Intermediate Care

The district nursing teams have experience with troubleshooting gastrostomies, a CFT advice sheet is available here. Management of gastrostomies now falls under the remit of dietetics, so if needing advice or escalation please call 01209318060 or email rcht.diethef@nhs.net.

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Gastrostomy Troubleshooting

 

PEG:      

Long term Tubes (lasts anything from 2-5yrs) inserted under sedation by the Gastroenterology team in an endoscopy unit.

• 2 types: FREKA PEG & CORFLO PEG.  Corflo usually inserted in Cornwall & Freka out of County. Both have to be inserted and removed in hospital.

• Every week the PEG tube should be rotated 360, then gently advanced approx 3 cm & pulled back into position.

(It is normal for the PEG to discolour over time to a mid to dark brown)

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RIG:   

Radiologically Inserted, under X-ray by the Radiologist.

• Short-term tube held in place by a 5ml water balloon.

• The balloon’s water is changed weekly and the RIG tube is changed every 12 weeks by a registered nurse.

 

 

Both PEG & RIG tubes should be rotated 360º daily to prevent adhesions.

EXCEPT JEJUNAL TUBES OR GASTROSTOMIES WITH JEJUNAL EXTENSION - rotating these will cause the tube to kink and displace out of the jejunum                                                                     

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PEJ:       

• Used for the delivery of enteral nutrition to the small bowel. Tube goes through the stomach into the jejunum. Radiology & endoscopy required for initial placement & tube changes.

• This tube should NEVER be rotated and sterile water or cooled boiled water should only be used to flush it.                     

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The external bolster on all tubes should sit 2-5mm from the skin (roughly the width of a pound coin)

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Complications:    

‘Buried bumper syndrome’: caused by the external fixation plate being placed too tightly against the patient’s skin causing the internal bumper to erode into the lining of the stomach.

Also occurs when the PEG tube is not advanced or rotated.

Signs include:

• A tube that does not move in and out of the stoma;

• Problems with constant alarming from the pump to say that feed is not being administered or there is an obstruction;

• Difficulty with flushing the tube or not being able to do so;

• Leakage around the site when trying to flush the tube.

• Infection

In this instance tube removal is impossible without surgical intervention

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Blocked Tube?

Common causes= poorly crushed meds/not flushing tube when feeds are completed.

How to unblock:

One pint of lukewarm water with 1 tsp bicarbonate soda dissolved, leave for 15mins then use gentle agitation with the syringe and keep going!  Can also try rolling the tube between the thumb & fingers before & while it is being flushed to can help to break up the blockage.

DO NOT use coke or other acidic drinks as it could curdle the feed or medication residue and make the blockage worse.

If it’s a Jejunal tube that’s blocked- DO NOT PUT BICARB DOWN TUBE- pt will need to be discussed with AGP as will require xray/endoscopy.

 

Tube fallen out?

Causes= deflated/ruptured balloon, tube deterioration, tube pulled out/trauma

Tract will start to heal over within 3 hours.

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If inserted more than 8 weeks ago, try to insert a foley catheter of same (or smaller) Fr (to keep tract patent). 

Or insert a balloon gastrostomy device of same FR (or smaller), check positioning with gastric aspirate (should be pH<5.5 at least 4 hrs after a feed and 2 hrs after fluid) NB . OR if spare tube not available, wash tube which has fallen out, insert and tape in place marked DO NOT USE. OR Use ENplugs if available.  Contact DNs immediately.

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If inserted within 8 weeks, will need Interventional radiology 01872 253962 for replacement. Speak to Acute GP service if this requires admission (however temporary)

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PEJ tubes:  can become displaced by coming out of the tract so feed may enter the abdominal cavity. For this reason a displaced PEJ tube requires Xray/endoscopy to verify tube position. Please discuss with AGP.

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If unable to replace tube, try a smaller Fr size to see if stoma can be kept open.

If still unable to repass a tube, arrange admission with Acute GP 

 

Radiology RCHT can dilate tract through a wire and replace RIG.

 

AN EMERGENCY GASTROSTOMY GRAB BOX IS SITUATED IN ED.

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Useful Contacts:

• Pharmacy info line 01872 252593 for advice on Px meds for gastrostomy tubes

• Feeding regime problems contact the Dieticians RCHT on 01872 252409 or rcht.diethef@nhs.net or telephone 01209 318060

• Gastroenterologist on-call contact via RCH switchboard

• Nutrition specialist nurse bleep via RCH switchboard x2409/ x2301

• Endoscopy Dept: x3820. Interventional Radiology x3962/ x2344

• Feeding pump problems: Fresanius Kabi: 0808 1001990 available 24hrs a day