Leaking G-tube: Difference between revisions

Revision as of 04:21, 27 January 2016

Background:

The percutaneous gastrostomy tube (PEG) is commonly indicated in:

patients with impaired ability to tolerate PO for caloric supplementation, hydration, frequent enteral medication dosing
oropharyngeal or esophageal obstruction
major facial trauma

A PEG may also be placed for:

passive gastric decompression
mechanical apposition of the stomach to the abdominal wall to prevent hiatal herniation.

Most PEGs are 18F to 28F and may be used for 12-24mo.

General complications include:

wound infection
necrotizing fasciitis
peritonitis
aspiration +/- pneumonia
leaks
dislodgment
bowel perforation
enteric fistulas
bleeding
gastric outlet obstruction
small bowel obstruction
ileus
esophageal or gastric perforation
buried bumper syndrome
fistula
gastric herniation through the stoma

Clinical Features:

Drainage from the stoma is common. Frequently this is due to a foreign body reaction (FBR) to the tube. Simple foreign body reactions should be differentiated from cellulitis and necrotizing fasciitis.

Differential Diagnosis:

purulent stomal drainage secondary to an inflammatory foreign body reaction
leakage of gastric contents around the tube (causing irritation and requiring a larger tube size)
deep infection with signs of peritonitis
necrotizing fasciitis (worsening edema, worsening erythema, bullae, soft tissue emphysema)
obstruction leading to leakage through the tube lumen
gastric herniation through the PEG
fungal infection is less common but can result in fungal peristomal cellulitis, peritonitis, and intra-abdominal abscesses
note: an infected tube may be a nidus of bacteremia: consider PEGs as a possible source in the septic patient

Management:

Simple FBR can be managed with local skin care (cleaning with hydrogen peroxide and warm water).
Leakage of gastric contents around the tube indicates that the percutaneous tract is too large for the tube. Management should include the physician or service responsible for placing the tube, and may include:
- removal for 24-48hrs (with the optional placement of a guidewire) to promote shrinking of the percutaneous tract
- complete removal of the PEG with the intent of tract closure and subsequent placement of a new PEG at an alternate location
Leakage of gastric fluid into the peritoneal cavity results in chemical and bacterial peritonitis.
- discontinue tube feeds
- start empiric antibiotics initiated
- obtain imaging and surgical consult

Disposition:

Simple foreign body reaction: home with skin care teaching
Otherwise: management in conjunction with consultant

References:

<Corbett* S.A. (2014). Systemic Response to Injury and Metabolic Support. InBrunicardi F, Andersen D.K., Billiar T.R., Dunn D.L., Hunter J.G., Matthews J.B., Pollock R.E. (Eds), Schwartz's Principles of Surgery, 10e. Retrieved January 23, 2016 fromhttp://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=980&Sectionid=59610843./>

<DeLegge, M.H. Gastrostomy tubes: Complications and their management. UpToDate. Accessed: 01/23/16. Last updated: Apr 15, 2015. https://www-uptodate-com.foyer.swmed.edu/contents/gastrostomy-tubes-complications-and-their-management?source=search_result&search=gastrostomy+tube&selectedTitle=2~142/>

Authors: