Leaking G-tube: Difference between revisions

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==Background:==
==Background==
The percutaneous gastrostomy tube (PEG) is commonly indicated in:
*The percutaneous gastrostomy tube (PEG) is commonly indicated in:
*patients with impaired ability to tolerate PO for caloric supplementation, hydration, frequent enteral medication dosing  
**patients with impaired ability to tolerate PO for caloric supplementation, hydration, frequent enteral medication dosing
*oropharyngeal or esophageal obstruction
**oropharyngeal or esophageal obstruction
*major facial trauma  
**major facial trauma
**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


A PEG may also be placed for:
==Clinical Features==
*passive gastric decompression
*Drainage from the stoma is common
*mechanical apposition of the stomach to the abdominal wall to prevent hiatal herniation.
*Frequently due to a foreign body reaction to the tube
*Simple foreign body reactions should be differentiated from cellulitis and necrotizing fasciitis


==Differential Diagnosis==
{{DDX G-tube}}


Most PEGs are 18F to 28F and may be used for 12-24mo.
==Diagnosis==
*Clinical diagnosis


==Management==
*Simple foreign body reactions 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; management may include:
**Discontinuing tube feeds
**Starting empiric antibiotics initiated
**Obtain imaging and surgical consult


General complications include:
==Disposition==
*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
*Simple foreign body reaction: home with skin care teaching
*Otherwise: management in conjunction with consultant
*Other management in conjunction with consultant


==See Also==
==See Also==
*[[G-tube complications]]
*[[G-tube complications]]
*[[Clogged feeding tube|Clogged G-tube]]
*[[Clogged G-tube]]
*[[Displaced G-tube]]
*[[Displaced G-tube]]
*[[Infected G-tube]]
*[[Infected G-tube]]
*[[Leaking G-tube]]
*[[Leaking G-tube]]


==References:==
==References==
<Bistrian B.R., Hoffer L, Driscoll D.F. (2015). Enteral and Parenteral Nutrition Therapy. In Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J (Eds),Harrison's Principles of Internal Medicine, 19e. Retrieved January 23, 2016 fromhttp://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=1130&Sectionid=63653665./>
<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./>
 
<Cruz E.S., Stolzenberg D, Moon D (2015). Medical Emergencies in Rehabilitation Medicine. In Maitin I.B., Cruz E (Eds), CURRENT Diagnosis & Treatment: Physical Medicine & Rehabilitation. Retrieved January 23, 2016 fromhttp://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=1180&Sectionid=70382621./>
 
<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/>


<Witting M.D. (2016). Gastrointestinal Procedures and Devices. In Tintinalli J.E., Stapczynski J, Ma O, Yealy D.M., Meckler G.D., Cline D.M. (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. Retrieved January 23, 2016 fromhttp://accessmedicine.mhmedical.com.foyer.swmed.edu/content.aspx?bookid=1658&Sectionid=109433184./>
[[Category:GI]]

Revision as of 19:13, 31 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
    • 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

Clinical Features

  • Drainage from the stoma is common
  • Frequently due to a foreign body reaction to the tube
  • Simple foreign body reactions should be differentiated from cellulitis and necrotizing fasciitis

Differential Diagnosis

G-tube complications

Diagnosis

  • Clinical diagnosis

Management

  • Simple foreign body reactions 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; management may include:
    • Discontinuing tube feeds
    • Starting empiric antibiotics initiated
    • Obtain imaging and surgical consult

Disposition

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

See Also

References

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