Basics
Description
- Extubation:
- Accidental or intentional
- More common with nasoenteric tubes compared with percutaneous endoscopic gastrostomy (PEG) tubes, gastrostomy tubes (G tubes), or jejunostomy tubes (J tubes)
- Occlusion:
- Small diameter:
- Most common with nasoenteric tubes
- Pill fragments
- Inadequate flushing
- Physical incompatibilities between formula and medications:
- Adherence of formula residue to inner wall
- Essential to rule out malposition, fracture, and dislodgment
- Peristomal wound infections:
- Risk factors:
- Malnutrition
- Stomal leak
- Local irritation
- Poor wound care
- Immunosuppression
- Diabetes mellitus
- Poor wound healing
- Obesity
- Excessive traction on tube:
- Leads to delayed maturation of gastrocutaneous tract
- Increases stomal leakage
- Stoma leak:
- Problematic with distal obstruction (mechanical or dysmotility); more common with high gastric residual
- Excessive tube motion
- Aspiration pneumonia:
- At risk:
- Impaired cough/gag reflex
- Delayed gastric emptying from ileus
- Obstruction
- Gastroparesis
- Gastroesophageal reflux (frequent with large nasoenteric tube)
- Diarrhea:
- Medication induced:
- Antibiotics
- Promotility agents
- Overgrowth of Clostridium difficile, other bacteria, or Candida
- High osmolar formula
- Feeding intolerance:
- High residual suggests GI motility dysfunction
- Delivery is too rapid
- High osmolarity formula
- Lactose or fat intolerance
- Low serum albumin
- Uncommon complications:
- Abdominal wall hematoma
- Fistulas:
- Hepatogastric
- Gastrocolic
- Colocutaneous
- Perforation (usually with placement)
- Pressure sores/ulcerations
- GI bleeding
- Esophagitis, gastric pressure ulcers, concomitant PUD
- Gastric outlet obstruction
- Partial or complete obstruction at the pylorus or duodenum by part of tube or Foley catheter balloon used for temporary replacement
- Buried bumper syndrome
- Rare but potentially serious
- Bumper becomes lodged between the gastric wall and skin due to gastric ulceration from excessive tension
- Bowel volvulus around PEG tube
Increased risk of aspiration:
- Delayed gastric emptying
- Immaturity of lower esophageal sphincter
Diagnosis
Signs and Symptoms
- Extubation:
- Occlusion:
- Unable to pass liquid through tube
- Tube migration:
- Distal displacement of PEG tube
- Obstruction at or distal to pylorus
- Dumping syndrome
- Ischemia
- Intussusception
- Evidence of distal prolapse on external tube (if marked)
- Peristomal wound infections:
- Cellulitis
- Abscess formation
- Necrotizing fasciitis
- Stoma leak:
- Leakage of feedings/GI tract contents around stoma
- Aspiration pneumonia:
- Cough
- Dyspnea
- Hypoxia
- Food particulate in pulmonary secretions
- Fever
- Misplacement of nasoenteric tube in pulmonary tree:
- Pneumothorax
- Hydrothorax
- Pleural effusion
- Bronchopleural fistula
- Pneumonia
- Diarrhea:
- Frequent loose stools
- Dehydration
- Intolerance to enteral nutrition:
- High residuals
- Associated with increased risk of aspiration
Essential Workup
- Carefully examine the tube site and position of feeding tube within wound
- For suspected tube migration, obtain a water-soluble contrast radiography of the tube to establish the tube position within the abdomen/stomach/intestine
Diagnosis Tests & Interpretation
Lab
- Peristomal wound infections:
- CBC for significant infections
- Blood culture if systemically ill
- Aspiration pneumonia:
- Pulse oximetry or arterial blood gas
- CBC
- Electrolytes, BUN/creatinine, glucose
- Blood and sputum culture
- Diarrhea:
- Stool for white blood cells/culture/C. difficile toxin
- GI bleeding
Imaging
- CXR:
- Nasoenteric tube position
- Aspiration pneumonia
- Water-soluble contrast radiography for suspected tube migration
Diagnostic Procedures/Surgery
Endoscopy to evaluate for tube migration
Treatment
Pre-Hospital
If extubation of tube has occurred, transport tube with patient to facilitate easier replacement
Initial Stabilization/Therapy
- ABCs
- IV fluid resuscitation for dehydration/sepsis
Ed Treatment/Procedures
Extubation
- Nasoenteric tube:
- Replace in emergency department
- Confirm position by radiograph before use
- PEG tube and gastrojejunal (G-J) tube:
- Takes 4-6 wk for gastrocutaneous tract/fistula to mature
- Improper or aggressive attempt at tube replacement could lead to disruption of gastrocutaneous tract and subsequent peritonitis
- PEG tube in place >4 wk:
- Replace in emergency department (may use a Foley catheter of equivalent size)
- Confirm by water-soluble radiographic study
- Secure catheter to abdominal wall to prevent distal migration
- PEG tube in place <4 wk:
- Do not replace in ED
- Risk of intraperitoneal placement
- May need hospital admission and endoscopic tube replacement
- Surgical G tube or J tube:
- Management similar to that for PEG tube
- Early dislodgment within 1st 3 days requires emergency surgical consult and antibiotic coverage for peritonitis
- May need endoscopic replacement if <4 wk old
Occlusion
- Attempt gentle irrigation with NS, water, carbonated soda, pancreatic enzymes
- If irrigation fails, replace tube
- Do not use meat tenderizer
Tube Migration
- If retraction of tube is possible and well tolerated:
- Secure tube externally
- Discharge home after brief trial of tube feeding
- If feeding is not tolerated, or if there are signs of persistent obstruction or peritonitis:
- Admit with consult to appropriate service (surgical/GI).
