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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