A patient presents to you from a nursing home, with paperwork stating that her G tube fell out this morning as her nurse was attempting to give her her daily medications. What further information do you need to know, and how do you proceed?
Gastrostomy (G) tubes
What is their purpose?
G tubes are mainly used for alimentation or gastric drainage/decompression.
Who places them?
Either a gastroenterologist using endoscopy or a radiologist using percutaneous fluoroscopy will place G tubes. Also, general surgeons can place them intraoperatively. Usually, G tubes placed by general surgery or GI will have a “bumper” or bolster that will need to be removed prior to any manipulation of the tube.
When can we replace them in the ED?
Consensus varies regarding the exact time period, but usually if a G tube has been in place for greater than 6 weeks, and it falls out, it cane be replaced at the bedside, with a tube of similar caliber. After all replacements, G tube position should be confirmed radiographically.
What if the patient doesn’t know the size of their G tube?
Start with a 16 or 18 French replacement G tube or Foley catheter.
How do I replace the G tube?
You will need a 16 or 18 French G tube or Foley catheter, water soluble lubricant, and viscous lidocaine.
1) Apply viscous lidocaine around the stoma.
2) Check the balloon on the catheter (you will ultimately be instilling 4.5 cc of fluid if the balloon takes 5 cc and 7 cc if the balloon takes 10 cc).
3) Have your patient lie supine.
4) Next, lubricate the tube and pass through the stoma. If using a Foley catheter, you should insert about 5 cm of the catheter.
***Do not continue to attempt to pass the catheter if you feel resistance.
How do we confirm correct placement?
Radiologists will instill water-soluble contrast material at a volume of 20-30 cc and then obtain a supine abdominal x-ray after 1-2 minutes. If the tube is in the correct place, the rugae of the stomach will be visible on x-ray. You can also confirm G tube placement by ultrasound by instilling 10 cc of normal saline into the tube, while simultaneously observing fluid enter the stomach on ultrasound.