gastrostomy tubes: a primer tamara simon, m.d. assisted by kim washington, cpnp special care clinic...
TRANSCRIPT
Gastrostomy Tubes:A Primer
Tamara Simon, M.D.Assisted by Kim Washington, CPNP
Special Care ClinicJuly 2004, August 2005
Purpose
• Allow for enteral feedings for children with:– swallowing dysfunction– severe gastroesophageal reflux– esophageal atresia– esophageal burns or strictures– craniofacial abnormalities– chronic malabsorption– failure to thrive
Procedure
• Placed using endoscopic technique– Done by GI or pediatric surgery– Placed with percutaneous endoscopic technique:
• Stomach and anterior abdominal wall punctured• Feeding catheter is inserted• Gastrocutaneous fistula forms around gastrostomy tube held in
placed by internal and external bumper guards• Sutures, if placed, hold the tube in the stoma
• Placed in conjunction with Nissen – Requires pH probe +/- upper GI series– Done by pediatric surgery
Procedure (continued)
• Gastrocutaneous fistula matures between 2-4 weeks and up to 3 months after creation
• Replacement with low profile button after stoma matures– Balloon tip (MIC-Key)– Mushroom tip (Bard)– Collapsible wing tip
MIC-Key Balloon-tipGastrostomy Button
Pros:No venting neededEasier to change
Cons:More mobile portionbetween button and balloonDevelops leaks
Bard mushroom tipGastrostomy Button with Obdurator
Pros:Sturdier constructionUsed in PEG placementdue to size
Cons:Venting apparatus neededDifficult to changeRequires training
Complications
• Wound infection
• Hemorrhage
• Mucosal injury
• Gastrostomy tube dysfunction:– Obstruction of tube– Dislodgement of tube – Cracking or fracture of tube
Complications (continued)
• Leakage around wall
• Granulation tissue formation
• Migration of tube
• Fistula formation
Wound infection• Seen in 20% of patients• Purulent, bloody, cellulitic skin; yellow-brown discharge
without signs of infection is normal• Avoid occlusive dressings because moisture accumulates and
predisposes to infection• Usually superficial and can be treated easily
– Clean with region with antiseptic– Apply topical antibiotics
• Cellulitis may be occasionally be present– Systemic antibiotics are required– Vigilance for necrotizing fasciitis
Hemorrhage
• Usually small amount of self-limited bleeding at the time of placement
• Bleeding remote from the time of placement may indicate ulcers or erosion of the gastric mucosa
Mucosal injury
• Range from erosions of gastric mucosa (gastritis) to perforation of stomach
• Can occur in gastric wall opposite the gastrostomy tube
Gastrostomy tube dysfunction: Obstruction of tube
• Most common cause of tube malfunction (14%)• Caused most often by formulas coagulating in
acidic pH– Avoid mixing medication with formula (some meds are
acidic) – Crushed pills, especially sustained release, commonly
cause obstruction– Proteinaceous material implicated
• Can be prevented by flushing before and after feeds and medication administration
Gastrostomy tube dysfunction: Obstruction of tube
• Attempt to flush gently with 5 ml warm water with 5 ml syringe, instill and pull back up to 5 times
• Try smaller syringe to create increased pressure• If successful, flush tube again to ensure patency• If unsuccessful, try solution of pancreatic enzymes (crush
Viokase 8 tablet and 325 mg sodium bicarbonate tablet into fine powder, mix with 5 ml warm water, instill in 10 ml syringe, wait 5 minutes
• Attempt to flush with 5 ml or smaller syringes• Can repeat above for 30 minutes
Gastrostomy tube dysfunction: Obstruction of tube
• Other solutions- carbonated liquids, meat tenderizer, and/or milking the tube
• Then notify GI/surgery that feeding tube cannot be cleared
Gastrostomy tube dysfunction: Dislodgement of tube
(immature fistula)• Immature fistula : < 4 wks post-surgical placement,
< 12 weeks post-percutaneous placement– Stoma relies on the apposition of skin and gastric
mucosa– Gastric layer closes faster than skin– Almost anything can be used to keep stoma
patent– The stomach is not sterile
Gastrostomy tube dysfunction: Dislodgement of tube
(immature fistula)– Gently place small Foley– However, complications could include detachment
of stomach from abdominal wall, development of false tract, peritonitis, pneumoperitoneum, and/or air embolism
– If any resistance felt, consult surgery or GI immediately
– If necessary, nasogastric tube can be inserted and stoma permitted to close
Gastrostomy tube dysfunction: Dislodgement of tube (cont)
• Mature fistula– Attempt to replace same size and type of tube
or button– If size not known, measuring device can be
used (consult G tube nurse); use taped Foley catheter left in place if nurse not immediately available
Gastrostomy tube dysfunction: Dislodgement of tube (cont)
– Original tube or Foley catheter can be inserted to maintain patency until device obtained • stoma closes in 24-48 hours• If fistula has almost closed, consult
surgery/GI and nasogastric tube can be inserted
– Place successively larger tubes (Foleys) every 30 minutes to dilate
– Do not dilate with hemostat!
