Feeding tubes
Key points
Patients that may require gastrostomy:
1. Unsafe/unable to swallow
2. Unable to tolerate large amounts of oral medication
3. Food avoidance disorders (e.g. ARFID)
4. Failure to thrive and unable to tolerate supplements
5. Gut disorders requiring continuous feeds or gastric venting
Referral should come from a Paediatrician/Gastroenterologist - not direct from GP
Standard scenario
Referral for PEG
History
Read referral letter and check investigations
Elicit above reasons for PEG
Previous management e.g. NG
If reason is failure to thrive - find out what type of feeds are required and have these been tried oral or NG
Vomiting - PEG changes shape of stomach and can exacerbate existing vomiting or cause new vomiting
Examination
Check weight
Abdomen for scars, distension
Investigations
Upper GI Contrast for malrotation/reflux/hiatus hernia
OGD + biopsies + pH study for reflux
Management
Consider whether PEG is appropriate
In context of reflux - Is a PEGJ needed? Is a fundoplication needed?
Procedure
Laparoscopic assisted PEG insertion or Primary button/balloon G tube
Buttons may have lower overall costs compared to PEGs - Systematic review and MA - BAPS 2021
Some centres provide radiologically inserted gastrostomy (RIG)
Post op feed regimens vary, but feeds can start 6 hours post op
Complications
Early leak + milk peritonitis - can be fatal - need contrast via PEG to confirm then laparoscopy and washout
PEG blocked - flush with coke or pass wire
Jej part of PEGJ blocked - pass wire, get XR for tip position
Leaking PEG causing skin excoriation - options:
1. Treat with PPI and barrier creams/dressings
2. Remove and allow tract to narrow or put in smaller tube
3. Admit and stop feed
4. Resite (2-hour procedure)
Special scenario - PEG placed in colon
Patient with PEG presents with severe diarrhoea, or faeculent discharge from site
History:
When tube inserted, previous abdominal surgery
Co-morbidities
Examine site
Manage as per adult case series (JPEN 2007 below)
Treat as per fistula -SNAP (Sepsis, nutrition, anatomy, procedure)
Place NG tube
Contrast study
Remove tube
If bumper in stomach - gastroscopy + remove
If in colon - can cut and push
Feed with NG if needed for 3-4 weeks
If fistula closed, proceed to laparoscopic redo PEG - needs 2-3 hours
If fistula not closed (few require this) Laparoscopic assisted +/- open closure + insertion of new gastrostomy
Special scenario - buried bumper
Suspect buried bumper if:
Cannot push gastrostomy in
Large abscess around gastrostomy site
Management
Treat sepsis
Gastroscopy - if confirmed buried bumper, make skin and fascia incisions either side of PEG tract and pull PEG out anteriorly, drain abscess cavity, then pass wire through (re-puncturing stomach under vision if needed) and introduce new PEG with endoscope, ensuring new bumper is within gastric lumen
Suture edges of skin and fascia (not tight around new tube if there is an abscess cavity so it can drain around it)
Page edited by Mrs Charnjit Seehra BSc November 2024
References
Friedmann R, Feldman H, Sonnenblick M. Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review of the literature. JPEN J Parenter Enteral Nutr. 2007 Nov-Dec;31(6):469-76. doi: 10.1177/0148607107031006469. PMID: 17947601.