Overview
Definition:
A gastrostomy tube (G-tube), often a percutaneous endoscopic gastrostomy (PEG) tube, is a surgically placed feeding tube that goes through the abdominal wall into the stomach
It bypasses the mouth and esophagus, providing direct access for nutrition, hydration, and medication administration.
Epidemiology:
The incidence of G-tube placement in pediatrics is variable, depending on the underlying condition
It is common in children with congenital anomalies, neurological impairments, prematurity, severe gastrointestinal disorders, and in those requiring prolonged nutritional support
Estimates suggest thousands of pediatric placements annually across India.
Clinical Significance:
Proper G-tube care is crucial to prevent significant complications, which can range from minor skin irritation to life-threatening events like sepsis or bowel perforation
Understanding and managing these tubes effectively is a core skill for pediatricians and pediatric surgeons, directly impacting patient outcomes and quality of life.
Indications For Placement
Nutritional Support:
Failure to thrive
inability to meet caloric needs orally due to prematurity, dysphagia, or increased metabolic demands.
Gastrointestinal Disorders:
Severe gastroesophageal reflux disease (GERD) refractory to medical management
motility disorders
short bowel syndrome
congenital GI anomalies.
Neurological Impairments:
Cerebral palsy
hypoxic-ischemic encephalopathy
genetic syndromes leading to poor coordination of swallowing or consciousness impairment.
Airway Protection:
Recurrent aspiration pneumonia secondary to impaired swallowing mechanisms.
Gastrostomy Tube Care
Site Care:
Daily cleaning of the stoma site with mild soap and water
Ensure the skin is dry
Rotate the tube gently (if not a low-profile device) 360 degrees daily to prevent adherence
Inspect for redness, swelling, or drainage.
Tube Maintenance:
Flush the tube with sterile water (5-10 mL for smaller tubes, 10-20 mL for larger tubes) before and after each feeding or medication administration
If the tube becomes clogged, attempt gentle flushing with warm water or a mixture of sodium bicarbonate and water, avoiding excessive force.
Feeding Administration:
Administer feedings as prescribed, at room temperature
Elevate the head of the bed during and for 30-60 minutes after feeding to reduce reflux and aspiration risk
Monitor for signs of intolerance like vomiting, diarrhea, or abdominal distension.
Medication Administration:
Administer medications in liquid form whenever possible
Crush solid medications into a fine powder and dissolve in a small amount of warm water before administration
Flush thoroughly after each medication to prevent clogging.
Complications
Early Complications:
Bleeding at the stoma site
leakage of gastric contents around the tube
infection of the stoma site (cellulitis or abscess)
peritonitis (rare, due to misplacement or perforation)
pain
accidental dislodgement of the tube.
Late Complications:
Stomal site infection or granulation tissue formation
skin breakdown or irritation from gastric leakage
tube occlusion or blockage
tube dislodgement
gastrocolic fistula formation (rare)
gastric outlet obstruction
weight loss or malnutrition due to inadequate feeding or malabsorption.
Prevention Strategies:
Strict adherence to proper site care and tube maintenance
Secure the tube adequately to prevent dislodgement
Educate caregivers thoroughly on all aspects of G-tube care
Regular follow-up with the healthcare team to monitor for early signs of complications
Use of appropriate-sized tubes and fixation devices.
Diagnostic Approach To Complications
History Taking:
Detailed history of when the complication began, any changes in feeding or medication, presence of fever, pain, vomiting, diarrhea, or leakage
Inquire about recent trauma or attempts to manipulate the tube.
Physical Examination:
Thorough examination of the stoma site, including palpation for tenderness, induration, or pus
Assess for abdominal distension, tenderness, bowel sounds, and signs of dehydration
Check vital signs for fever or tachycardia.
Investigations:
Stoma site wound culture if infection is suspected
Abdominal X-ray to assess tube position and rule out perforation or obstruction
Contrast study of the G-tube to evaluate patency and leakage
Complete blood count (CBC) to assess for infection or anemia.
Management Of Complications
Stoma Site Infection:
Local wound care
topical or oral antibiotics based on culture results
Severe infections may require surgical debridement or exploration.
Leakage:
Ensure proper tube fixation
Apply barrier creams or absorbent dressings
If persistent, may require adjustment of tube size or type, or surgical revision.
Tube Occlusion:
Attempt gentle flushing with water or enzyme solutions
If unsuccessful, may require exchange of the G-tube
In some cases, specialized techniques or interventional radiology may be needed.
Tube Dislodgement:
Immediate reinsertion of a replacement tube if possible, especially if within a few days of initial placement
If significant time has passed or the tract has closed, surgical or endoscopic replacement may be necessary
This is a medical emergency in some cases.
Key Points
Exam Focus:
High-yield for DNB/NEET SS: Common complications (site infection, leakage, occlusion, dislodgement), their immediate management, and preventative strategies
Recognize red flags indicating serious complications.
Clinical Pearls:
Always educate caregivers thoroughly and assess their understanding
Document all care instructions
Never force a flush if resistance is met – this can cause tube damage or rupture
Early recognition and intervention are key to preventing severe outcomes.
Common Mistakes:
Aggressive flushing of occluded tubes
Inadequate stoma care leading to infection
Failure to secure the tube properly
Overlooking signs of leakage leading to skin breakdown
Delaying intervention for dislodgement or suspected serious complications.