Infected G-tube: Difference between revisions

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*Necrotizing fasciitis: immediate abx, consider MRI to confirm dx, surgical debridement
*Necrotizing fasciitis: immediate abx, consider MRI to confirm dx, surgical debridement


==See Also:==
==See Also==
https://wikem.org/wiki/Clogged_feeding_tube
*[[G-tube complications]]
 
*[[Clogged feeding tube|Clogged G-tube]]
https://www.wikem.org/wiki/Displaced_G-tube
*[[Displaced G-tube]]
 
*[[Infected G-tube]]
*[[Leaking G-tube]]


==References:==
==References:==

Revision as of 17:43, 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

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:

Physical exam may be significant for erythema, tenderness, and purulent exudate.

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)
  • 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

Diagnosis/Workup:

Diagnosis is based on exam and ancillary markers of infection. Consider bacterial and fungal cultures.

Management:

The G-tube does not need to be removed routinely unless there are signs of peritonitis, signs of necrotizing fasciitis, or the infection does not respond to antibiotic treatment.

  • Most infections are minor
  • ABX choices generally include a first generation cephalosporin or quinolone
  • MRSA coverage may be indicated on a center-dependent basis

Disposition:

  • Cellulitis: consult GI or GS, IV abx, tube may need to be removed (see above)
  • Necrotizing fasciitis: immediate abx, consider MRI to confirm dx, surgical debridement

See Also

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./>

<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./>