Displaced G-tube

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
• Displacement is estimated to occur in 1.6-20% of patients with PEG tubes

Anatomy

The G-tube creates a connection via a hollow tube, from the gastric lumen, through the gastric wall and peritoneum, and through the abdominal wall

Clinical Features

• G-tube fully removed or partially removed with deflated balloon exposed

Differential Diagnosis

G-tube complications

• Clogged G-tube
• Displaced G-tube
• Infected G-tube
• Leaking G-tube

Evaluation

• Clinical diagnosis

Management

Within 2-4 Weeks of Insertion

• Do not attempt to replace the tube
• May not represent sufficient time for full epithelialization of the percutaneous tract
• Efforts at replacement may result in intra-peritoneal tube
• Urgent general surgical, gastroenterology, or radiology consult is recommended
• Admit for IV antibiotics and monitor for peritonitis

More Than 2-4 Weeks

• Reinsertion should be attempted as soon as possible
  • Mature stomas close rapidly (within minutes to hours)
• Replacement tubes should be of the same size as the initial tube
• If the original size is unknown, a 16 or 18 French G tube or a Foley catheter may generally be used

Replacing a G-Tube

1. Deflate the balloon
2. Lubricate the tube with lidocaine jelly
3. Position the patient reclined in bed to decrease abdominal pressure and relax abdominal wall musculature
4. Reinsert the tube along the tract
   • Never force the tube
   • Forcing the tube may separate the stomach from the abdominal wall and result in intraperitoneal placement of the G tube
   • If unable to replace g-tube, attempt one size smaller or a foley catheter
5. Inflate the balloon with NS (amount written in milliliters on the port)
6. Apply gentle traction to position the balloon against the gastric wall
7. Adjust the external bolster against the skin with approximately 1cm of mobility and secure with tape and gauze
8. Not recommended to place gauze between external bolster and skin
9. Confirm positioning. Options include:
   • Inject 20-30mL of water-soluble contrast [Gastrografin], then obtain an upright abdominal XR
   • Inject of 10cc NS through the tube under direct ultrasound visualization of the stomach
   • Check tube fluid: gastric fluid pH is normally <4

Disposition

• Tubes in place less than 2-4 weeks need urgent surgical, gastroenterology, or radiology consult
• Otherwise, tubes may be reinserted as described above, with urgent surgical, gastroenterology, or radiology consult if the tube is not replaced easily

External Links

• YouTube - Gtube Replacement

See Also

• G-tube complications