Frequent minor complications are associated with the use of these tubes, including purulent drainage and leakage around the stomal site, clogging, dislodgement, and vomiting and diarrhea.
Drainage from the stomal site is a common finding and represents a foreign-body reaction due to the catheter. As long as there is no evidence of cellulitis or necrotizing fasciitis, local skin care with hydrogen peroxide and warm water will usually clear up the problem. If there is granuloma formation with localized bleeding from friable skin, local treatment with silver nitrate will usually help.
Leakage of gastric contents can become a problem. This is managed by careful insertion of a larger tube. Care should be used not to force too large a tube into the stoma, as this can cause separation of the stomach wall from the abdominal wall.
Prevention is the best treatment for clogging of gastrostomy (G) and jejunostomy (J) tubes. Frequent flushing with water and careful crushing of pills will usually prevent this problem. Vomiting and diarrhea can be relieved by decreasing the amount of the feedings and/or diluting them.
If the tube cannot be unclogged or if it has fallen out, replacement will be necessary. If the tube was placed by a surgeon or gastroenterologist and has not been replaced, it will probably have a bolster (also called a mushroom) holding the tube in place ( Fig 8.5.-1). This will prevent the tube from being removed. The tube must either have the bolster removed endoscopically or the tube may be cut off and the bolster allowed to pass through the GI tract. 12 The latter technique is generally safe in adults; however, its use in children has been associated with more frequent complications. 13 Endoscopic removal is advisable when there is suspected or potential obstructive disease of the GI tract, such as pyloric stenosis, intestinal pseudoobstruction, and intestinal stricture (e.g., due to radiation, ischemia, or inflammatory bowel disease). If the tube is cut, an abdominal radiograph should be obtained 1 week later to confirm passage of the internal component. Most reported complications from a retained internal bolster have occurred when the bolster did not pass within 1 to 2 weeks. 14
FIG. 85-1. Percutaneous endoscopic gastrostomy tube with a mushroom bolster in place. (Adapted from Gauderer MWL, Ponsky JL: A simplified technique for constructing a tube feeding gastrostomy. Surg Gynecol Obstet 152:83, 1981, with permission.)
When the feeding tube has already been replaced or was originally placed via radiographic technique, it should have a balloon holding it in place. The balloon can usually be deflated and the tube easily removed. If there is a problem with removal, the tube can be cut off halfway down; this will usually allow the balloon to deflate. If the catheter still cannot be removed easily, it can be cut off at the skin and the internal component allowed to pass. It should be replaced as quickly as possible to prevent closure of the tract. While there is no published research stating how long it takes for a tract to mature, tracts that are 7 to 10 days old will probably remain open long enough to allow replacement. The physician must first determine, if possible, which type of tube is being used. If the tube is available, replacement with the same size is usually possible. If the tube is not available, it can be difficult to determine whether the tract is for a jejunostomy or gastrostomy tube. Location on the abdominal wall is not helpful. A tract for a G tube is usually larger. Old records may be useful and should be obtained if possible. After determining the type of tract and size of tube used previously, insertion should be performed by the physician using a water-soluble lubricant. If the size of the tube being replaced cannot be ascertained, it is reasonable to start with a 16-Fr replacement gastrostomy tube or Foley catheter. The lubricated tube should pass easily into the stoma without any additional equipment. If resistance is met, the attempt should be abandoned. A smaller tube can be tried to keep the tract open. After replacing the tube, a 20- to 30-mL bolus of a water-soluble contrast material (e.g., Gastrografin) should be instilled through the tube and a supine abdominal x-ray obtained within 1 to 2 min. 15 The x-ray should demonstrate rugae of the stomach for a G tube and flow into a small bowel for a J tube. If there is any question of improper placement, immediate consultation should be obtained.
A special caution regarding jejunostomy tubes should be noted. Jejunostomy tracts are smaller, and smaller-size tubes are used (8 to 14 Fr). These tubes are usually not sutured in place and frequently become dislodged. They can be replaced with catheters made specifically for jejunostomies or with Foley catheters. If a Foley catheter is used to replace a lost jejunostomy catheter, the balloon should never be inflated because it can cause a bowel obstruction or damage the jejunum. The tube is lubricated, inserted into the stoma, and advanced 20 cm. These tubes are easily replaced if the tract is mature: however, if resistance is met, referral to a radiologist for fluoroscopic placement using guidewires is recommended.16
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