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'''Displaced Gastrostomy Tube'''
''Displaced Gastrostomy Tube''  
==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
*Displacement is estimated to occur in 1.6-20% of patients with PEG tubes


==Background:==
===Anatomy===
The percutaneous gastrostomy tube (PEG) is commonly indicated in:
The G-tube creates a connection via a hollow tube, from the gastric lumen, through the gastric wall and peritoneum, and through the abdominal wall
*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:
==Clinical Features==
*passive gastric decompression
*G-tube fully removed or partially removed with deflated balloon exposed
*mechanical apposition of the stomach to the abdominal wall to prevent hiatal herniation.


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


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


==Management==
===Within 2-4 Weeks of Insertion===
*Do not attempt to replace the tube
**This many not represent sufficient time for full epithelialization of the percutaneous tract
*Urgent general surgical, gastroenterology, or radiology consult is recommended
===More Than 2-4 Weeks===
*Reinsertion should be attempted as soon as possible
**Mature stomas close rapidly (within minutes to hours)
*Replacement tubes should be of the same size as the initial tube
*If the original size is unknown, a 16 or 18 French G tube or a Foley catheter may generally be used
===Replacing a G-Tube===
#Deflate the balloon
#Lubricate the tube with lidocaine jelly
#Reinsert the tube along the tract. '''Never force the tube'''. Forcing the tube may separate the stomach from the abdominal wall and result in intraperitoneal placement of the G tube.
#Inflate the ballon with NS
#Apply gentle traction to position the balloon against the gastric wall
#Confirm positioning. Options include:
#*Inject 20-30mL of water-soluble contrast [Gastrografin], then obtain an upright abdominal XR.
#*Inject of 10cc NS through the tube under direct ultrasound visualization of the stomach.
#*Check tube fluid: gastric fluid pH is normally <4.


General complications include:
==Disposition==
*wound infection
*Tubes in place less than 2-4 weeks need urgent surgical, gastroenterology, or radiology consult
*necrotizing fasciitis
*Otherwise, tubes may be reinserted as described above, with urgent surgical, gastroenterology, or radiology consult if the tube is not replaced easily
*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


Displacement is estimated to occur in 1.6-20% of patients with PEG tubes.
==External Links==
 
==Anatomy:==
The G-tube creates a connection via a hollow tube, from the gastric lumen, through the gastric wall and peritoneum, and through the abdominal wall.
 
==Management of the Displaced Tube:==
Within 2-4 weeks of insertion: do not attempt to replace the tube, as this many not represent sufficient time for full epithelialization of the percutaneous tract. Instead, urgent general surgical, gastroenterology, or radiology consult is recommended.
 
If the PEG tube has been in place for more than 2-4 weeks, reinsertion should be attempted as soon as possible, as mature stomas close rapidly (within minutes to hours). 
*Replacement tubes should be of the same size as the initial tube.
*If the original size is unknown, a 16 or 18 French G tube or a Foley catheter may generally be used.
 
'''To replace a tube''':
 
1. Deflate the balloon
 
2. Lubricate the tube with lidocaine jelly
 
3. Reinsert the tube along the tract. '''Never force the tube'''. Forcing the tube may separate the stomach from the abdominal wall and result in intraperitoneal placement of the G tube.
 
4. Inflate the ballon with NS
 
5. Apply gentle traction to position the balloon against the gastric wall
 
6. Confirm positioning. Options include:
*Inject 20-30mL of water-soluble contrast [Gastrografin], then obtain an upright abdominal XR.
*Inject of 10cc NS through the tube under direct ultrasound visualization of the stomach.
*Check tube fluid: gastric fluid pH is normally <4.
 
==Disposition:==
Tubes in place less than 2-4 weeks need urgent surgical, gastroenterology, or radiology consult.
 
Otherwise, tubes may be reinserted as described above, with urgent surgical, gastroenterology, or radiology consult if the tube is not replaced easily.


==See Also==
==See Also==
Line 75: Line 57:


==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]][[Category:Procedures]]

Revision as of 18:39, 31 January 2016

Displaced Gastrostomy Tube

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
  • Displacement is estimated to occur in 1.6-20% of patients with PEG tubes

Anatomy

The G-tube creates a connection via a hollow tube, from the gastric lumen, through the gastric wall and peritoneum, and through the abdominal wall

Clinical Features

  • G-tube fully removed or partially removed with deflated balloon exposed

Differential Diagnosis

G-tube complications

Diagnosis

  • Clinical diagnosis

Management

Within 2-4 Weeks of Insertion

  • Do not attempt to replace the tube
    • This many not represent sufficient time for full epithelialization of the percutaneous tract
  • Urgent general surgical, gastroenterology, or radiology consult is recommended

More Than 2-4 Weeks

  • Reinsertion should be attempted as soon as possible
    • Mature stomas close rapidly (within minutes to hours)
  • Replacement tubes should be of the same size as the initial tube
  • If the original size is unknown, a 16 or 18 French G tube or a Foley catheter may generally be used

Replacing a G-Tube

  1. Deflate the balloon
  2. Lubricate the tube with lidocaine jelly
  3. Reinsert the tube along the tract. Never force the tube. Forcing the tube may separate the stomach from the abdominal wall and result in intraperitoneal placement of the G tube.
  4. Inflate the ballon with NS
  5. Apply gentle traction to position the balloon against the gastric wall
  6. Confirm positioning. Options include:
    • Inject 20-30mL of water-soluble contrast [Gastrografin], then obtain an upright abdominal XR.
    • Inject of 10cc NS through the tube under direct ultrasound visualization of the stomach.
    • Check tube fluid: gastric fluid pH is normally <4.

Disposition

  • Tubes in place less than 2-4 weeks need urgent surgical, gastroenterology, or radiology consult
  • Otherwise, tubes may be reinserted as described above, with urgent surgical, gastroenterology, or radiology consult if the tube is not replaced easily

External Links

See Also

References

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