1. G Tube ABC’s
and some D’s about
Enteral Feeding

2. 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

3. Methods of Enteral Feeding
Oral
“Temporary” devices
Nasogastric (NG)
Nasojejeunal (NJ)
Orogastric (OG)
Orojejeunal (OJ)
“Permanent” devices
Gastrostomy Tube (GT)
Gastrojejeunal Tube (GJT)
Jejeunal Tube (JT)

4. 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

5. 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

6. 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

7. 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

8. 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

9. The Brand Names Standard or Non-skin level device (Tube)
Mic-Key Tube
Core-pac
One-step
Skin Level Devices (Button)
Mic-Key Button
Bard
Ross
Genie

10. Yeah Baby…Let’s Accessorize
Bolus Feeding and Continuous Feeding adaptors
Venting Tubes
Extension Sets

11. 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

12. If this is an EMERGENCY, hang up and call 911
Tube Breaks at the shaft
Try to secure with a clamp (hemostat)
Immediately call practitioner that placed the device
Tube Gets Clogged
Instill 5 cc cola beverage and allow to stand minutes then flush
May need to change tube

13. 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

14. Changing a Mic-Key button
Quick and easy, no anesthesia needed
Needed supplies
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
Steps:
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

15. 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

16. 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

17. Case 3 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

18. Methods of Gastrostomy Tube Placement
Percutaneous Endoscopic Gastrostomy Tube
Interventional Radiology (Push Gastrostomy)
Surgically Placed (Open or Staam Gastrostomy)

19. One Fine Day in YOUR OFFICE….
9 months old male presents for a WCC
MOP says things are going well, but she’s concerned that the kid is really scrawny.
Review of Birth Hx reveals an uncomplicated vaginal birth with no antenatal and prenatal complications and Ht and Wt at 25%.
He has had 2 ear infections, but no other hospitalizations, illnesses or surgeries.

20. One Fine Day in YOUR OFFICE….
Reviewing the child’s growth records, you note that he has quickly fallen off the 25% isobar, and his HT and WT are now just below the 3%. His HC remains near the 25%.
A ROS is unremarkable: no prolonged jaundice, diarrhea, rashes, cardiac symptoms, pulmonary symptoms.
Family Hx is unremarkable including no CF, muscle dystrophies.