TABLE 3.
Common complications associated with gastrostomy (G) and gastrojejunostomy (GJ) tubes
| Complication/presentation | Possible causes | Interventions |
|---|---|---|
| Tube migration | ||
| G tube has moved past pyloric sphincter, patient may not tolerate feeds, there may be retching or vomiting with or without feeding. It can cause dumping syndrome or hypoglycemia The GJ tube tip can flip back into stomach – patient usually presents with vomiting of formula/feeding intolerance |
Tube is not adequately secured to skin Gastrointestinal peristalsis |
For G tube:
For GJ tube:
|
| Site infection (Figure 3) or subcutaneous abscess | ||
| Common signs/symptoms: Tenderness (often is the first sign; sometimes is not recognized, particularly in the neurologically impaired patient) Redness Swelling Increased purulent and/or foul-smelling discharge Fever Pustule formation adjacent to stoma Pinpoint rash, may indicate fungal infection Note: a small amount of crusty yellow/green discharge from stoma is normal (15) |
Poor site care, and dressing in place for prolonged periods of time Bacterial infections often caused by Staphylococcus aureus, Pseudomonas species, Escherichia coli, Enterobacter cloacae, Streptococcus, Lactobacillus and Bacteroides species (15) Fungal infections are common, particularly if area is moist and/or the patient has oral thrush or candidal diaper dermatitis Low-profile tubes that are too small/tight can cause stoma/skin breakdown and infection |
Clean site daily with soap and water or during bathing Warm saline compresses. Take a piece of 2×2 gauze with a Y-shaped cut. Soak gauze with warm (not hot) normal saline. Place gauze around site and compress for 3–5 min. Repeat 2–3 times. Dry site well with gauze, a clean washcloth or let it air dry. Repeat 3–4 times daily. Topical antibiotic creams (such as Polysporin [Johnson & Johnson Inc, Canada], Bactroban [GlaxoSmithKline Inc, Canada] or Fucidin [Leo Pharma Inc, Canada]) applied to site (not recommended for more than 5–7 days) If redness continues to spread beyond site, or there are signs of systemic toxicity (eg, fever), an oral antibiotic, such as Keflex (MM Therapeutics Inc, Canada) or clindamycin, may need to be considered For fungal infections, treat with mixture of hydrocortisone/nystatin cream Remove all dressings Treat any granulation tissue Ultrasound may be necessary to diagnose a subcutaneous abscess Consider sending a culture of any purulent discharge |
| Granulation tissue (Figure 4) | ||
| Overgrowth of tissue around the stoma Often pink, ‘cauliflower-like’ appearance, moist and bleeds easily |
Excessive movement of tube, or trauma to site Dressing over stoma Low-profile tube is inappropriately sized (too long or short) |
Ensure tube is secured to skin Remove dressing Apply warm saline compresses 3–4 times daily If saline compresses are not effective and tissue is large, moist and friable, consider applying silver nitrate every 2–3 days until it resolves. Protect surrounding skin with a barrier cream before applying silver nitrate to avoid burning normal skin (1,15) For balloon devices, ensure balloon is intact and appropriately inflated |
| Leakage and enlarged stoma (Figure 5) | ||
| Excessive leakage of acidic gastric contents from stoma causing skin breakdown and enlargement of stoma Gastric leakage can cause contact dermatitis (Figure 6) |
Excessive movement of tube Accumulation of granulation tissue Poor motility, constipation, chronic cough or vomiting Cracked tube |
Tape tube securely to abdomen Do not insert a tube with a larger bore size (it will further enlarge the stoma) If child has poor motility, may benefit from motility agent, laxative Consider high-dose proton pump inhibitors to decrease acidity of leaking contents Check balloon regularly (every week) for recommended amount of water, and fill as required Pull back on tube gently until resistance is felt to ensure internal securing device is flush to stomach wall. Do not pull tube too tight If there is skin breakdown from leakage, use a barrier cream (eg, Proshield [Healthpoint Canada ULC, Canada], petroleum jelly or zinc oxide) For contact dermatitis, consider spraying affected area with Flonase (GlaxoSmithKline Inc, Canada) Foam dressings such as Allevyn (Smith & Nephew, United Kingdom) adhesive dressing can be considered but must be replaced frequently Consider removing tube for a short period of time to promote constriction of tract. A small bore Foley catheter can be inserted to ensure tract does not close (15). Patient may need to be fed by GJ tube or fed nothing by mouth (admission to hospital for total parenteral nutrition) to decrease gastric leakage and promote healing of enlarged stoma |
| Obstructed tube | ||
| Cannot instill formula or medications through tube | Inadequate flushing Inadequate dissolving of medications Administering medication that is known to block the tube such as the following:
|
Flush tube with warm tap water before and after administering formula and medications (volume of the flush will depend on size of child and any fluid restriction) For children receiving a continuous feed, tube should be flushed every 4–6 h Use liquid form of medications when possible Do not crush medications that are sustained released, enteric coated or microencapsulated (16) Dissolve any tablet medications completely, administer immediately followed by a water flush Caution and extra flushes should be used when administering medications that can be given by tube but are known to block easily such as the following:
Blocked tubes: flush with carbonated water using a 1–3 mL syringe. Gently push or pull on the syringe to attempt to clear the blockage Pancreatic enzymes are used in some institutions Tube may need replacement (1,15,16). When waiting for GJ tubes to be replaced under fluoroscopy, consider alternate methods for providing hydration and medications (could include intravenous, nasogastric or removal of GJ tube and replacement with Foley catheter). Administration through a nasogastric tube or Foley catheter should only be considered in patients with a history of tolerating small volumes of fluids in the stomach Pressure from trying to unblock tube can cause tube breakdown and will need replacement |
| Tube dislodgement | ||
| Tube is out of tract | Tube is not anchored in place Balloon has deflated Tube is damaged or defective |
Secure tube to abdominal wall at all times, not on diaper or clothing Consider dressing patients with undershirts, put sleepers on back to front or overalls to make it difficult to grab tube G and GJ tubes that have been in place for 8 weeks or less from initial date of insertion are considered to have immature tracts and should have a Foley catheter inserted into the tract to prevent closure of the stoma. The Foley catheter should be one size smaller than the patient’s initial tube. The balloon should not be inflated with water and the Foley catheter should not be used for feeding. The permanent tube should be replaced by the health care provider and placement must be confirmed G tubes that have been in place for more than 8 weeks can be replaced with a balloon device or Foley catheter that is the same size as the initial tube. The balloon can be inflated and the tube can be used after placement is confirmed by aspirating gastric contents from the new tube. Consider checking tube placement under fluoroscopy if replacement was difficult or if positioning is questionable GJ tubes should always be replaced under fluoroscopy, but a Foley catheter can be inserted to prevent the tract from closing |
| Intussusception | ||
| Intestinal obstruction at the site of the GJ tip (9,17–19) | Small size of patient Large bore size of tube Pigtail end of tube Intestinal motility |
Insert a smaller bore GJ tube Radiologist can cut off pigtail Shorten length of GJ tube Consider returning to gastric feeding Consider surgical option (ie, Nissen fundoplication) |
References are provided in parentheses where applicable