Pediatric emergency medicine trisk 1169

gastroesophageal reflux. Gastric feedings are more common than jejunal
feedings.
Enteral feeding via gastrostomy and jejunostomy tubes (J-tubes) has become
more common. Therefore, ED physicians should become comfortable with the
various types of gastric tubes and jejunal tubes, the supporting types of apparatus,
and the complications inherent in the use of these lifesaving enteral feeding
devices.

Pathophysiology
G-tubes are inserted via percutaneous endoscopic gastrostomy (PEG), open
gastrostomy, laparoscopy, or radiologic percutaneous gastrostomy. The PEG
technique is the most common. Laparoscopic and radiologic percutaneous
gastrostomies are more recent techniques of enteral tube placement.
Jejunostomy can be performed via an open technique or percutaneously.
Jejunal feeding can also be accomplished by placing a jejunal tube via the
gastrostomy (“G-J tube”). This method allows jejunal feeding and enables
venting of gastric air.

Equipment
Gastrostomy Tubes
Several types of G-tubes are available. Most are made of polyurethane, silicone,
or rubber. These devices vary in length, the number of ports, the type of catheter
tip, the number of lumens, and the manner of securing to the patient’s skin ( Fig.
135.10 ). The mushroom types (Button by Bard Interventional Products Division,
Billerica, MA) have soft flexible tips that require an obturator or stylet to stretch
the tip. These devices have a single lumen. The balloon-tip devices (MIC-KEY,
Medical Innovations Corporation, Draper, UT) have become most popular and
have replaced some of the mushroom-tip devices. The inflatable balloon is
located at the tip, similar to a urinary Foley catheter. They are straightforward to
secure and do not dislodge as easily. These tubes may have multiple ports and
lumina. The low-profile G-tube (button) ( Fig. 135.11 ) has the advantage of not

having a long piece of tubing arising from the stoma. They may have either
mushroom or balloon tips. The MiniONE Balloon Button (Applied Medical
Technology, Brecksville, OH) offers a lower profile and has been reported to
reduce skin irritation due to use of high-grade silicone. Replacement devices need
to be matched for both the size of the stoma (the external diameter of the tube)
and the length of the stoma tract. Buttons have unidirectional anti-reflux valves


that are fragile. In some centers, button devices are placed at the time of the initial
gastrostomy.
Jejunal Tubes
Jejunal tubes that pass through the gastrostomy (“GJ” tubes) are usually smalldiameter tubes (8F), an example of which is the Frederick Miller feeding tube set
manufactured by Cook (Bloomington, IN). These tubes have a small mercury
weight at the distal tip and are placed under fluoroscopy. Several types of surgical
jejunostomy feeding tubes are available, including Malecot and MIC-KEY jejunal
tubes.

Clinical Findings/Management
Complications related to gastrostomy and jejunostomy can be divided into
mechanical tube–related problems and problems with the stoma.
Tube-Related Problems
Dislodgment. Dislodgment is one of the most common complications of G- and
J-tubes. This situation may occur as a result of a traumatic event, such as
accidental tension on the external tubing, occult balloon deflation, or rupture of
the balloon. When G-tube dislodgment leads to an ED visit, many parents either
recall the size of the tube or bring one along to the ED. If neither of these occurs,
the patient’s medical record is a helpful resource for locating the most recent tube
size.
The patient with tube dislodgment may present with a benign stoma or with
active bleeding related to trauma. If the tube size is unknown or if various tube

sizes are not available, the most common temporizing method of replacement is
insertion of a Foley catheter. A crucial consideration is the interval of time since
the dislodgment. If hours have elapsed, the stoma may be constricted and require
insertion of a smaller replacement tube.
Determining the interval since initial placement of the gastrostomy is
important. Perioperative displacement (within 1 month of initial placement) is
treated differently than dislodgment of a tube from a mature stoma. If a recently
placed G-tube dislodges, temporary replacement with a smaller Foley catheter
may prevent pushing the recently fixed stomach away from the anterior
abdominal wall. A gastroenterologist or surgeon should then be consulted for
definitive care. An older tube that has dislodged should be replaced urgently with
the same size and type of the tube, if possible, to avoid narrowing of the stoma.
However, often parents may present several hours after a tube has been dislodged


and this may require placement of a smaller tube to keep the stoma patent. The
ED physician can then replace the tube with increasingly larger tubes until the
original size is successfully inserted. The physician must use caution when
reinserting a G-tube because too much force can lead to tube insertion into the
peritoneal cavity through a false tract. If the ED provider is not able to easily
withdraw gastric fluid after reinsertion, then the patient should have contrast
injection imaging to confirm correct placement in the stomach prior to using the
tube for feeding or medications.
A jejunal tube that has dislodged needs to be replaced by the subspecialist who
placed it initially. For example, a J-tube that was inserted via the gastrostomy
should be replaced by the interventional radiologist under fluoroscopy. A surgical
J-tube requires replacement by a surgeon.
Clogging. Clogging or obstruction of the lumen of the G-tube or J-tube can occur
as a result of dried, solidified formula or twisting or kinking of the tube. Tube
obstruction is discovered when the caregivers cannot infuse fluids. If formula is

suspected as the cause, aspiration of the clot and gentle flushing of the lumen
should be attempted. Warm water is recommended as the most effective fluid.
Despite reports of the success of various carbonated drinks in this situation, their
effectiveness is controversial. When the G-tube becomes clogged, insertion of a
stylet is not recommended because this technique may result in perforation of the
tubing beneath the skin level. Repositioning of the tube should be attempted next;
if this procedure is not effective, removal and replacement are necessary. If the
gastrostomy is fresh (within 1 month), the surgeon or gastroenterologist should be
consulted before removal of the clogged tube. Caregivers should be reminded of
the need for proper flushing with each use. If the patient has a button, the
extension tubing should be removed from the button before flushing it.


FIGURE 135.10 Gastrostomy tube replacement for balloon-type (A ), mushroom-type (B ),
and collapsible wing-type (C ) catheters.