Talk:G-tube complications

Cut and paste from old G-tube page:

Background

• Four components: tube, internal bolster, external bolster, and ports
• External bolster very important as distal migration of tube with peristalsis can result in bowel obstruction and perforation
• Sizes range from 12 to 24 Fr

Complications

Dislodged Gastrostomy Tube

• Tracts may close within hours if relatively new tube
• Foley catheters function well as temporary replacements
• Procedure:
  • Obtain Foley size comparable to original tube
  • Lubricate tube liberally
  • Advance tube no more than 8-10 cm (in adult) to avoid entering esophagus, duodenum
  • Should not be significantly painful, require dissection, or considerable force
  • Pass smaller size tube if necessary to maintain tract without forceful insertion
  • Slowly inflate balloon, careful not to inflate balloon to max volume
  • Aspirate gastric contents to confirm placement
  • Place external bolster with these options:
    • Retention suture much like in chest tube placement
    • T-bar from 3cm section of another foley
      • Apply T-bar before insertion
      • Cut hole on either side of 3 cm section, just large enough for replacement tube to be passed through
      • Pull through replacement tube with hemostats
  • Tube may be used for feedings if:
    • Free flowing contents to gravity drainage
    • Tube contrast KUB (gastrograffin) without extravasation
  • Arrange for surgical outpt f/u within 24-48 hrs
• Special considerations
  • Some tubes have circuitous route (Witzel), making tract difficult to approach
  • Small percutaneous endoscopic jejunostomies (PEJ) tubes are not replaceable
  • Extravasation in contrast KUB requires holding feeds and c/s with surgeon
  • Simple cellulitis around external site - PO antibiotics and good wound care
  • Obtain surgical c/s if replacement difficult

Nonfunctioning Gastrostomy Tube

Differential

• Replacement for:
  • Fractured tube
  • Tube with ruptured balloon
• Kinked tube may need only external bolster replacement
• Clogged tubes should be gently irrigated first
  • Water, NS, or carbonated drink
  • Consultants may use enzymatic slns, or dislodge with endoscopic snares, biopsy forceps, etc
  • DeClogger® plastic wand with screw thread, tunneled into tube in clockwise fashion

Removal of tube

• Remove tube if mature tract and if unable to unclog
• Determine type of tube, as most are removable with gentle traction
  • Most internal T-bars or soft caps deform with gentle traction
  • Internal balloon devices simply need to be deflated, but if balloon doesn't deflate:
    • Try cutting tube close to ports with hemostat in place to prevent inward migration
    • OR guidewire may be placed into balloon port to puncture balloon
• If cannot remove with with gentle traction, c/s surgeon that placed tube
• DO NOT simply cutting the tube at the skin and pushing remained of tube into pt to pass through GI tract
  • May cause bowel obstruction and perforation
  • Only choose this option in c/s with primary surgeon

Fresh or Immature Tracts

• New tubes should not be manipulated without c/s with the specialist that placed it
• Clogged tube may need to remain in place to finish stenting tract
• Inadvertent removal of tube through fresh tract may lead to peritoneal contamination and subsequent peritonitis
  • If spillage of contents possible, pt needs admission, antibiotics, and observation for development of peritonitis
  • Tract will need to close spontaneously, and replacement PEG in 7-10 days

Sources

• Gastrostomy Tube Replacement, in Reichman, EF: Emergency Medicine Procedures, ed 2. New York, McGraw-Hill, 2013, (Ch) 64.

Authors

Neil Young