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 (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 septic patient''


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


Most PEGs are 18F to 28F and may be used for 12-24mo.
==Diagnosis==
*Diagnosis is based on exam and ancillary markers of infection
*Consider bacterial and fungal cultures


 
==Management==
General complications include:
*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
*wound infection
*ABX choices generally include a first-generation cephalosporin or quinolone
*necrotizing fasciitis
*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:==
Physical exam may be significant for erythema, tenderness, and purulent exudate.
 
==Differential Diagnosis:==
*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)
*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:==
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, 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
*MRSA coverage may be indicated on a center-dependent basis


==Disposition:==
==Disposition==
*Cellulitis: consult GI or GS, IV abx, tube may need to be removed (see above)
*Cellulitis: Consult GI or GS, IV abx, tube may need to be removed
*Necrotizing fasciitis: immediate abx, consider MRI to confirm dx, surgical debridement
*Necrotizing fasciitis: Immediate abx, consider MRI to confirm dx, surgical debridement


==See Also==
==See Also==
*[[G-tube complications]]
*[[G-tube complications]]
*[[Clogged feeding tube|Clogged G-tube]]
*[[Clogged G-tube]]
*[[Displaced G-tube]]
*[[Displaced G-tube]]
*[[Infected G-tube]]
*[[Infected G-tube]]
*[[Leaking G-tube]]
*[[Leaking G-tube]]


==References:==
==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./>
<references/>
 
<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./>
[[Category:ID]][[Category:GI]]

Revision as of 19:03, 31 January 2016

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

Diagnosis

  • 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
  • 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
  • Necrotizing fasciitis: Immediate abx, consider MRI to confirm dx, surgical debridement

See Also

References

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