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G Tube ABC’s
and some D’s about
Enteral Feeding
Indications for Enteral Feedings
• Inability to consume an adequate amount of food
to maintain health
– Considerations
• Appropriateness of enteral feeding route
• Safety: Risk of aspiration
• Duration of therapy
• Need of enteral access for theraputic maneuvers
– Medications for HIV, Refractory Constipation,
Pancreatitis
Methods of Enteral Feeding
• Oral
• “Temporary” devices
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Nasogastric (NG)
Nasojejeunal (NJ)
Orogastric (OG)
Orojejeunal (OJ)
• “Permanent” devices
– Gastrostomy Tube (GT)
– Gastrojejeunal Tube (GJT)
– Jejeunal Tube (JT)
Appropriate Evaluation Prior to GT
• Upper GI
– Evaluation for anatomic abnormalities
• pH Probe
– Evaluation of Reflux
• Dysphagia Protocol/Swallowing Study
– Assess ability to protect the airway
• Trial of Nasogastric Feeding
The Competition: Practitioners who
place feeding devices
• Surgeons
– Open Gastrostomy, Gastrojejeunal or Jejeunal Tube
– Fundoplication
• Interventional Radiologists
– Push Gastrostomy, Gastrojejeunal or Jejeunal Tube
• Gastroenterologists
– Percutaneous Endoscopic Gastrostomy or
Gastrojejeunal Tube
Decisions, Decisions:
GT vs GJ Tube vs GT with Fundoplication
• Gastrostomy Tube:
– Device enters through the skin into the stomach with
usually a single access port
– Pros
• Easy to place, can be done under conscious sedation
• Reversable procedure
– Cons
• Provides no protection against aspiration
Decisions, Decisions:
GT vs GJ Tube vs GT with Fundoplication
• GJ or J Tube
– Feeding device placed through skin into stomach, a portion of
the tube fed through pylorus into the jejunum. Feeding port in
the jejunum, may have a second port in stomach (for
medications, etc).
– Pros
• Easy to place, may be done with conscious sedation
• Provides increased protection against aspiration
– Cons
• Requires continuous feeding method
• Often more difficult to maintain
Decisions, Decisions:
GT vs GJ Tube vs GT with Fundoplication
• G Tube with Fundoplication
– Feeding device through skin with surgically created
wrap of the stomach antrum around the lower
esophagus
– Pros
• Provides greatest protection against aspiration
• Provides remedy for reflux esophagitis
– Cons
• Requres general anesthesia
• Irreversible procedure, feeding device removable
The Brand Names
• Standard or Non-skin level device (Tube)
– Mic-Key Tube
– Core-pac
– One-step
• Skin Level Devices (Button)
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Mic-Key Button
Bard
Ross
Genie
Yeah Baby…Let’s Accessorize
• Bolus Feeding and Continuous Feeding
adaptors
• Venting Tubes
• Extension Sets
If this is an EMERGENCY, hang up
and call 911
• Tube Falls Out
– MUST be replaced within 1-4 HOURS
– Need to know type size(French) and length (cm)
– In a pinch, place a similar sized (French) foley catheter into
gastrostomy tube site then call the practitioner that placed the
device (you can always call the GI division if in doubt)
– Important caveat: it takes 4-6 weeks for the device tract to
mature. Get guidance from a practitioner familiar with feeding
devices before replacing a newly created tube.
– You can verify correct placement of a tube using xray
contrast or by aspirating back stomach contents
– Can reuse the same tube if no signs of breakage
If this is an EMERGENCY, hang up
and call 911
• Leaking Tube
– With Mic-Key Button or Tube, can try to inflate
balloon a little more (max inflation 6-8 cc) max
inflation usually stamped on tube or in package
insert
– Reinforce with gauze for others
– May need to change out tube and replace with
correct size device
Changing a Mic-Key button
• Quick and easy, no anesthesia needed
• Needed supplies
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Lube
Sterile water or saline (or not so sterile in a pinch)
Gauze
Cath tip syringe (Luer-lok works as well)
Optional: stoma measuring device
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Test balloon on new tube and pre-lubricate
Deflate balloon on old tube
Pull out old tube
Slide in new tube
Inflate balloon
Give patient a sticker or other prize
• Steps:
Some Cases: Case One
• 14 yo trauma patient with a closed head injury
• Tired patient, unable to sustain activity for more
than ten minutes
• Expected full recovery in 2 months
• Normal intact gag
Case 2
• 4 year patient with seizures
• Oral aversion and chokes and gags with
medications and feeds
• No weight gain past 3 months
• Normal dysphagia study, no history of aspiration
pneumonia
• Expected to remain in same clinical state
Case 3
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8 months old former 33 week premie infant
Chronic lung disease
GERD
History of aspiration pneumonia
No weight gain for two months despite fortified
feeds
• Abnormal dysphagia study