Makindo Medical Notes

Patients who rely on their gastrostomy tube for nutrition and medication must be treated as an emergency if issues arise. Immediate supportive nutrition and alternative medication routes should be provided while re-establishing definitive gastrostomy access.

About

• Percutaneous Endoscopic Gastrostomy (PEG) and Radiology-Inserted Gastrostomy (RIG) are commonly used for patients requiring long-term enteral nutrition or medication administration. These tubes are crucial for patients with chronic neurological conditions like traumatic brain injury, stroke, or cerebral palsy.
• A Percutaneous Endoscopic Jejunostomy (PEJ) is a narrow extension tube passed through the PEG tube into the jejunum, which can block easily and may require replacement.

Common Issues with Gastrostomy Tubes

• Blocked tube
• Tube dislodgement
• Split or leaking tube
• Pain during use
• Tube stuck in the gastrostomy

Blocked Tube

• Common causes include thick feeds, improper medication preparation, and the tube's narrow calibre. This occurs in up to 45% of patients. Prevention involves:
  • Crushing and dissolving medications completely in water before administration.
  • Flushing the tube with 30-60 mL of water after medication and every 4 hours.
  • Avoiding saline, which can crystallize and cause blockages.

How to Unblock the Tube

• Use warm water from a running tap to flush the tube. Do not use Coca-Cola, saline, or other fluids.
• Use a 10ml, 20ml, or 50ml purple gastrostomy syringe to aspirate debris. Avoid regular syringes with Luer lock or slip tips.
• If successful, confirm the tube’s position by checking the pH of aspirated gastric contents. A pH ≤ 5.5 indicates correct placement.

If the Tube Remains Blocked

• For patients entirely dependent on their gastrostomy tube, admit them as an emergency. Contact the gastroenterology registrar on-call.
• Establish IV access and start IV fluids (e.g., 0.9% saline). Prescribe alternative routes for essential medications, such as IV or PR.
• If delays occur, consider nasogastric (NG) feeding and involve a dietician.

Site Infections

• Infection occurs in around 30% of cases and is associated with poor hygiene or tight external flanges.
• Symptoms include inflammation, discharge, and pain. Take a swab of the site and prescribe antibiotics if infection is confirmed.

Complications

• To diagnose complications, the NPSA (2010) recommends:
  • CT scan
  • Contrast study: Dye is inserted through the PEG tube to check for leaks or blockages.
  • Surgical review if necessary.

References

• Gastrostomy ('PEG') Tubes and the ED