1. See link for details regarding lack of efficacy
    2. No support for continued use in the literature

III. Types: Enterostomy Tube

  1. G-Tube: Gastrostomy or Gastric Tube
    1. Typically with two ports (one for feeding, one for balloon)
      1. Balloon (contains 2.5 to 5 ml water) fixes the tube inside of the Stomach
      2. An additional small port may be present for delivering medications
    2. Internal V-Shaped Valve
      1. Valve opens when brand-specific extension set is attached to the port
      2. Valve closes when the extension set is removed, preventing backflow out of the port
      3. Single extension set allows for food delivery, medication delivery and venting
    3. Uses
      1. Medication delivery
      2. Feedings may be drip or bolus
    4. Maintenance
      1. Flush tube after every food or medication delivery
      2. Replace tube every 3-6 months (or when balloon fails)
  2. Button G-Tube (brands MIC-Key or MINI b)
    1. Specific low-profile G-Tube that sits flush with skin level and less likely to become caught on clothing
    2. Requires special attachment (inserted and turned 90 degrees) to use for feeding
    3. Labeled with two size dimensions (width in Fr, and length/thickness of the abdominal wall segment)
  3. GJ-Tube: Combined tube with both Gastric and Jejunal ports
    1. Typically with three ports (G-port, J Port, gastric balloon)
    2. Medication delivery or bolus feeds via gastric port
    3. Continuous drip feeds via jejunal port
  4. J-Tube: Jejunostomy or Jejunal Tube
    1. Requires drip feeds
    2. Bolus feeds result in Osmotic Diarrhea

IV. Complications: Gastrostomy or Jejunostomy

  1. Tube
    1. Stoma closure or stenosis
  2. Skin
    1. Inflammation and bleeding
    2. Bumper erodes into abdominal wall
    3. Cellulitis
  3. Chest
    1. Tube erodes into pleura
    2. Arrhythmia
    3. Mediastinitis
  4. Gastric
    1. Gastric perforation
    2. Gastric prolapse
    3. Gastrocolic fistula
  5. Gastrointestinal
    1. Pneumoperitoneum
    2. Evisceration
    3. Intussusception
    4. Peritonitis
    5. Abdominal abscess

V. Signs: Stoma Abnormal Findings

  1. Drainage or infection
  2. Granulation tissue
  3. Excess bleeding
  4. Perforation

VI. Complications: Enterostomy Tubes (G-Tubes, GJ Tubes, J Tubes)

  1. G-Tube dislodgement
    1. See below for dislodgement from skin
    2. Dislodgement of tube into peritoneal cavity is a medical emergency
      1. Higher morbidity and mortality
  2. Gastric Tube clogging (especially common with the narrow lumen of G-J Tubes)
    1. General
      1. Attempt warm water flushes first, and may attempt unclogging with enzymes
      2. Have a low threshold to replace clogged G-Tubes in mature tracks (present >6-8 weeks)
    2. Lukewarm water via 60 ml catheter tip syringe
      1. Let water sit in tube 20 minutes
      2. Then move plunger back and forth
      3. Consider using a small syringe to generate increased negative pressure
      4. Consider gently rotating the tube
    3. Instill Pancreatic Enzymes (e.g. creon, Viokace) and then flush with saline as above
      1. Mix Viokace tablet AND Sodium Bicarbonate 325 mg tablet in 5 ml water
      2. Instill into Gastric Tube, and repeat 1-2 times as needed
    4. Instill a small amount of Coca Cola (or warm saline), allow to stand for 10-15 minutes, and then flush
      1. Some caution against this, due to acidic solution clumping of Proteins
    5. Prevent clogging
      1. Flush tube with 30 ml water every 8 hours or more
      2. Administer medications via tube one at a time
        1. Flush tube before and after each medication with 15-30 cc water
    6. References
      1. (2016) Presc Lett 23(8)
  3. Granulation tissue or Granuloma (shiny pink tissue at skin tube entry site)
    1. Bleeding
      1. Consider Silver Nitrate for small Granulomas
      2. Consult surgery for larger bleeding Granulomas
    2. Non-bleeding
      1. No treatment is needed
      2. Medium potency Topical Corticosteroids may be considered if patients or parents wish
  4. Irritant Contact Dermatitis secondary to Stomach acid (G-Tube leak)
    1. Secretion extravasation can be reduced by securing balloon against inner abdominal wall
    2. Apply calmoseptine ointment (Zinc Oxide mixed with Menthol) to act as moisture barrier
      1. Cover with a thin piece of gauze and secure with tape
      2. Tape in a tic-tac-toe pattern (2 strips of tape across the tube and 2 strips across the gauze)
    3. Consider applying topical Maalox to the area to increase pH at the skin surface
  5. G-Tube leak
    1. Typically causes local Contact Dermatitis secondary to Stomach acid
    2. Determine the site of leakage
      1. From around the tube
        1. Small leak is not uncommon (and may be increased with acute illness)
        2. However, significant leak that causes skin breakdown, weight loss or distress should be addressed
      2. From the tube lumen
        1. A few drops of leakage is not uncommon
        2. Significant leakage suggests that the internal V-Valve is broken (replace the tube)
    3. Check that balloon is not underinflated or popped and correct if this is the case
      1. Inflate balloon to proper volume and pull back the balloon until it meets resistance against the Stomach wall
    4. Refer back to surgery or Intervention Radiology if not corrected
  6. Concern for poorly fitting G-Tube
    1. Gently lift the tube and rotate
    2. There should be little space between the outer flange and skin
    3. The tube should easily rotate without significant discomfort
  7. Fungal Skin Infection (common)
    1. Apply Antifungal (e.g. Nystatin, Clotrimazole)
  8. Cellulitis (uncommon, except following tube placement)
    1. Presents with exquisite tenderness at ostomy site with or without fever or pustular discharge
    2. Start with First Generation Cephalosporins (e.g. Keflex)
    3. Discuss more significant Cellulitis with general surgery
  9. Vomiting
    1. Consider pyloric obstruction (see below)
    2. Consider recent feeding regimen changes (feeding volumes or bolus frequency)
    3. Consider more typical causes of Vomiting (Acute Gastroenteritis, Urinary Tract Infection)
  10. Pyloric obstruction
    1. Results from G-Tube migration distally
    2. Typically presents with Vomiting
    3. Attempt repositioning of tube
      1. Confirm ballon inflated
      2. Pull back G-Tube until resistance met (balloon lodged against Stomach wall)
      3. Secure tube at skin surface
      4. Sandwich skin between balloon inside Stomach and adjustable plastic disc against outer skin
  11. Aspiration Pneumonia
    1. Due to aspiration as a comorbid risk for patients requiring G-Tube placement

