Overview of Gastrostomy Tube Replacement
A G-tube, or gastrostomy tube, is a tube that goes into your stomach. It is used to give food and medicines to people who have trouble swallowing. Doctors often choose to put the tube in using a special kind of camera called an endoscope. This is better than doing a big surgery because it’s less invasive and patients can start eating again more quickly.
During the procedure, the doctor makes a small cut in the skin on your belly. They put the G-tube in through this cut using one of two methods: a “push” method (where they put the tube in through the cut) or a “pull” method (where they pull the tube out from the inside of your stomach through the cut). Once the tube is in place, a special kind of healing process takes place over the next 2-4 weeks, creating a secure pathway, called a gastrocutaneous tract, from your skin to your stomach.
However, some conditions can make this healing process take longer. These include severe malnutrition, weak immune systems, and having a lot of fluid in the tummy or “ascites”.
If the tube comes out within a month after placement, doctors usually replace it using the endoscope. If the tube falls out after this secure pathway is mature (usually after 4-6 weeks), it is usually replaced at the patient’s bedside.
It’s important to note that if the tube falls out within the first 4 weeks, it should not be replaced without a surgeon’s advice. This is because replacing the tube at this stage can be dangerous and can lead to an infection in the belly (called peritonitis), and even a hole (perforation) in the stomach if the tube goes in the wrong place. This discussion will help clarify when to replace a G-tube in adults once the secure skin-to-stomach pathway is fully formed.
Anatomy and Physiology of Gastrostomy Tube Replacement
When placing a G-tube (a feeding tube that goes directly into the stomach) using an endoscope (a flexible tube with a camera at the end), the doctor starts by inserting the gastroscope into your body. After the gastroscope is inserted, air is blown into your stomach to make it bigger. The doctor then looks for the best place to insert the G-tube. This is usually about an inch below the edge of your ribcage and towards the middle of your body.
The doctor then turns on a light on the endoscope. The light shines through the wall of your stomach, and the doctor looks for the spot where the light is brightest. This is the best place to insert the G-tube. The doctor can make sure this is the right spot by pressing on it and watching to see that the stomach wall moves at the same time. Once they’re sure they have the right place, they mark it with a special pen that can be used on skin.
After the tube is placed with the endoscope, the opening between the tube and your body needs time to heal. As it heals, the outer wall of your stomach sticks to the inside of your belly. This creates a passage between your stomach and your skin called a gastrocutaneous fistula.
Why do People Need Gastrostomy Tube Replacement
There are several reasons why a tube that is used for percutaneous endoscopic gastrostomy (PEG) might need to be replaced. Percutaneous endoscopic gastrostomy is a procedure where doctors insert a tube through your skin and into your stomach to provide nutrition. Here are some situations where the tube might need to be replaced:
– If the PEG tube has moved out of place within the first 24 hours, a temporary tube (like a Foley catheter, a tube used to drain urine from the bladder) should be put in the existing pathway to stop it from closing. This closing can start happening between 8 to 24 hours and gets narrower over time.
– If the PEG tube stops working properly.
– If the G-tube, a tube that helps food bypass the mouth and throat and go directly to the stomach, becomes blocked and regular methods to unblock it are unsuccessful. These methods can include flushing the tube with water or a mixture of pancreatic enzymes and a bicarbonate solution.
When a Person Should Avoid Gastrostomy Tube Replacement
In certain situations, a doctor may advise against replacing a PEG tube (a tube that goes into the stomach to assist with feeding) at the patient’s bedside or without imaging guidance. These circumstances include:
If the G-tube (a type of feeding tube) has moved or is not working properly within the first four weeks of its placement, it may not be advisable to replace it at the bedside. This period is crucial for the development of a secure path or ‘track’ from the skin to the stomach where the tube is placed.
Large amounts of fluid accumulation in the belly, a condition known as massive ascites, is another situation where replacing the tube may not be advised.
If there are any signs of peritonitis (an infection of the tissue lining your abdomen), replacing the tube should not be done without further medical review.
Having a blood clotting disorder can also make such a procedure risky because of the increased chance of heavy bleeding.
Lastly, if the tube has moved out of place and remained so for more than 24 hours, it may not be safe to replace it at the bedside. This is because the ‘track’ or pathway may have narrowed or closed completely.
Equipment used for Gastrostomy Tube Replacement
When it comes to replacing a G-tube (a feeding tube that goes directly into your stomach) at the bedside, your doctor will need the following items:
- A new G tube that’s the same size as the old one
- A small syringe that can hold up to 10 mL of saline (a solution of salt and water)
- A guidewire to help insert the new feeding tube
- A special kit for dressing the wound
- Different sizes of gauze (2 x 2 and 4 x 4) to clean, cover and protect the area around the tube
- Swabs soaked in alcohol and povidone-iodine to disinfect the skin
- A gastroscope, a flexible tube with a light and camera, only if there’s a chance that an endoscopic replacement might be considered. An endoscopic replacement involves using this tool to visualise the inside of your stomach during the procedure.
Preparing for Gastrostomy Tube Replacement
Before a doctor can assess a patient with a tube in their body, they first have to inspect the tube to ensure it’s working correctly. Occasionally, these tubes can stop working properly. This is why it’s exceptionally important for the doctor to understand the patient’s medical history and to know what type of tube is in place. Different tubes work in different ways, for instance, some have an internal cap shaped like a mushroom, while others have an internal balloon.
