Troublesome G-Tubes

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Key History and Physical Exam

When gathering a history on a patient with a dislodged G-tube, it’s important to obtain certain key pieces of information about the placement and history of the tube. Whether through direct query of the patient or chart review, the clinician should identify the date of tube placement in order to determine whether the tract is mature enough to attempt bedside replacement. Most sources agree that the gastrocutaneous tract formed by GT placement is fully matured by approximately 4-6 weeks.(1,2) If the tube has been in place for <4 weeks, bedside replacement should not be attempted as there is a high likelihood of perforation or false tract creation leading to peritonitis from gastric leakage or introduction of feeds directly into the peritoneal cavity.(1) The clinician should also identify the type and size of tube placed and use the same variety for replacement. Reviewing the chart for signs of any previous complications with the patient’s G-tube is also beneficial. Lastly, it’s extremely important to note how long the tube has been displaced and if anything was inserted to maintain patency of the stoma. Most sources suggest that narrowing or closure of gastrocutaneous fistula tract begins in as little as 4-8 hours.(1) However, from 4-24 hours of displacement the Emergency Department clinician may still attempt bedside replacement. After 24 hours, all tracts will have narrowed to a certain extent and may have completely closed, making bedside replacement difficult and more prone to complication. 

In performing a physical examination of a patient with a dislodged G-tube, there are several key pathologies you should attempt to detect as they will impact clinical decision making. Firstly, thorough palpation of the abdomen should be performed to detect any signs of ascites or peritonitis. If clinical suspicion for either of these conditions is elevated based on exam, bedside replacement should not be attempted.(1) The G-tube stoma should be thoroughly inspected for any signs of infection including erythema, warmth, fluctuance, purulent discharge, or disproportionate tenderness. A suspected infection such as cellulitis or abscess is also a relative contraindication to bedside replacement and should prompt the clinician to consult surgery or transfer the patient to a facility with surgical specialists if none exist at the current institution.

Approach to Placement

Once the decision has been made that an attempt at bedside replacement of the G-tube is appropriate, the actual process is fairly straightforward. The clinician will need to gather the necessary materials: G-tube of similar size and type to previous, alcohol or povidone-iodine swabs, 10cc syringe, feeding/irrigation syringe, adaptor, sterile water, 4x4 gauze, and dressing kit. It is also helpful to obtain flexible foley catheters that are several sizes smaller than the one you are attempting to place in case you need to dilate the tract. (3) If you haven’t yet obtained the correct size G-tube, use any appropriately sized foley catheter or red rubber catheter that will fit. The most important thing is to place something in the tract before it begins to close. 

  1. Locate and gather all necessary supplies

  2. Remove your desired tube from the packing, test the balloon by inflating it with the manufacturer-recommended amount of sterile water, and inspect for any damage

  3. Clean the area of the stoma with alcohol swabs, chlorhexidine, or povidone-iodine. 

  4. Lubricate the end of the tube with sterile gel

  5. Insert the lubricated end of the tube into the stoma and apply very gentle pressure. Do not force against resistance. You may change the angle of entry or rotate the tube slowly to ease it in, but always do so with very little force

  6. When the tube has been inserted all the way into the tract, inflate the balloon with the recommended amount of sterile water and then pull gentle traction against the tube until you feel resistance of the balloon against the stomach wall. 

  7. To confirm placement, you can use a large irrigation/feeding syringe full of air and inject into the feeding port while auscultating in the epigastric area for borbyrygmi and/or draw back at the same port to aspirate gastric contents (testing the pH of the contents confirms gastric placement). Some institutions may require a gastrografin abdominal XR to confirm placement (although Showalter et al. found that imaging confirmation of 237 patients in a pediatric ED did not reduce complication rate and did prolong ED stay). (4) 

  8. Secure the tube against the abdominal wall with a dressing to ensure that it does not become accidentally dislodged again. 

