Makindo Medical Notes

Those who rely on their gastrostomy and its tube for nutrition and administration of medication must be treated as an emergency and should be admitted to an area with the immediate intervention of providing supportive nutrition and alternative means of administering medication whilst electively re-establishing definitive gastrostomy access.

About

• Percutaneous endoscopic gastrostomy (PEG) and radiology-inserted gastrostomy (RIG) have become the modality of choice for providing enteral access to patients who require long-term enteral nutrition and or administration of medication. In many such as those patients with chronic neurological dysfunction from traumatic brain injury, stroke and or cerebral palsy, the gastrostomy tube is the sole route nutrition and timely administration of medications is delivered in the community and is therefore dependent on the functioning of the gastrostomy tube. Patients may present directly to the ED.
• A Percutaneous Endoscopic Jejunostomy is a tube that is passed through the PEG tube into the jejunum. This extension tube is narrow and therefore may block easily. If this happens the tube will need to be changed.

What is wrong with the gastrostomy tube?

• Tube is blocked
• Tube has fallen out
• Tube is split and leaking fluid
• Painful to administer stuff through the gastrostomy
• Tube is stuck in the gastrostomy and won't move in and out of the gastrostomy

Blocked Tube

• Thick enteral nutrition feed, medications (thick gloopy syrups versus crushed tablets), and other things can clog the PEG tube which itself predisposes to being blocked by being such narrow calibre. This complication occurs in up to 45% of patients. Prevention is the key to avoiding this problem.
• Medications should be crushed and dissolved completely in water before administrating through the PEG tube. The PEG tube should be flushed with 30-60 mL of free water using a large syringe after medication administration and every 4 hours. Use of saline to irrigate can cause crystallization and promote clogging.

How to unblock the blocked gastrostomy tube

• An infusion of warm water from a running tap (no need for sterile water) to unclog the PEG (or RIG) tube is superior to other agents and as such should be the only intervention in association of aspiration of the gastrostomy tube contents with a syringe. Do not infuse coca-cola, saline, whatever fluid that is not warm water down the gastrostomy tube. Do not insert a guidewire down the lumen of the gastrostomy tube. On needs a gastrostomy tube syringe. Gastrostomy tube syringes have purple plunges and are the only syringes that have the required tip to fit the gastrostomy tube end. Do not use 'normal' non-purple syringes such as those with a Luer lock or slip tip as these tips will not fit onto the gastrostomy tube end
• Using a 10ml, 20ml or 50ml purple nutrition syringe firstly try to aspirate the crud that is blocking the lumen of the gastrostomy tube. After attaching the purple nutrition syringe to the gastrostomy tube end, repeatedly withdraw the syringe plunger and gently push the plunger pack in using air alone. If this intervention does not work, then fill the purple nutrition syringe with warm water from a running tap and try to infuse warm water through the gastrostomy tube to unclog the lumen.
• If you are successful in unblocking the blocked gastrostomy tube, confirm its correct placement inside the stomach by measuring the pH of (hopefully the gastric) contents aspirated. Gastric aspirates have a pH of 5.5 and below. Use the gastric pH indicator strips/paper that are found in the 'Sorting out a PEG' box held in the ED store cupboard. If the aspirate has a pH of 5.5 or below, then the PEG (or RIG) is safe to use, safe for the feed to be reconnected and safe for medication to be administered.

If the blocked gastrostomy tube remains blocked

• If the patient has complete dependence on gastrostomy tube for nutrition and administration of medication. Admit as an emergency to the acute gastroenterology take and contact the acute gastroenterology registrar on-call.
• Establish IV access and prescribe, start IV crystalloid such as 0.9% saline 1L at a maintenance rate e.g. 8 hourly. Prescribe essential medications such as anti-epileptics using an alternative route to the enteral/oral route e.g. IV, PR. If there is a delay then NG feeding might be considered. Involve dietician.

Site infection

• The most common complication is an infection at and around the insertion site; this occurs in around 30% of cases. Infection can occur as a result of poor hygiene when handling the tube; the internal and external flange being too tight has also been associated with higher rates of infection (Ghevariya et al, 2009).
• Infection can present as inflammation around the site, coupled with discharge and pain or discomfort. A swab should be taken if the site has clinical signs of infection. Appropriate antibiotics should be prescribed.

Complications

• To explore the cause of problems that arise and plan appropriate management the NPSA (2010) suggests considering either: A CT scan, Contrast study (dye is inserted through the PEG tube and X-rays are taken to see if the dye goes into the stomach); Surgical review.

References

• Gastrostomy ('PEG') tubes and the ED