Overview
Definition:
A jejunostomy tube (J-tube) is a surgically created opening into the jejunum for enteral nutrition or decompression
Complications can arise from its placement, presence, or removal, with intestinal volvulus being a significant, potentially life-threatening concern.
Epidemiology:
While specific incidence rates for jejunostomy-related volvulus are not precisely defined, it is an uncommon but serious complication
Risk factors include long-standing tubes, poor tube fixation, abdominal surgery, and conditions predisposing to intestinal motility disorders
The overall complication rate for jejunostomy tubes ranges from 10-20%.
Clinical Significance:
Understanding and preventing jejunostomy tube complications, particularly volvulus, is crucial for patient safety
Prompt recognition and management of volvulus can prevent bowel ischemia, perforation, and sepsis, significantly impacting patient outcomes and reducing morbidity and mortality
This knowledge is vital for residents preparing for DNB and NEET SS examinations.
Indications For Jejunostomy
Nutritional Support:
Long-term enteral feeding when oral or gastric routes are not feasible due to head and neck cancer, gastrointestinal surgery recovery, or severe malnutrition.
Decompression:
Relief of gastric outlet obstruction or distal small bowel obstruction when a nasogastric tube is contraindicated or insufficient.
Bariatric Surgery:
Adjunct in some bariatric procedures for post-operative feeding.
Pancreatitis:
Enteral feeding distal to the stomach in severe pancreatitis to reduce pancreatic stimulation.
Complications
Early Complications:
Bleeding at the stoma site
Infection of the stoma
Perforation of the bowel during insertion
Tube dislodgement
Minor leakage
Paralytic ileus.
Late Complications:
Stricture formation at the stoma site
Internal or external fistula formation
Bowel obstruction from adhesions or tube migration
Incisional hernia
**Volvulus.**
Prevention Strategies:
Meticulous surgical technique with secure fixation of the tube to the bowel wall and abdominal fascia
Liberal use of omentum or other tissues to buttress the jejunal loop
Ensuring adequate bowel length for tube passage
Close monitoring of tube position and function postoperatively
Educating patients and caregivers on proper tube care and recognizing early warning signs
Avoidance of excessive tension on the tube
Regular radiological assessment if malposition is suspected
Use of guidewires during insertion to ensure proper lumen
Postoperative abdominal X-ray to confirm position and rule out malrotation or loops.
Volvulus Prevention And Management
Risk Factors For Volvulus:
Long-term indwelling tubes
Poor fixation of the jejunum
Previous abdominal surgeries leading to adhesions
Conditions causing abnormal intestinal motility
Rapid changes in feeding rate or volume
Migration of the tube to an abnormal position.
Prevention Measures:
Secure and appropriate fixation of the jejunostomy loop to the abdominal wall
Use of omental wrap around the jejunal loop
Avoiding excessive tension on the tube
Regular patient repositioning
Gradual initiation and titration of enteral feeds
Ensuring tube patency
Periodic imaging to assess tube position if concerns arise.
Signs And Symptoms Of Volvulus:
Sudden onset severe abdominal pain
Abdominal distension
Nausea and vomiting, often bilious
Fever
Tachycardia
Absent bowel sounds
Tenderness to palpation
Palpable mass in the abdomen
Signs of peritonitis if ischemia occurs.
Diagnostic Approach:
High index of suspicion in patients with jejunostomy tubes presenting with acute abdominal symptoms
Abdominal X-ray may show dilated loops of bowel and air-fluid levels
CT scan of the abdomen is the investigation of choice, demonstrating a characteristic whirl sign, dilated proximal bowel, and collapsed distal bowel
Ultrasound can also be helpful in identifying a twisted mesentery
Laboratory investigations may reveal leukocytosis, electrolyte imbalances, and elevated inflammatory markers.
Management Of Volvulus:
Immediate cessation of enteral feeding
Nasogastric tube decompression
Aggressive fluid resuscitation and electrolyte correction
Broad-spectrum antibiotics
**Urgent surgical exploration is mandatory** to untwist the volvulus, assess bowel viability, and perform resection and anastomosis if necessary
Stoma revision or creation of a new ostomy may be required
Careful consideration of tube reinsertion after resolution of the acute event.
Diagnostic Approach General
History Taking:
Detailed history of the jejunostomy tube insertion (indication, date, surgical technique)
Onset, duration, character, and severity of abdominal pain
Associated symptoms like nausea, vomiting, fever, and changes in bowel habits
Review of feeding regimen and any recent changes
History of previous abdominal surgeries.
Physical Examination:
General appearance: signs of distress, hydration status
Abdominal examination: inspection for distension, scars, stoma site condition
auscultation for bowel sounds
palpation for tenderness, guarding, rebound tenderness, masses
percussion for tympany
Assess stoma for signs of infection or leakage.
Investigations:
Complete Blood Count (CBC) to assess for infection and anemia
Electrolytes, Renal Function Tests (RFTs) to assess hydration and metabolic status
Liver Function Tests (LFTs) to assess for hepatic involvement
Amylase and Lipase to rule out pancreatitis
Abdominal X-ray (plain films) to assess bowel gas pattern and detect obstruction
CT scan of the abdomen and pelvis with oral and IV contrast for detailed anatomical evaluation, assessing tube position, bowel loops, and complications like volvulus or ischemia
Contrast fluoroscopy through the tube can confirm its intraluminal position and assess transit
Upper GI Endoscopy if gastric outlet obstruction is suspected.
Differential Diagnosis:
Other causes of acute abdomen in patients with jejunostomy tubes include intra-abdominal abscess, cholecystitis, appendicitis, pancreatitis, peptic ulcer disease with perforation, bowel ischemia from other causes, and intra-abdominal adhesions causing obstruction.
Key Points
Exam Focus:
Volvulus is a surgical emergency requiring prompt diagnosis and intervention
Key features are sudden severe pain, distension, and vomiting
CT abdomen is crucial for diagnosis
Surgical exploration is mandatory.
Clinical Pearls:
Always consider volvulus in a patient with a jejunostomy tube presenting with acute abdomen
Secure fixation and omental wrapping are key preventative measures
Educate patients on warning signs
Early recognition of subtle symptoms can prevent catastrophic outcomes.
Common Mistakes:
Delaying surgical intervention due to misdiagnosis or underestimation of severity
Inadequate fixation of the tube during surgery
Failure to adequately decompress the bowel
Inadequate fluid resuscitation and electrolyte management
Underestimating the risk of bowel ischemia in prolonged volvulus.