and formula build up over time and ultimately can lead to complete occlusion of the tube lumen. Resins and bulking agents are contraindicated through any enteric feeding device as they both can lead to obstruction of the tubing. Likewise, all medications and formula administrations should be followed by a 20 ml flush to prevent blockage.
The management of a clogged feeding tube depends on the type of tubing. An NG or OG tube should simply be replaced. Likewise, a G‐tube in a well‐healed tract with no trauma should also be replaced if simple declogging measures do not remove the obstruction. Every effort should be made to release the obstruction for GJ and NJ tubes, as the placement of both of these requires fluoroscopic guidance.
Most feeding tube obstructions can be flushed with a 60 ml syringe. First, try pumping air into the tubing to break apart the clot. If that does not work, the best irrigant is warm water. Carbonated beverages and colas have been studied and are inferior. Finally, if warm water does not remove the obstruction, then a mixture of pancreatic enzymes dissolved in a bicarbonate solution can be used. The mixture is left in the feeding tubing for two to three minutes, and then flushed through with warm water. One option is to mix a pancrelipase tablet with 650 mg of bicarbonate in 10 ml of water. If neither of these treatments is successful, a contrast‐enhanced radiograph should be ordered to confirm tube placement, and alternative diagnoses such as buried bumper or G‐tube displacement should be considered.
Ulceration
Ulcerations from enteric feeding devices can be at the proximal and distal ends of the tubing. For both NG and G‐tubes, the pressure of the device against the nasal ala and abdominal wall, respectively, can lead to local superficial bleeding. Bleeding that comes directly from a tube aspirate is more indicative of GI tract bleeding. In the case of an NG tube, the tubing can irritate the lining of the esophagus and develop into esophageal ulceration. For a G‐tube, the pressure of the internal retention device against the stomach lining can form an ulcer. Superficial ulcerations can be treated with tube repositioning, but internal ulcerations require tube removal to allow for healing.
Peritonitis
Peritonitis in a patient with an enteric feeding device is caused by an improperly placed tube, until proven otherwise. In the case of NG tube placement, the tube perforates the bowel wall; and in the case of G‐tube placement, the tube can be improperly placed in the peritoneum. Patients may initially be asymptomatic but will progress to diffuse abdominal tenderness, rebound, and sepsis. All NG tubes should have radiographic confirmation of their placement. For G‐tubes, patients with immature tracts, trauma to the tract, or any difficulty placing the G‐tube should have a contrast‐enhanced radiograph to confirm tube placement. Some argue that if a patient is observed receiving a feeding without difficulty, the tube is likely properly positioned. However, patients with multiple comorbidities may not be able to show discomfort. One must have a heightened level of suspicion and err on the side of caution when confirming NG and G‐tube replacements because while complications are rare, they can be life‐threatening.
Gastric Outlet Obstruction
Gastric outlet obstruction is a significant complication, but the insightful physician will be able to identify the problem and treat it within moments. Obstruction is caused by the retention balloon blocking the pylorus either because the tube migrated to the pylorus in the case of a standard G‐tube or because the balloon is overfilled in the case of a low‐profile button. Patients will present with abdominal pain, nausea, feeding intolerance, and nonbilious emesis. A contrast‐enhanced radiographic study that shows dye filling the small intestine but sparing the stomach confirms the diagnosis (Figure 1.5). Treatment is relatively anticlimactic and includes deflating the internal balloon, repositioning it away from the pylorus and reinflating it or simply reducing the amount of fluid in the retention balloon itself.
Buried Bumper Syndrome
Buried bumper syndrome (BBS) is a rare but life‐threatening complication of children with G‐tubes. BBS is defined as the presence of an embedded internal fixation device into the gastric mucosa of the abdominal wall. This is typically caused by securing the external retention device too tightly to the skin surface and thus narrowing the space between the internal and external retention devices and pressing the internal device into the gastric mucosa. Rates of BBS in adults average 1% but can be as high as 5% in pediatric patients. This is seen with both internal balloons and rigid retention devices, but it is more common with the latter. Risk factors for BBS include pediatric age, jejunal extension from the G‐tube, multiple G‐tube placements, and improper home care. Pediatric patients are at a higher risk because of their expected weight gain and compression against the external bolster. Those with GJ tubes are at higher risk because the weight of jejunal extensions is thought to pull the internal bolsters out of their perpendicular placement and cause unequal pressure on the stomach wall. Finally, repeat G‐tube replacements can increase the inflammatory reaction in the stomach wall and thus encourage tissue growth around the internal retention device.
Figure 1.5 Radiograph of a G‐tube dye study shows dye within the small intestine only. This image is consistent with a gastric outlet obstruction whereby the balloon is located in the pylorus blocking dye from filling the stomach.
Patients can be asymptomatic and simply present with inability to feed through the tube. The classic triad for BBS is inability to insert the G‐tube further into the stomach, loss of tube patency (unable to feed or draw back from tubing), and leakage around the tube site. BBS can be complicated by GI bleeding, perforation, and peritonitis, which can be fatal.
BBS is diagnosed by endoscopy. However, abdominal ultrasound and computerized tomography (CT) scan can help identify bumper location if it is not apparent on endoscopy. Depending on the extent of the internal bumper's migration through the gastric mucosa, the bumper may be removed either endoscopically or surgically. Bumpers that have passed through the lamina muscularis propria and are located between the stomach and abdominal wall will need surgical removal.
Intussusception
Intussusception is a well‐described complication of patients with jejunal feeding devices (NJ, GJ, and J‐tubes). Intussusception is defined as one part of the small intestine invaginating or folding into the adjacent portion of small bowel. Complications arise from the pressure placed on the outer layer of small bowel tissue as the inner layer presses against it, thereby decreasing blood flow to the tissue. The pathogenesis of intussusception requires a lead point to pull one section of small bowel into the other. Contrary to classic intussusception where the lead point is either gastric lymphatic tissue or cancerous material, in patients with an enteric feeding device, the extension tubing in the jejunum serves as the lead point.
Patients with intussusception typically present with abdominal pain, bilious emesis, and/or hematemesis. Because of the many comorbidities of patients with enteric feeding devices, the patient may appear asymptomatic. One must have a heightened clinical suspicion. Diagnosis is made by contrast‐enhanced radiography, ultrasound, endoscopy, upper GI, or abdominal CT scan. Tube‐related intussusceptions resolve with tube removal.
Colocutaneous Fistula
Colocutaenous fistula formation is a complication only seen with the
