Overview
Definition:
Nasogastric (NG) tubes are flexible tubes inserted through the nose into the stomach, primarily used for feeding, decompression, or lavage
Nasojejunal (NJ) tubes are similar but extended further into the jejunum, bypassing the stomach and proximal duodenum, typically for specialized feeding indications where gastric access is compromised or inappropriate.
Epidemiology:
Enteral feeding via tubes is common in neonates and pediatric patients with various conditions including prematurity, congenital anomalies, neurological impairments, and critical illness
The choice between NG and NJ tubes depends on specific clinical scenarios, with NJ tubes being less common but vital in select cases.
Clinical Significance:
Appropriate selection and placement of NG/NJ tubes are crucial for providing adequate nutrition, managing gastrointestinal dysfunction, and preventing complications
Misplacement or inappropriate use can lead to significant morbidity
Understanding the indications, contraindications, and procedural nuances is essential for pediatric residents preparing for DNB and NEET SS exams.
Indications
Ng Tube Indications:
Nutritional support in infants and children unable to feed orally
Gastric decompression for intestinal obstruction or ileus
Administration of medications
Gastric lavage for poisoning or bleeding
Obtaining gastric aspirates for diagnostic purposes.
Nj Tube Indications:
Long-term enteral nutrition when gastric emptying is severely impaired or absent (e.g., gastroparesis, severe gastroesophageal reflux, post-gastric surgery)
Management of significant aspiration risk despite NG tube
Conditions requiring jejunal feeding to avoid gastric distension or irritation.
Contraindications:
Absolute contraindications are rare but include esophageal atresia or tracheoesophageal fistula (for NG tubes)
Relative contraindications for both include severe facial trauma, coagulopathy, and history of esophageal or gastric surgery
For NJ tubes, significant jejunal obstruction or atresia would be a contraindication.
Placement Technique
Ng Tube Placement:
Measure tube from nose to earlobe to xiphoid process
Lubricate the tip
Gently insert into the nostril, directing downwards towards the pharynx
Encourage swallowing to aid passage
Once in the stomach, confirm placement radiographically (X-ray is gold standard).;
Nj Tube Placement:
Often requires a weighted tip or guidewire for passage through the pylorus
May be inserted blindly (similar to NG) and advanced, or placed under fluoroscopic or endoscopic guidance
Advance the tube until it passes through the pylorus into the jejunum
Radiographic confirmation of jejunal placement is mandatory.
Confirmation Methods:
Radiographic confirmation (chest X-ray or abdominal X-ray) is the gold standard for both NG and NJ tubes
Other methods include aspirating gastric/jejunal contents and checking pH (gastric aspirate pH < 5.5, jejunal aspirate pH > 6.0), or observing for bubbling in aspirate with air insufflation (less reliable)
Visualizing the tube entering the stomach/jejunum under endoscopy is definitive.
Differences And Selection
Anatomical Differences:
NG tube terminates in the stomach
NJ tube extends into the jejunum, bypassing the stomach and duodenum.
Feeding Considerations:
NG feeding is suitable for most patients requiring enteral support
NJ feeding is preferred when gastric access is problematic due to delayed gastric emptying, aspiration risk, or intolerance to gastric feeding.
Risk Of Complications:
NG tubes carry risks of misplacement into the airway, esophageal injury, and gastric irritation
NJ tubes have similar risks but also increased risk of malabsorption if malpositioned in the duodenum or proximal jejunum, and potential for bowel obstruction or perforation due to more distal placement.
Complications
Tube Related Complications:
Misplacement into the airway leading to respiratory distress or pneumonia
Esophageal erosion or perforation
Nasal irritation, sinusitis, or epistaxis
Gastric irritation, vomiting, or abdominal discomfort
Bowel obstruction or perforation (especially with NJ tubes)
Tube occlusion or dislodgement.
Feeding Related Complications:
Aspiration pneumonia
Diarrhea or constipation
Electrolyte imbalances
Hyperglycemia or hypoglycemia
Refeeding syndrome (especially if started too aggressively)
Malnutrition due to inadequate intake or malabsorption.
Prevention Strategies:
Strict adherence to placement confirmation protocols
Regular monitoring of tube position and patency
Gradual advancement of feeding rates
Close monitoring of vital signs, intake, output, and laboratory parameters
Use of prokinetic agents if gastric emptying is delayed
Consideration of surgically placed feeding tubes (gastrostomy, jejunostomy) for long-term needs.
Key Points
Exam Focus:
Differentiate indications for NG vs
NJ tubes
Recognize radiographic confirmation as the gold standard for placement
Understand complications and their management
Recall specific patient populations benefiting from NJ tubes (e.g., gastroparesis, severe GER with aspiration risk).
Clinical Pearls:
Always confirm tube placement visually via X-ray before initiating feeding or medication administration
If encountering difficulty inserting an NJ tube blindly, consider fluoroscopic or endoscopic guidance
Educate nursing staff thoroughly on tube care and monitoring.
Common Mistakes:
Relying solely on pH testing or air auscultation for placement confirmation
Initiating feeds without radiographic confirmation
Failing to recognize and manage early signs of complications like tube dislodgement or occlusion
Using an NG tube when jejunal feeding is clearly indicated.