Infected G-tube: Difference between revisions

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==Background:==
==Background==
The percutaneous gastrostomy tube (PEG) is commonly indicated in:
*The percutaneous gastrostomy tube (PEG) is commonly indicated in:
*patients with impaired ability to tolerate PO for caloric supplementation, hydration, frequent enteral medication dosing  
**patients with impaired ability to tolerate PO for caloric supplementation, hydration, frequent enteral medication dosing
*oropharyngeal or esophageal obstruction
**oropharyngeal or esophageal obstruction
*major facial trauma  
**major facial trauma
**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


A PEG may also be placed for:
==Clinical Features==
*passive gastric decompression
*Most infections are minor ([[rash|erythema]], tenderness, and purulent exudate at g-tube site)
*mechanical apposition of the stomach to the abdominal wall to prevent hiatal herniation.
*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)
*Deeper infection may show 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 [[sepsis|septic]] patient''


==Differential Diagnosis==
{{DDX G-tube}}


Most PEGs are 18F to 28F and may be used for 12-24mo.
==Evaluation==
*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, necrotizing fasciitis, or the infection does not respond to initial antibiotic treatment
*Antibiotic choices generally include a first-generation [[cephalosporin]] or [[quinolone]]
*[[MRSA]] coverage may be indicated on a center-dependent basis


General complications include:
==Disposition==
*wound infection
*[[Cellulitis]]: Consult GI or surgery, IV antibiotics, tube may need to be removed
*necrotizing fasciitis
*[[Necrotizing fasciitis]]: Immediate antibiotics, consider MRI to confirm diagnosis, surgical debridement
*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:==
==See Also==
Physical exam may be significant for erythema, tenderness, and purulent exudate.
*[[G-tube complications]]


==Differential Diagnosis:==
==References==
*purulent stomal drainage secondary to an inflammatory foreign body reaction
<references/>
*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:==
[[Category:ID]][[Category:GI]]
Diagnosis is based on exam and ancillary markers of infection. Consider bacterial and fungal cultures.
[[Category:Surgery]]
 
==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:==
https://wikem.org/wiki/Clogged_feeding_tube
 
https://www.wikem.org/wiki/Displaced_G-tube
 
 
==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./>

Latest revision as of 17:13, 29 October 2019

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
    • 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

Clinical Features

  • Most infections are minor (erythema, tenderness, and purulent exudate at g-tube site)
  • 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)
  • Deeper infection may show 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

Differential Diagnosis

G-tube complications

Evaluation

  • 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, necrotizing fasciitis, or the infection does not respond to initial antibiotic treatment
  • Antibiotic choices generally include a first-generation cephalosporin or quinolone
  • MRSA coverage may be indicated on a center-dependent basis

Disposition

  • Cellulitis: Consult GI or surgery, IV antibiotics, tube may need to be removed
  • Necrotizing fasciitis: Immediate antibiotics, consider MRI to confirm diagnosis, surgical debridement

See Also

References

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