gastroesophageal reflux Gastric feedings are more common than jejunal feedings Enteral feeding via gastrostomy and jejunostomy tubes (J-tubes) has become more common Therefore, ED physicians should become comfortable with the various types of gastric tubes and jejunal tubes, the supporting types of apparatus, and the complications inherent in the use of these lifesaving enteral feeding devices Pathophysiology G-tubes are inserted via percutaneous endoscopic gastrostomy (PEG), open gastrostomy, laparoscopy, or radiologic percutaneous gastrostomy The PEG technique is the most common Laparoscopic and radiologic percutaneous gastrostomies are more recent techniques of enteral tube placement Jejunostomy can be performed via an open technique or percutaneously Jejunal feeding can also be accomplished by placing a jejunal tube via the gastrostomy (“G-J tube”) This method allows jejunal feeding and enables venting of gastric air Equipment Gastrostomy Tubes Several types of G-tubes are available Most are made of polyurethane, silicone, or rubber These devices vary in length, the number of ports, the type of catheter tip, the number of lumens, and the manner of securing to the patient’s skin ( Fig 135.10 ) The mushroom types (Button by Bard Interventional Products Division, Billerica, MA) have soft flexible tips that require an obturator or stylet to stretch the tip These devices have a single lumen The balloon-tip devices (MIC-KEY, Medical Innovations Corporation, Draper, UT) have become most popular and have replaced some of the mushroom-tip devices The inflatable balloon is located at the tip, similar to a urinary Foley catheter They are straightforward to secure and not dislodge as easily These tubes may have multiple ports and lumina The low-profile G-tube (button) ( Fig 135.11 ) has the advantage of not having a long piece of tubing arising from the stoma They may have either mushroom or balloon tips The MiniONE Balloon Button (Applied Medical Technology, Brecksville, OH) offers a lower profile and has been reported to reduce skin irritation due to use of high-grade silicone Replacement devices need to be matched for both the size of the stoma (the external diameter of the tube) and the length of the stoma tract Buttons have unidirectional anti-reflux valves that are fragile In some centers, button devices are placed at the time of the initial gastrostomy Jejunal Tubes Jejunal tubes that pass through the gastrostomy (“GJ” tubes) are usually smalldiameter tubes (8F), an example of which is the Frederick Miller feeding tube set manufactured by Cook (Bloomington, IN) These tubes have a small mercury weight at the distal tip and are placed under fluoroscopy Several types of surgical jejunostomy feeding tubes are available, including Malecot and MIC-KEY jejunal tubes Clinical Findings/Management Complications related to gastrostomy and jejunostomy can be divided into mechanical tube–related problems and problems with the stoma Tube-Related Problems Dislodgment Dislodgment is one of the most common complications of G- and J-tubes This situation may occur as a result of a traumatic event, such as accidental tension on the external tubing, occult balloon deflation, or rupture of the balloon When G-tube dislodgment leads to an ED visit, many parents either recall the size of the tube or bring one along to the ED If neither of these occurs, the patient’s medical record is a helpful resource for locating the most recent tube size The patient with tube dislodgment may present with a benign stoma or with active bleeding related to trauma If the tube size is unknown or if various tube sizes are not available, the most common temporizing method of replacement is insertion of a Foley catheter A crucial consideration is the interval of time since the dislodgment If hours have elapsed, the stoma may be constricted and require insertion of a smaller replacement tube Determining the interval since initial placement of the gastrostomy is important Perioperative displacement (within month of initial placement) is treated differently than dislodgment of a tube from a mature stoma If a recently placed G-tube dislodges, temporary replacement with a smaller Foley catheter may prevent pushing the recently fixed stomach away from the anterior abdominal wall A gastroenterologist or surgeon should then be consulted for definitive care An older tube that has dislodged should be replaced urgently with the same size and type of the tube, if possible, to avoid narrowing of the stoma However, often parents may present several hours after a tube has been dislodged and this may require placement of a smaller tube to keep the stoma patent The ED physician can then replace the tube with increasingly larger tubes until the original size is successfully inserted The physician must use caution when reinserting a G-tube because too much force can lead to tube insertion into the peritoneal cavity through a false tract If the ED provider is not able to easily withdraw gastric fluid after reinsertion, then the patient should have contrast injection imaging to confirm correct placement in the stomach prior to using the tube for feeding or medications A jejunal tube that has dislodged needs to be replaced by the subspecialist who placed it initially For example, a J-tube that was inserted via the gastrostomy should be replaced by the interventional radiologist under fluoroscopy A surgical J-tube requires replacement by a surgeon Clogging Clogging or obstruction of the lumen of the G-tube or J-tube can occur as a result of dried, solidified formula or twisting or kinking of the tube Tube obstruction is discovered when the caregivers cannot infuse fluids If formula is suspected as the cause, aspiration of the clot and gentle flushing of the lumen should be attempted Warm water is recommended as the most effective fluid Despite reports of the success of various carbonated drinks in this situation, their effectiveness is controversial When the G-tube becomes clogged, insertion of a stylet is not recommended because this technique may result in perforation of the tubing beneath the skin level Repositioning of the tube should be attempted next; if this procedure is not effective, removal and replacement are necessary If the gastrostomy is fresh (within month), the surgeon or gastroenterologist should be consulted before removal of the clogged tube Caregivers should be reminded of the need for proper flushing with each use If the patient has a button, the extension tubing should be removed from the button before flushing it FIGURE 135.10 Gastrostomy tube replacement for balloon-type (A ), mushroom-type (B ), and collapsible wing-type (C ) catheters