Gastrostomy button (Low profile balloon gastrostomy e.g. MIC-KEY button®, MiniONE button®)
Gastro-jejunostomy button (G-J button e.g. MIC-KEY gastro-jejunal feeding tube®)
PEG tube (e.g. Freka® PEG, CorFlo® PEG)
PEG-J tube: (e.g. Freka® PEG-J, CorFlo® PEG-J)
Balloon gastrostomy (e.g. MIC gastrostomy®):
Ok, got that … Troubleshooting
Complications often depend on the type of tube – balloon or PEG, gastrostomy or gastrojejunostomy.
Tube has fallen out
This is probably the most common ED problem. They tend to be a balloon tube (the balloon bursts) and then it’s an urgent problem. If the tract is left empty it will close up in hours and may need a laparotomy to replace the tube.
Replace the tube if you can (family will often have a spare and many will do this at home). Otherwise put a foley catheter in the tract, tape it to the skin and call the relevant surgical team if you can’t replace the tube.
Lie the child down on the bed, bring a selection of catheters (6Fr, 8Fr, 10Fr, 12Fr) and lots of lube, aim to gently place the largest catheter that will go in, insert about 5cm in a larger child, 3cm in a smaller child. Tape the tube securely to the tummy.
DO NOT do this if this is a primary balloon gastrostomy. See below.
The jejunal part has fallen out / flipped up
Again this is an urgent problem. The family may report milk coming back through the gastric port/ milky vomiting, a PEG-J that is strangely easy to flush, a tube that looks different to normal or a jejunal tube in the nappy or stoma bag!
PEG-J’s are made from different parts. The jejunal tube is fed through the gastric part and can fall off (into the patient). This can be confirmed on x-ray and a radiologist will need to re-thread a new jejunal tube. The old tube will usually pass out per rectum or via a stoma. Don’t use the jejunal part of the tube until it has been replaced.
Balloon gastro-jejunostomies are made as one piece but the jejunal end can flip back into the stomach (can be confirmed on x-ray). A radiologist will need to re-site the tube. Don’t use the jejunal part of the tube until it has been re-sited.
The tube is leaking / split
Leaking from skin level
This can happen if the child is unwell and the gastric motility is reduced (higher than normal pressure in the stomach).
Is the PEG/PEG-J loose? If the tube moves in and out a lot, pulling it snug and securing the flange may stop the leak.
Balloon tubes may have too little water so changing the water and adding 1ml may help. Padding the tube with a thick dressing or using a shorter tube may also help.
The family should have contact with a CNS who can help.
Leaking from further down the tube
This is often due to a split tube or connector on a PEG / PEG-J. It can be fixed without an anaesthetic as long as the split isn’t close to the skin. You need to find the parts that are specific to the tube, then cut the damaged part off and put a new end on – like DIY or Lego. Usually a nurse specialist or paediatric surgeon does this but knowing which tube the child has is essential.
The tube is blocked
This usually happens with longer tubes. Hospitals often have a protocol for unblocking, and there are a lot of hospital guidelines on the web. If simple measures don’t work change the tube (see below).
These can occur when a tube leaks, is infected or a granuloma forms. The family should have a CNS or enteral feeding nurse who should be able to help
- Infection: swab the site for bacteria and fungi and treat. Use a dressing to stop the tube rubbing
- Leaking: See leaking tube.
- Granuloma: Usually not an ED problem. More common in clinic or on the ward.
** unless this is a primary gastrostomy button and was placed for the first time within 6 weeks. If a primary button falls out within 6 weeks call the surgical team who did the operation urgently.
a The PEG ends vary between brand. Here’s a couple of pictures of PEG tube ends and PEG-J ends for reference
There are always exceptions!
Primary gastrostomy buttons
Some surgeons create a new gastrostomy and use a button as the first tube (primary button). Many place a PEG first and then change the PEG for a button once the tract has healed. If a primary button falls out before the tract has healed (in the first 6 weeks) placing a new tube roughly could push the stomach away from the abdominal wall and leave the end of the tube in the peritoneum. After 6 weeks, the gastrostomy tract has healed and is like an ear piercing – you can change the tube without worrying where it will go. Ask the surgical history. The tract starts to form when it is first made, a general anaesthetic is required and they won’t have had a gastrostomy before then.
Other uses for balloon gastrostomies
These are brilliant devices, they can be used in other ostomies e.g. vesicostomies, jejunostomies. Changing them is the same but they usually sit somewhere else in the abdomen (rather than in the left upper quadrant or epigastrium as gastrostomies do).
There are lots of other tube types out there and other brands including malecot tubes, Cor-flo PEGs. If in doubt ask a senior or your local friendly surgical registrar, if you can take a photo of the tube (with consent) this will help the conversation.
As the PEG tubes can be assembled/disassembled like Lego® occasionally people will have odd-looking tubes. This lass has a Corflo PEG end with a Freka securing device (external flange). Combination tubes should be the minority.