VII. Complications: G-Tube dislodged

  1. Precautions
    1. Stoma closure risk
      1. Replace tube as soon as possible (may otherwise close within hours)
    2. Hypoglycemia risk
      1. Check bedside Glucose if G-Tube out for extended period
    3. GJ-Tube or J-Tubes
      1. Typically require Intervention Radiology for Jejunal Tube positioning
      2. May temporize with G-Tube or measures described below (e.g. Foley Catheter)
  2. G-Tube in place <6 weeks
    1. Contact surgery, gastroenterology or Intervention Radiology to replace tube due to risk of false tract
    2. Risk of tract separation from Stomach and peritonitis
    3. In some cases (e.g. pediatric Gastrostomy Button), tract may be mature enough for replacement at 3 weeks
  3. G-Tube in place >6 weeks
    1. Epithelialized tract allows for typically simple replacement with minimal risk of false tract
    2. Confirm Stomach placement with pH testing of secretions (see below)
  4. Preparation
    1. Obtain consent for changing tube or replacing dislodged tube
    2. Prepare sterile set-up (same G-Tube size and type, gloves, Suture and saline to inflate balloon)
    3. Check balloon for leaks
      1. Inflate with 5 ml sterile water, compress balloon for leaks, then withdraw fluid
    4. Examine stoma for signs infection
    5. Apply antiseptic (e.g. Hibiclens) to stoma site
    6. Lubricate the stoma and tract with viscous Lidocaine via an angiocatheter
    7. Lubricate the end of the G-Tube
  5. G-Tube replacement fails (or tube is without balloon)
    1. Consider pre-treatment with Opioid Analgesic prior to insertion (e.g. Morphine or Intranasal Fentanyl)
    2. Replace with a similar size tube as the one lost (consider starting smaller tube and dilating to size needed)
      1. Temporize with Foley Catheter or Feeding Tube of smaller caliber than original G-Tube
    3. Tube insertion
      1. Lubricate tube and tract with viscous Lidocaine
      2. Insert during patient inspiration if possible (may be easier insertion)
      3. Apply steady pressure while inserting tube
      4. Avoid excessive force
      5. Expect a small amount of bleeding due to granulation tissue in the area
    4. Inflate balloon with correct amount of sterile water (not saline)
      1. Device should be secure in position, but not too tight to compress skin with excess pressure
    5. Tape securely to Abdomen to prevent inward migration (risk of pylorus obstruction - see above)
      1. Consider wrapping tube at skin surface with gauze or dental tampon to prevent tube migration
    6. Arrange close followup with surgery for definitive G-Tube replacement
  6. G-Tube or Foley Catheter insertion process
    1. When using a Foley Catheter
      1. Apply a bolster to the catheter to prevent inward migration
        1. May use the bolster from the dislodged or removed prior G-Tube
      2. Floppy Foley Catheter may be difficult to insert
        1. Nylon-handled cotton swab may be placed inside the Foley Catheter distal side port
        2. Cotton swab allows for distal catheter rigidity to allow for insertion
    2. Over-estimate tube insertion depth (insert further than necessary)
      1. Inflate the balloon
        1. G-Tube: Tube should be marked with recommended balloon inflation volume
        2. Foley Catheter: 5cc for child and 3cc for infant
      2. Then pull the tube's balloon flush against the Stomach wall
    3. Confirm placement
      1. Auscultate for air (borborygmi) instilled into Stomach
      2. Aspirate gastric secretions from Stomach and check pH to confirm acidic (pH 2-3, yellow)
    4. XRay Dye study for tube placement confirmation (as indicated)
      1. Indications
        1. Difficult G-Tube replacement
        2. G-Tube out for an extended period (>2 hours)
      2. Inject 15-30 ml of contrast via G-Tube into Stomach
        1. Instill undiluted iohexol (Omnipaque) or similar water soluble dye (gastrograffin)
      3. Obtain immediate KUB XRay or fluoroscopy to confirm placement
        1. Stomach should be well outlined
        2. No extravasation into peritoneum

VIII. References

  1. Claudius and Behar in Herbert (2013) EM:Rap 13(10): 7-9
  2. Fisher and Swaminathan (2024) EM:Rap, accessed 2/1/2024
  3. Herman (2016) Crit Dec Emerg Med 30(5): 12-3
  4. Herbert (2012) EM:Rap 2(9): 7
  5. Mason, Woods and Jacobson in Herbert (2020) EM:Rap 20(2): 10-12
  6. Warrington and Pitocchi (2017) Crit Dec Emerg Med 31(12): 9
  7. Finucane (1999) JAMA 282:1368 [PubMed]
  8. Li (2002) Am Fam Physician 65(8):1605-10 [PubMed]

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