- If external tube is cut (accidental or intentional) and the inner tube is within the abdomen:
- Inner bumper usually passes through GI tract
- Cases of obstruction, subsequent perforation, and peritonitis have been reported, especially in children
Peristomal Wound Infections
- Local wound care
- Antibiotics:
- 1st-generation cephalosporin (cefazolin or cephalexin)
- Ampicillin/sulbactam
- Amoxicillin/clavulanic acid
- Clindamycin (penicillin allergic)
- Outpatient management for milder cases
- More severe cases require surgical consult for possible drainage/debridement and inpatient care
- Prophylactic use of antibiotic (cefazolin) before tube placement decreases wound infection (3% vs. 18%)
Peristomal Leak
- Change from intermittent to continuous delivery
- Decrease rate of infusion
- Optimize nutritional status
- Relieve excess tension on tube
- Administer prokinetic agents (e.g., metoclopramide)
- Do NOT place larger tube
- Local care:
- Keep site clean and dry
- Barrier creams
Aspiration Pneumonia
- Stop enteral feeding
- Administer oxygen and broad-spectrum antibiotics
- Endotracheal intubation with mechanical ventilation for respiratory failure and airway protection when indicated
- Prevent by:
- Elevation of head of bed
- Monitoring gastric residual
- Use of continuous infusion at graduated rate
- Use of prokinetic agent
Diarrhea
- Manage cause
- Correct fluid and electrolyte imbalance
- Try isotonic, hypotonic, or fat- or lactose-free formulas
- High-fiber formula if above measures fail
- Antimotility agents:
- Loperamide
- Kaopectate
- Cholestyramine
Formula Intolerance
Prokinetic agents promote gastric emptying
Medication
- Amoxicillin/clavulanic acid (Augmentin): 500-875 mg (peds: 25-45 mg/kg/24 h) PO q12h
- Ampicillin/sulbactam: 1.5-3 g (peds: 100-200 mg/kg/24 h) IV q6h
- Cefazolin (Ancef, Kefzol): 500 mg-1 g (peds: 25-100 mg/kg/24 h) IV q6h
- Cephalexin (Keflex): 250-500 mg (peds: 25-50 mg/kg/24 h) PO q6h
- Cholestyramine: 2-4 g (peds: >6 yr 80 mg/kg q8h) PO q6-12h
- Clindamycin: 150-300 mg (peds: 5-10 mg/kg) IV q6h
- Kaopectate: 30 mL (peds: 3-6 yr old, 7.5 mL; 6-12 yr old, 15 mL) PO after each loose bowel movement up to 7 times per day
- Loperamide (Imodium): 4 mg initially, then 2 mg (peds: 1 mg q8h if 13-20 kg; 2 mg q12h if 20-30 kg; 2 mg q8h, if >30 kg not to exceed 9 mg/d) PO up to 16 mg/d
- Metoclopramide: 5-10 mg (peds: 0.1-0.2 mg/kg to max. 0.8 mg/kg/d) PO/IV/IM q6h (30 min before feeds and every night)
Follow-Up
Disposition
Admission Criteria
- PEG tube extubation within 1 wk of placement
- Surgical G tube or J tube extubation within 3 days of placement
- Significant peristomal wound infection
- Aspiration pneumonia
- Diarrhea associated with dehydration
- Active GI bleeding
- Peritonitis
Discharge Criteria
Successful replacement of extubated feeding tube
Issues for Referral
GI consult or surgical consult for feeding tube replacement when cannot be placed successfully in the emergency department
Followup Recommendations
Primary care or GI follow-up for recurrent feeding tube complications
Pearls and Pitfalls
- Radiography should be used to confirm placement of all feeding tubes
- Do not attempt replacement of a newly placed PEG tube, G tube, or J tube in the ED
Additional Reading
- Metheny NA, Meert KL, Clouse RE. Complications related to feeding tube placement. Curr Opin Gastroenterol. 2007;23:178-182.
- Niv E, Fireman Z, Vaisman N. Post-pyloric feeding. World J Gastroenterol. 2009;15(11):1281-1288.
- Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16(4):407-418.
- Stayner JL, Bhatnagar A, McGinn AN, et al. Feeding tube placement: Errors and complications. Nutr Clin Pract. 2012;27(6):738-748.
Codes
ICD9
- 536.40 Gastrostomy complication, unspecified
- 536.49 Other gastrostomy complications
- 996.79 Other complications due to other internal prosthetic device, implant, and graft
- 536.42 Mechanical complication of gastrostomy
- 536.41 Infection of gastrostomy
- 536.4 Gastrostomy complications
ICD10
- K94.20 Gastrostomy complication, unspecified
- T85.518A Breakdown (mechanical) of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
- T85.528A Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
- T85.598A Other mechanical complication of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
- K94.22 Gastrostomy infection
- K94.23 Gastrostomy malfunction
- K94.29 Other complications of gastrostomy
SNOMED
- 473177008 Obstruction of nasogastric tube (disorder)
- 443181001 Obstruction of percutaneous endoscopic gastrostomy tube (finding)
- 473160008 Migration of nasogastric tube (disorder)
- 426032000 Malfunction of gastrostomy tube (disorder)
- 407547003 Stoma seal leaking (finding)
- 442858008 Infection of gastrostomy site (disorder)