Enterostomy

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Indications
Types: Enterostomy Tube
Complications: Gastrostomy or Jejunostomy
Signs: Stoma Abnormal Findings
Complications: Enterostomy Tubes (G-Tubes, GJ Tubes, J Tubes)
Complications: G-Tube dislodged
References
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II. Indications

Anticipated enteral feeding beyond 4 weeks
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

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)
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)
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
J-Tube: Jejunostomy or Jejunal Tube
1. Requires drip feeds
2. Bolus feeds result in Osmotic Diarrhea

IV. Complications: Gastrostomy or Jejunostomy

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

V. Signs: Stoma Abnormal Findings

Drainage or infection
Granulation tissue
Excess bleeding
Perforation

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

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
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)
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
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
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
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
Fungal Skin Infection (common)
1. Apply Antifungal (e.g. Nystatin, Clotrimazole)
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
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)
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
Aspiration Pneumonia
1. Due to aspiration as a comorbid risk for patients requiring G-Tube placement

VII. Complications: G-Tube dislodged

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)
G-Tube in place <6 weeks (<4 weeks in some guidelines)
1. Risk of tract separation from Stomach and peritonitis
2. Contact surgery, gastroenterology or Intervention Radiology to replace tube (due to risk of false tract)
3. In some cases (e.g. pediatric Gastrostomy Button), tract may be mature enough for replacement at 3 weeks
G-Tube in place >6 weeks (>4 weeks in some guidelines)
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)
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
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
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. Aspirate gastric secretions from Stomach and check pH to confirm acidic (pH< 5, typically pH 2-3, yellow)
    1. PH testing may be unreliable if on Antacids (e.g. Proton Pump Inhibitors)
  2. Instill 30-50 ml of water into G-Tube (if not performing XRay Dye Study as below)
    1. Instillation should be resistance-free and painless
  3. Auscultate for air (borborygmi) instilled into Stomach
    1. Not considered reliable
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. Use low osmolality iodinated contrast that is not a peritoneal irritant
    2. Instill undiluted iohexol (Omnipaque) or similar water soluble dye (gastrograffin)
      1. Other contrast agents include diatrizoate and Iopamidol
      2. Avoid Barium Contrast agents
  3. Obtain immediate KUB XRay or fluoroscopy to confirm placement
    1. Stomach should be well outlined (rounded appearance of Stomach margin, with the folds of gastric rugae)
    2. No extravasation into peritoneum
    3. No abdominal free air (only present in the first 72 hours after Gastrostomy surgery)

VIII. References

Broder (2024) Crit Dec Emerg Med 38(6): 24-6
Claudius and Behar in Herbert (2013) EM:Rap 13(10): 7-9
Fisher and Swaminathan (2024) EM:Rap, accessed 2/1/2024
Herman (2016) Crit Dec Emerg Med 30(5): 12-3
Herbert (2012) EM:Rap 2(9): 7
Mason, Woods and Jacobson in Herbert (2020) EM:Rap 20(2): 10-12
Warrington and Pitocchi (2017) Crit Dec Emerg Med 31(12): 9
Finucane (1999) JAMA 282:1368 [PubMed]
Li (2002) Am Fam Physician 65(8):1605-10 [PubMed]

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