Next, the doctor removes the dressing or bandage to examine the cut that was made in the skin to insert the tube. This cut, or “percutaneous incision,” is examined carefully to look for any signs of infection, if the cut is closing up, or if the tube has shifted underneath the skin. To do this safely, the doctor cleans the area with sterilizing alcohol or povidone-iodine, which is a type of disinfectant, to keep the area clean.
Lastly, the area is covered with a special protective cover, called a sheath, or a surgical drape. This is to avoid spreading any germs onto the tube during the tube replacement procedure. This routine inspection makes sure that the tube is working correctly and helps to keep the patient safe from any infections.
How is Gastrostomy Tube Replacement performed
If the PEG tube (a tube that goes from the outside of your skin directly into your stomach) is not working properly and needs to be removed, doctors must be very careful not to disrupt the path it has created inside your body. If this tube is filled and held in place by a small pillow-like device (mushroom tip), the doctor applies a light pull on the outside section of the tube to remove this internal ‘mushroom’. But, they must be very careful not to use too much force, as it could damage the tube’s path.
If the tube doesn’t come out easily with gentle pulling, the doctor may need to use a special tool to cut the mushroom tip from inside your body and then pull out the rest of the tube from the outside. If the tube has an inflatable balloon to hold it in place inside your body, this balloon must be emptied of liquid (about 8 to 10 mL) before the tube can be removed.
When placing the new PEG tube, doctors normally use one with a balloon tip to reduce the risk of disrupting the old track caused by the first tube. They make sure the balloon inflates properly by testing it with 8 to 10 mL of saline solution (a type of saltwater) outside the body. Once tested, the balloon is deflated, and the tube is inserted into the path. This can be done by feeling the location or using a guidewiren or X-ray imaging. The balloon is then filled with saline solution inside the body, and the tube is adjusted until it sits securely against the stomach wall. To protect the tube, the outside part is covered with a special dressing. After that, the tube’s lower parts are cleaned and covered.
After putting in the new tube, it’s essential to confirm that it’s sitting in the right place. Although they could listen for stomach sounds as they put in air through the tube, this method is not very reliable. The gold standard for checking tube placement is using an endoscope, a special kind of camera. But due to cost, this isn’t always an option. Instead, most doctors confirm tube placement by putting a type of dye that shows up on X-rays through the tube and then taking an X-ray of the abdomen.
Possible Complications of Gastrostomy Tube Replacement
If you’ve had a procedure where a PEG tube (a feeding tube inserted into your stomach through the skin and muscle in your abdomen) has been put into place, and then replaced, you might undergo some complications. The main risk is the tube accidentally being placed inside the lining of your abdominal cavity, called peritoneal placement.
You should suspect this problem if, after the tube was replaced or after you start eating again through the tube, you begin to experience abdominal pain, fever, and signs of a severe inflammation of the lining of your abdomen on examination. This inflammation is known as peritonitis.
If this happens, your doctor will quickly undertake some tests to confirm the tube placement. This could involve using a special dye that can be seen on x-rays, or a CT scan, which is a special type of x-ray that can show detailed images of the inside of your body. If this problem has occurred, your tube feeds, which are the nutrients you receive through the tube, will be stopped immediately.
You’ll also be given a quick referral to a surgeon and broad-spectrum antibiotics, which can kill many types of bacteria, will be begun as soon as possible. Afterward, doctors will closely watch your blood pressure, heart rate, and breathing (known as hemodynamic monitoring), and step in with surgical assistance if needed.
Other complications are rare, but it is possible for the site where the tube was replaced to get infected. This is especially likely if the balloon that holds the tube in place is not fully inflated or is not lying flat against the inner surface of the stomach. This could lead to the stomach’s contents leaking out into the tube track. Although very rare, there could be bleeding due to injury during the tube replacement.
What Else Should I Know About Gastrostomy Tube Replacement?
A G-tube, or gastrostomy tube, is a device inserted into your stomach to provide nutrition or medicine directly if you cannot eat or swallow normally. Sometimes, it may not work correctly or may fall out. This issue is quite common and can happen to patients in hospitals, clinics, or at home.
In some places, either the gastroenterology team (specialists in digestive systems) or interventional radiology team (experts in image-guided procedures) will handle the G-tube replacement, depending on who initially installed the tube. If you notice your G-tube isn’t working right or if it has fallen out, you should reach out to either of these services promptly.
When the G-tube comes out, the hole (fistula) in your stomach skin starts to close up quite fast, sometimes as quickly as 8 hours, but generally within 24 hours. The longer the tube is out, the more likely it is that the hole has become too narrow or closed up entirely.
If more than a day has passed after your G-tube has fallen out, don’t try to force a new tube or a Foley catheter (a similar device to a G-tube) into the hole yourself. Instead, please schedule an appointment with a specialised service like a gastrointestinal or interventional radiology team who can safely manage the replacement.
If your G-tube has fallen out for less than 24 hours, consider using a temporary tube like a Foley catheter to keep the hole open and get in touch with a specialist for a full replacement. Once the G-tube is replaced, it’s recommended to have an X-ray with contrast material to ensure the tube is correctly positioned within the stomach.
If you develop signs of peritonitis (a serious inflammation of the abdomen’s lining) after the tube replacement, this may suggest the tube was mistakenly placed inside your belly area. If this happens, you need to be further evaluated promptly.