Indications for Consult/Transfer

While dislodged G-tubes can often be addressed and replaced by EM clinicians, there are several circumstances in which it becomes necessary to either consult your in-house general surgery or IR service or transfer your patient to a facility with those capabilities.(1,2) 

  • Exam revealing signs of peritonitis or ascites

  • Significant coagulopathy 

  • Displacement of tube >24 hours

  • Tube present for <4-6 weeks

  • Failed bedside placement

  • Presence of GJ tube (these cannot be replaced at bedside)

Complications of Bedside Placement

As with any procedure, there are several key complications to be aware of when replacing G-tubes at the bedside. The most serious of these is the inadvertent creation of a false tract and introducing the tube directly into the peritoneal cavity leading to direct introduction of feeds or gastric contents into the peritoneum.(1,5) To avoid this complication, it’s important to never attempt bedside or blind G-tube replacement in a tract that is <4 weeks old as these are not matured and have a much higher risk of false tract creation. In mature tracts, the clinician should utilize gentle pressure to guide the tube into the fistula without forcing against any resistance. Finally, any patient with a history of difficult tube placement, complications of tube exchange, or history of false tract creation is not a good candidate for bedside insertion. Gastric outlet obstruction is also a possible complication due to an overfilled balloon, although this is much more common in pediatrics.(6,7) Other theoretical complications of bedside G-tube placement in the Emergency Department include infection and bleeding, but there is little to no evidence of these complications in either EM or surgical literature.

References

  1. Shah R, Shah M, Aleem A. Gastrostomy tube replacement . In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/NBK482422/.

  2. Maxwell CI, Hilden K, Glasgow RE, Ollerenshaw J, Carlisle JG, Fang JC. Evaluation of gastropexy and stoma tract maturation using a novel introducer kit for percutaneous gastrostomy in a porcine model. JPEN. Journal of parenteral and enteral nutrition. 2011;35(5):630-635. https://journals-sagepub-com.uc.idm.oclc.org/doi/full/10.1177/0148607111413596. doi: 10.1177/0148607111413596.

  3. Bhambani S, Phan TH, Brown L, Thorp AW. Replacement of dislodged gastrostomy tubes after stoma dilation in the pediatric emergency department. The western journal of emergency medicine. 2017;18(4):770-774. https://www-ncbi-nlm-nih-gov.uc.idm.oclc.org/pubmed/28611900. doi: 10.5811/westjem.2017.3.31796.

  4. Showalter CD, MD, Kerrey B, MD, Spellman-Kennebeck S, MD, Timm N, MD. Gastrostomy tube replacement in a pediatric ED: Frequency of complications and impact of confirmatory imaging. The American journal of emergency medicine. 2012;30(8):1501-1506. https://www.clinicalkey.es/playcontent/1-s2.0-S073567571100578X. doi: 10.1016/j.ajem.2011.12.014.

  5. Gyu Young Pih, Hee Kyong Na, Suk-kyung Hong, et al. Clinical outcomes of percutaneous endoscopic gastrostomy in the surgical intensive care unit. Clinical endoscopy. 2020;53(6):705. https://kiss.kstudy.com/ExternalLink/Ar?key=3837527.

  6. Wong CWY, Chung PHY. Gastrostomy tube migration causing gastric outlet obstruction and gastric perforation in children—two case reports. Translational pediatrics. 2021;10(7):1940-1946. https://pubmed-ncbi-nlm-nih-gov.uc.idm.oclc.org/PMC8349959. doi: 10.21037/tp-21-155.

  7. Acord M, Pollock A. Gastric outlet obstruction from a button-type percutaneous gastrostomy tube. Pediatric emergency care. 2017;33(7):522-523. http://ovidsp.ovid.com.uc.idm.oclc.org/ovidweb.cgi?T=JS&NEWS=n&CSC=Y&PAGE=fulltext&D=ovft&AN=00006565-201707000-00017. doi: 10.1097/PEC.0000000000001234.

Authorship

Written by Sophia Newton, MD, PGY-1 University of Cincinnati Department of Emergency Medicine

Editing and Posting by Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine

Cite As: Newton, S. Hill, J. Troublesome G-Tubes. TamingtheSRU. www.tamingthesru.com/blog/2023/12/14/troublesome-g-tubes. 12/20/23.