Crash course in feeding tubes

Flatter feeding tubes

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®)

Dangly feeding tubes:

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 the most common ED problem. They tend to be balloon tubes (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. 

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-Js 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 an x-ray, and a radiologist must 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 if the split isn’t close to the skin. You need to find the parts specific to the tube, cut the damaged piece 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. Change the tube if simple measures don’t work (see below).

Skin problems

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.

Summary

** 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

Special cases

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 six 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 six weeks, the gastrostomy tract has healed and is like an ear piercing – you can change the tube without worrying about where it will go. Ask about 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.  

Other uses for balloon gastrostomies

These are brilliant devices; they can be used in other ostomies, e.g. vesicostomies and 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).

Other tubes

There are lots of other tube types out there and other brands including malecot tubes, and Cor-flo PEGs. If you have any doubts, please 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.

Combination feeding tubes

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.