Why is this a pearl?
We get G-tube dislodgments quite often at Sinai, and they can be an easy patient encounter with a quick note and quick dispo. But they made me so nervous as an intern and early 2! Now I love ‘em and you can love ‘em too!
** GJ-tubes or J-tubes do not get replaced in the ED.
Tell me about the PEG tube.
Gastrostomy tube (G-tube) or Percutaneous Endoscopic Gastrostomy tube (PEG tube) is a tube placed in the stomach for long-term enteral nutritional support. Once the tube is placed, a fistulous gastrocutaneous tract is formed and matures in about 2-4 weeks. **This is not a hard rule, tract maturity can take longer in certain conditions including immunocompromised states, smoking, large ascites, malnutrition** If you’re concerned about tract maturity, see below.
When do I consult surgery?
If a PEG tube becomes dislodged within one month of initial placement, surgery needs to replace it. Patients at this stage are at significant risk of peritonitis and perforation due to spillage of gastric contents into the peritoneum through the immature track. Also, if you attempt to replace the tube or insert a foley blindly via an immature tract, you could accidentally place it in the peritoneum. BAD NEWS BEARS. Surgery needs to be involved if you’re concerned that the tract is not mature.
Additionally, the patient ideally presents within 24 hours of the tube being dislodged. The lumen begins to narrow within 8-24 hours after the tube becomes displaced and continues to narrow after that. If under 24 hours, we should either replace with a G-tube of similar size or place as large a foley as we can to maintain the tract. If it is greater than 24 hours and the tract has closed or narrowed so much that we can’t fit our smallest foley, surgery needs to be involved.
LET’S DO THIS
At least 4-6 weeks since initial placement and less than 24 hours since dislodged? We can usually replace it bedside.
1. Take a history, examine the patient, inspect the site of the G-tube. What’s my abdominal exam and how concerned am I about the patient? Is the tube malfunctioning or is it dislodged? When was it placed? How long has it been since it became dislodged or began to malfunction? Does the site look infected? Does surgery need to be involved?
2. Chart check. If the tube is in there, what kind of tube is it? Does the G-tube have an internal mushroom cap or is there a balloon at the end? Look it up if the patient or aide don’t have the information.
3. Gather your materials. As always in EM, set yourself up for success in any procedure, small or large.
- G-tube of similar size to prior G-tube or a foley of similar size
- Saline flushes
- Dressing kit
- Gauze
- Lubricant
4. REMOVE. If present, the old tube needs to be removed. You should not experience unusual resistance at any point during this process. If you’re uncomfortable with the level of resistance, stop and grab your senior/attending and consider getting surgery involved.
- If the old tube has an internal mushroom cap, then apply gentle traction to the external part of the tube to remove the internal mushroom. If you are meeting resistance such that you’re applying force, stop — you don’t want to disrupt the tract. Surgery should get involved.
- More commonly, the G-tube will have an internal balloon. Deflate the balloon by aspirating the fluid through the balloon port with an empty 10mL syringe. There’s usually 8-10mL of fluid in there. Remove the tube.
5. REPLACE. For the replacement G-tube, use a ballon tip G tube similar in size to the initial one or as large a foley as you can fit. First, confirm that the balloon is working outside of the body by inflating it with 8-10mL of NS. Deflate it. Apply some lube to the balloon end. Blindly place the G-tube into the tract. This might require some patience. If you apply some constant, gentle pressure for a few minutes, it will likely slide in. Once inside, inflate the ballon with 8-10mL of NS. Tug on the tube slightly till you meet some resistance to ensure that the internal balloon is lying against the gastric wall. Flush and cap the ports. Dress the tube.
6. CONFIRM. To confirm it, you need a G-tube study — essentially a contrast enhanced abdominal XR. You’ll likely have to go to radiology (UGH) and push some contrast through the port, then they’ll shoot a plain film. On the image, you should be able to see the contrast in the stomach if it was placed successfully in the right location.
7. FOLLOW UP. That foley needs to be exchanged for an actual G-tube soon. They need prompt surgery follow up!
