between the abdominal wall and the stomach wall and piercing the G‐tube through all three tissue layers. While, in some cases, patients present with colonic obstruction, this complication may not be detected until the first tube change at which point the tube is replaced into the colonic wall but does not make it to the stomach wall. The feeds are started directly into the colon, and the patient develops diarrhea and dehydration. Treatment includes removing the G‐tube and surgical closure of the fistula.
Consultation
Surgical consultation is needed for surgical emergencies: intussusception, BBS, colocutaneous fistula, peritonitis, and necrotizing fasciitis. Immature tube dislodgement will require replacement by the team responsible for its initial placement, but the emergency department team can initially manage all mature tracts. Consultation is needed if there is significant trauma to the tract, the tube is improperly positioned on dye study, or the patient is unable to tolerate feeds following tube replacement. GJ and J‐tube replacements will typically need interventional radiology consultation. Stomal site bleeding, leakage, or infection may be initially managed by the emergency department and seen in subspecialty clinic for further care. Similarly, gastric outlet obstruction can first be treated with tube repositioning by the emergency department team, but if the obstruction does not resolve, surgical consultation is needed.
Further Reading
1 1 Pearce, C.B. and Duncan, H.D. (2002). Enteral feeding: nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad. Med. J. 78: 198–204.
2 2 Prabhakaran, S., Doraiswamy, V.A., Nagaraja, V. et al. (2012). Nasoenteric tube complications. Scand. J. Surg. 101: 147–155.
3 3 Taheri, M.R., Singh, H., and Duerken, D.R. (2011). Peritonitis after gastrostomy tube replacement: a case series and review of literature. J. Parenter. Enteral Nutr. 35: 56–60.
4 4 Ibegbu, E., Relan, M., and Vega, K.J. (2007). Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding. World J. Gastroenterol. 13: 5285–5284.
5 5 Jamil, Y., Idris, M., Kashif, N. et al. (2012). Jejunoduodenogastric intussusception secondary to percutaneous gastrostomy tube in an adult patient. Jpn. J. Radiol. 30: 277–280.
6 6 Cyrany, J., Rejchrt, S., Kopacova, M., and Bures, J. (2016). Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy. World J. Gastroenterol. 22: 618–627.
7 7 Stewart, C.E., Mutalib, M., Pradhan, A. et al. (2016). Buried bumper syndrome in children: incidence and risk factors. Eur. J. Gastroenterol. Hepatol. 29: 181–184.
8 8 Goldin, A.B., Heiss, K.F., Hall, M. et al. (2016). Emergency department visits and readmissions among children after gastrostomy tube placement. J. Pediatr. 174: 139–145.
9 9 Powers, J., Chance, R., Bortenschalger, L. et al. (2003). Bedside placement of small‐bowel feeding tubes in the intensive care unit. Crit. Care Nurse 23: 16–24.
10 10 Tiancha, H., Jiyong, J., and Min, Y. (2015). How to promote bedside placement of postpyloric feeding tube: a network meta‐analysis of randomized controlled trials. J. Parenter. Enteral Nutr. 39: 521–530.
11 11 Gallagher, E.J. (2004). Nasogastric tubes: hard to swallow. Ann. Emerg. Med. 44: 138–141.
12 12 Cirgin Ellett, M.L.C., Cohen, M.D., Perkins, S.M. et al. (2012). Comparing methods of determining insertion length for placing gastric tubes in children 1 month to 17 years of age. J. Spec. Pediatr. Nurs. 17: 19–32.
13 13 Stepter, C.R. (2012). Maintaining placement of temporary enteral feeding tubes in adults: a critical appraisal of the evidence. Medsurg Nurs. 21: 61–69.
14 14 Irving, S.Y., Lyman, B., Northington, L. et al. (2014). Nasogastric tube placement and verification in children: review of the current literature. Crit. Care Nurse 34: 67–78.
15 15 Cirgin Ellett, M.L.C., Cohen, M.D., Croffie, J.M.B. et al. (2014). Comparing bedside methods of determining placement of gastric tubes in children. J. Spec. Pediatr. Nurs. 19: 68–79.
16 16 Otjen, J.P., Iyer, R.S., Phillips, G.S., and Parisi, M.T. (2012). Usual and unusual causes of pediatric gastric outlet obstruction. Pediatr. Radiol. 42: 728–737.
17 17 Campwala, I., Perrone, E., Yanni, G. et al. (2015). Complications of gastrojejunal feeding tubes in children. J. Surg. Res. 199: 67–71.
18 18 Zamora, I.J., Fallon, S.C., Orth, R.C. et al. (2014). Overuse of fluoroscopic gastrostomy studies in a children's hospital. J. Surg. Res. 190: 598–603.
19 19 Guana, R., LOnati, L., Barletti, C. et al. (2014). Gastrostomy intraperitoneal bumper: migration in a three‐year‐old child: a rare complication following gastrostomy tube replacement. Case Rep. Gastroenterol. 8: 381–386.
20 20 Saavedra, H., Losek, J.D., Shanley, L., and Titus, M.O. (2009). Gastrostomy tube related complaints in the pediatric emergency department: identifying opportunities for improvement. Pediatr. Emerg. Care 25: 728–732.
21 21 Jacobson, G., Brokish, P.A., and Wrenn, K. (2009). Percutaneous feeding tube replacement in the ED‐are confirmatory x‐rays necessary? Am. J. Emerg. Med. 27: 519–524.
22 22 Showalter, C.D., Kerrey, B., Spellman‐Kennebeck, S., and Timm, N. (2012). Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging. Am. J. Emerg. Med. 30: 1501–1506.
23 23 Wu, T.H., Lin, C.W., and Yin, W.Y. (2006). Jejunojejunal intussusception following jejunostomy. J. Formos. Med. Assoc. 105: 355–358.
24 24 Hughes, U.M., Connolly, B.L., Chair, P.G., and Muraca, S. (2000). Further report of small‐bowel intussusceptions related to gastrojejunostomy tubes. Pediatr. Radiol. 30: 614–617.
2 Gastrointestinal Diversions : Colostomies, Ileostomies, Mucous Fistulas, and Spit Fistulas
Ellen G. Szydlowski1,2 and Peter Mattei1,3
1 Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
2 Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
3 Division of General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
Introduction
Patients may require a gastrointestinal (GI) diversion for several reasons, including congenital causes and acquired lesions. The most common type of GI diversion is the ostomy where a purposeful anastomosis is created between a segment of the GI tract and the external skin. An ostomy can be established almost anywhere along the GI tract, including the large intestine (colostomy), distal small intestine (ileostomy), and the esophagus (esophagostomy or spit fistula). These GI diversions may be temporary or permanent, and the emergency department (ED) physician should be comfortable with the evaluation and management of the different types of ostomies and their potential complications.
Equipment/Device
The type of ostomy is classified
