G-Tube Troubleshooting: Tips and Tricks for the Primary Care Provider

Column Author: Elizaveta Khenner, MD | Pediatric Resident

Column Editor: Kathleen Berg, MD, FAAP | Hospitalist - Pediatrics; Associate Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

Gastrostomy tube (i.e., G-tube) placement is one of the most common surgical procedures in pediatrics,¹ with an estimated 1.4 million children born every year with a condition that requires assisted feeding with a nasogastric or gastrostomy tube.² Despite the high prevalence of this procedure, it is associated with one of the highest rates of hospital revisit, approximately 30% within 30 days of placement.¹ At one institution, G-tube-related complaints accounted for an average of 1.6 emergency department (ED) visits each day, taking an average 4.6 hours to resolve.³

When assessing G-tube complaints, one of the most important first steps is to evaluate the fit of the tube. A properly fitted G-tube should fit snugly. You should be able to rotate it without any resistance.³ A “pick-up test,” in which the tube is gently lifted, is another easy way to assess fit: if the tube easily gives about 2 millimeters between the hub/button and the skin, it is well fitted.³ If the tube does not spin, indents during the pick-up test, or exhibits signs of a pressure injury, it is likely too small or too tight. A tube that moves more than 5 millimeters with this test is too loose.³

If a tube is loose but not dislodged, you can slightly overfill the balloon by about 2-3 milliliters to stabilize it within the stoma. If that is not enough support, a “Colorado Dressing” can be used, which consists of an absorbent foam dressing around the stoma site and four pieces of tape tightly surrounding each side of the tube and holding down the flap.³ It is important to not leave connecting tubing on an already loose G-tube, as this can produce a “keyhole” effect and widen the stoma.

Tube dislodgement is one of the most common complications. In one study, 79% of caretakers of children with G-tubes reported some kind of dislodgment, with 24% experiencing complete dislodgement.¹ Of the patients who experienced dislodgement, 39% had to visit the ED. At another institution, dislodgement was responsible for 49.5% of G-tube related ED visits.¹

Tubes that are dislodged or too loose need to be replaced. First-time tubes that are less than 30 days old should be replaced surgically or by interventional radiology. Tubes older than that can be replaced at bedside or in the office. If the tube has been dislodged for several hours, the tract may need to be dilated. If you are unable to dilate the tract, a Foley catheter can be used to maintain the tract’s patency until the patient is transferred or a suitable G-tube replacement is found, though practitioners should remember to not place the Foley beyond the pylorus, as it can cause a gastric outlet obstruction.³ When replacing a G-tube, remember to always confirm the location of the tube, usually by aspirating gastric contents.

Around 29% of families experience leakage of the tube.² Leakage around the tube is due to either a poor fit or failure or disintegration of the balloon bumper.³ In these cases, tubes need to be resized or replaced. If leaking is still a problem despite resizing the length of the tube, a gastric outlet or motility problem should be considered.³ Remember to not place excess traction on the tube by layering gauze under it or upsizing to a larger diameter tube, as these can actually dilate the stoma and increase leaking, as well as cause pressure injuries.

The opposite problem, that of a too-tight tube, carries the risk of “buried bumper syndrome,” a serious complication occurring in about 1% of patients,⁵ requiring endoscopy or even surgery to remove the tube. It is caused by excessive compression of tissue between the internal and external fixation devices,⁶ leading to tissue ischemia and necrosis. Over time, the gastric mucosa grows to cover the internal bumper. This syndrome should be suspected if you are not able to move the tube inwards. Prevention is key: avoid excessive traction of the G-tube on the skin as discussed above, and when mobilizing the tube, allow 1-2 millimeters of free space between the skin and the tube’s external bumper.⁵

Skin breakdown, irritation and infection around the stoma site are also very common concerns.² Redness at the site is rarely caused by a bacterial infection, and is more commonly attributable to pressure injury, yeast, contact dermatitis or chemical burn. Dermatitis should be addressed by reducing moisture at the site with an absorbent dressing. Chemical burns due to leakage of gastric contents should be addressed by treating the leak and standard burn care with 1% silver sulfadiazine cream.³

It is important to distinguish the skin complications described above from hypergranulation tissue (HGT), which occurs in up to 68% of patients.^2,7 This is a highly vascular, friable type of tissue that occurs as a result of chronic irritation and friction.^4,7 It is distinguished by an uneven, cauliflower-like appearance. The excess tissue leads to increased moisture and bleeding, skin breakdown, as well as leaking of feeds and gastric contents, which can easily become a vicious cycle.^3,4,7 Keeping the site as dry as possible and G-tube well secured with minimal friction are key to prevention.⁴ The tissue can be cauterized with silver nitrate, then treated with a topical steroid such as triamcinolone twice daily for seven to 10 days.^3,4 A surprisingly effective remedy is finely sprinkled table salt once daily, which has reduced the size of the HGT in as early as three days.⁸

Primary care providers who are comfortable managing common G-tube issues can play an invaluable role, since identifying and addressing these complications in a primary care setting can prevent ED visits and worsening of complications.

References:

1. Ruffolo LI, McGuire A, Calderon T, et al. Emergency department utilization following pediatric gastrostomy tube placement is driven by a small cohort of patients. J Pediatr Surg. 2021;56(5):961-965. doi:10.1016/j.jpedsurg.2020.07.016
2. Aedla M, Zhou A, Sompel K, et al. A study of postoperative complications occurring at home with pediatric gastrostomy feeding tubes. J Pediatr Gastroenterol Nutr. 2022;75(1):30-35. doi:10.1097/MPG.0000000000003474
3. Blinman T, Hiller D. Troubleshooting the pediatric gastrostomy. Nutr Clin Pract. 2023;38(2):240-256. doi:10.1002/ncp.10958
4. Boeykens K, Duysburgh I, Verlinden W. Prevention and management of minor complications in percutaneous endoscopic gastrostomy. BMJ Open Gastro. 2022;9:e000975. doi:10.1136/ bmjgast-2022-000975
5. Boeykens K, Duysburgh I. Prevention and management of major complications in percutaneous endoscopic gastrostomy. BMJ Open Gastro. 2021;8:e000628. doi:10.1136/ bmjgast-2021-000628
6. Cyrany J, Rejchrt S, Kopacova M, Bures J. Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy. World J Gastroenterol. 2016;22(2):618-627. doi:10.3748/wjg.v22.i2.618
7. León AH, Hebal F, Stake C, Baldwin K, Barsness KA. Prevention of hypergranulation tissue after gastrostomy tube placement: a randomised controlled trial of hydrocolloid dressings. Int Wound J. 2019;16(1):41-46. doi:10.1111/iwj.12978
8. Tanaka H, Arai K, Fujino A, et al. Treatment for hypergranulation at gastrostomy sites with sprinkling salt in paediatric patients. J Wound Care. 2013;22(1):17‐20. doi:10.12968/jowc.2013.22.1.17