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| ===Background===
| | #REDIRECT[[G-tube complications]] |
| *Four components: tube, internal bolster, external bolster, and ports
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| *External bolster very important as distal migration of tube with peristalsis can result in bowel obstruction and perforation
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| *Sizes range from 12 to 24 Fr
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| ==Complications==
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| ===Dislodged Gastrostomy Tube===
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| *Tracts may close within hours if relatively new tube
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| *Foley catheters function well as temporary replacements
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| *Procedure:
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| **Obtain Foley size comparable to original tube
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| **Lubricate tube liberally
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| **Advance tube while meeting only mild resistance no more than 8-10 cm to avoid leaving stomach into esophagus, duodenum
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| **Should not be significantly painful, require dissection, or considerable force
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| **Pass smaller size tube if necessary to maintain tract without forceful insertion
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| **Slowly inflate balloon, careful not to inflate balloon to max volume
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| **Aspirate gastric contents to confirm placement
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| **Place external bolster with these options:
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| ***Retention suture much like in chest tube placement, but with slack for movement
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| ***T-bar from 3cm section of another foley
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| ****Apply T-bar before insertion
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| ****Cut hole on either side of 3 cm section, just large enough for replacement tube to be passed through
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| ****Pull through replacement tube with hemostats
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| ***Tube my be used for feeds if there is free flowing contents to gravity drainage
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| ***May obtain tube contrast KUB to confirm placeent
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| **Arrange for surgical outpt f/u within 24-48 hrs
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| *Special considerations
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| **Some tubes have circuitous route (Witzel), making tract difficult to approach
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| **Not all percutaneous endoscopic jejunostomies (PEJ) tubes are replaceable, especially the small Fr ones
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| **Extravasation in contrast KUB requires holding feeds and c/s with surgeon
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| **PO antibiotics and good wound care for simple cellulitis around external site
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| **Obtain surgical c/s if replacement difficult
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| ===Nonfunctioning Gastrostomy Tube===
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| ====Differential====
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| *Replacement for:
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| **Fractured tube
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| **Tube with ruptured balloon
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| *Kinked tube may need only external bolster replacement
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| *Clogged tubes should be gently irrigated first
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| **Water, NS, or carbonated drink
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| **Consultants may use enzymatic slns, or dislodge with endoscopic snares, biopsy forceps, etc
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| **DeClogger® plastic wand with screw thread, tunneled into tube in clockwise fashion
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| ====Removal of tube====
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| *Remove tube if mature tract and if unable to unclog
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| *Determine type of tube, as most are removable with gentle traction
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| **Most internal T-bars or soft caps deform with gentle traction
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| **Internal balloon devices simply need to be deflated, but if balloon doesn't deflate:
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| ***Try cutting tube close to ports with hemostat in place to prevent inward migration
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| ***OR guidewire may be placed into balloon port to puncture balloon
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| *If cannot remove with with gentle traction, c/s surgeon that placed tube
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| *'''DO NOT''' simply cutting the tube at the skin and pushing remained of tube into pt to pass through GI tract
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| **May cause bowel obstruction and perforation
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| **Only choose this option in c/s with primary surgeon
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| ====Fresh or Immature Tracts====
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| *New tubes should not be manipulated without c/s with the specialist that placed it
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| *Clogged tube may need to remain in place to finish stenting tract
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| *Inadvertent removal of tube through fresh tract may lead to peritoneal contamination and subsequent peritonitis
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| **If spillage of contents possible, pt needs admission, antibiotics, and observation for development of peritonitis
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| **Tract will need to close spontaneously, and replacement PEG in 7-10 days
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| ==Sources==
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| *Gastrostomy Tube Replacement, in Reichman, EF: Emergency Medicine Procedures, ed 2. New York, McGraw-Hill, 2013, (Ch) 64.
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| [[Category:GI]]
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