Gastrostomy tube dysfunction: Cracking or fracture of tube
– Remove original• Balloon-tip (MIC-Key) - remove after
deflating balloon• Mushroom or collapsible-wing tip (Bard)-
gentle traction or, if necessary, cut tip at external surface of wall and push into stomach for later excretion or removal by endoscopy
Gastrostomy tube dysfunction: Replacement of tube
– Balloon tip (MIC-Key)• Clean site and select proper replacement• Test new button by inflating and deflating
balloon with water or saline- 360° inflation• Lubricate tube with water soluble jelly• Gently insert in stoma perpendicular to
abdominal wall- 3 cm beyond balloon • Reinflate balloon with water or saline (3-5 ml
for infants, 5-7 ml for children)
Gastrostomy tube dysfunction: Replacement of tube
• Test placement• Apply gentle traction pulling balloon against
gastric mucosa• Button should lie flat against abdomen
Gastrostomy tube dysfunction:replacement of tube
– Mushroom and collapsible-wing tips• Insert obdurator into open sides of tip to distend tip
before placing in stoma• With tip distended, tube is inserted into stoma
perpendicular to abdominal wall with steady pressure until flush with abdominal wall
• Once fully inserted, obdurator is removed• Test placement• Button should lie flat against abdomen
Confirming gastric placement• Check pH of aspirate (<5)• Check color of aspirate• If no aspirate obtained, inject 5 ml air and aspirate
again• Also reposition patient• Transpyloric placement (for NG)
– Bilious, high pH– Withdraw tube 3-5 cm and recheck
• Pulmonary placement bilious, high pH– Respiratory distress, serosanguinous aspirate, pH 5-6– Remove immediately
Leakage around wall• Occurs in 10% of patients• Looks like formula• May be caused by:
– clogged tube– deterioration of tube- check balloon– stoma that is enlarged due to external traction on the tube
• May be treated with :– Sorbsan around the site if the stoma is too big – Stoma adhesive powder and Maalox/Aquaphor solution
can be used for leakage alone
Granulation tissue
• May accumulate on abdominal wall• Bleeds easily, causes discharge, irritation, and
discomfort• Clean secretions or crusts from site• Apply water soluble jelly to normal tissue in 5 cm
circle surrounding granulation• Silver nitrate stick can be used to cauterize tissue
once daily for 7-10 days (up to 3 weeks) until granuloma is gone
Granulation tissue
• Recurrences are frequent• Check for prolapse (pinker, regular color) which
does not respond to silver nitrate – i.e. doesn’t turn gray
• Apply Kenalog cream tid for 2 weeks (wait 1 hour if after silver nitrate)
Migration of Tube
• Can migrate down the intestinal tract or up the esophagus
• Downward migration can cause obstruction or even perforation
• Upward migration can cause aspiration
Further Questions
• Questioning potential complications?• Get a radiologic dye study +/- abdominal
radiographs, upper GI series, or endoscopy• Consult G tube nurse• Consult Kim Washington if Special Care
Clinic patient• Consult gastroenterologist or surgeon who
originally placed G tube
References
• Teoh DL. Tricks of the Trade: Assessment of High-Tech Gear in Special Needs Children. Clinical Pediatric Emergency Medicine. 3(1), March 2002.
• Washington, K. G Tube Care handout. • Joffe, M. Troubleshooting Lines, Tubes,
and Catheters. Pediatric Hospitalist Meeting, Denver, July 2005.