Gastrostomy (gastro = stomach, stoma = opening, -y = procedure/method) is the name for the procedure to place a feeding tube into the stomach. The feeding tube is called as the Gastrostomy tube, or commonly the G-tube. There are several types of feeding tubes, the most commonly used are the PEG and the Mic-Key button. These tubes are the means of providing nutrition directly into the stomach via a tube through the stomach wall. Their use can be either to support a person who is unable to take in sufficient calories by mouth or in some cases to completely remove the need for food or fluid by mouth.
Some people with neuromuscular (and other) conditions have difficulties with chewing and swallowing (dysphagia). This can sometimes lead to aspiration (food or drink 'going down the wrong way' - ending up in the lungs), which in turn can lead to bacterial infections and possibly pneumonia. If this is the case, it may be necessary to avoid certain food & drink, or in some cases to cease oral feeding completely. This is assessed by the health care team - usually using a videofluoroscopy (a method of filming and assessing the swallowing process)
There are various different types of G-tubes. The two main ones are a PEG (Percutaneous Endoscopic Gastrostomy) and Mic-Key button.
Moss Tubes, Inc.
Kimberly Clark (Ballard)
The PEG is a length of tubing with a valve at the end which protrudes several inches from the incision area. Sometimes this is put in first until the stoma site has healed well. One end goes into the stomach, while the other end (a couple of inches long) stays outside the body. The valve is opened at feeding times and food is pumped through the tube directly into the stomach.
The PEG can then be replaced with a button.
Kimberly Clark (Ballard)
MIC-KEY Button Tube
Genie Button Tube
Wizard Button Tube
This works along a very similar principle to the PEG. A button looks very much like the small valve that is used to inflate a child's beach-ball. It is made of clear, soft plastic and sits right next to the skin, flush to the body. A length of tubing is connected at feeding times.
In both cases, the stomach will still fill and empty as usual and feelings of hunger and satiation remain unaffected.
Method to install the G-tube
Placing a G-tube is a surgical procedure usually requiring general anesthetic and lasting about 20-30 minutes. The most common process is for the surgeon to pass a tube with a light at the end (an endoscope), through the mouth and into the stomach. The surgeon then locates the light through the skin and makes a small (pen sized) hole (“Stoma”). In some circumstances (when there is curvature of the spine for example) the surgeon may use a tube with a camera attachment; this allows the surgeon to see inside the stomach, reducing the risk of 'nicking' any major organs. The G-tube is then placed through the Stoma directly into the stomach. The tube is usually held in place with a water filled balloon or a small disc. The patient is observed in a recovery area for about an hour, and then moved to their hospital room. Depending on their level of health prior to having the PEG installed, their stay could be 1 to 2 days for observation of acceptance of the feedings. The stomach and abdomen will usually heal in 5 to 7 days.
This procedure is considered a minor operation, however all operations contain an element of risk; this risk is greater for people with neuromuscular conditions. The main element of risk is in relation to an anesthetic and a potentially weakened respiratory system. It is important that these issues are fully discussed with appropriate health care professionals, before making a final decision to proceed with the procedure.
The operation usually requires hospitalization for about a week, this is to give time to recover and also to get used to the gastrostomy. It sometimes takes a little while for the body to accept the G-tube and tolerate regular feeds. This will be monitored and assessed by the health care team.
1) Type and amount of food fed through the G-tube:
Commercial food: It is usually recommended that a commercially available prepared (canned) formula and water for hydration be fed through the tube. This will provide a balanced diet including all the essential vitamins and minerals needed. Some of these formulas contain fiber so that regular bowel movement can be maintained even if the person is unable to eat fruit, vegetables and other high fiber foods. It is important to understand that nutrition is a very critical to the continued well being of the person. Because of the need to make commercial brands of food supplements taste good to the public, they are high in fat and sugar content. The formula that comes commercially prepared is in powder form which requires dilution with water. Common brands, typically with or without fibers, include Ensure, Jevity, NuBasics, Boost, and Isocal among others. Most come in 8 oz. cans and contain 250 calories.
Table Food: Table foods may be blended according to instructions from the physician. Many people use homemade formulas prepared from cooked, blended foods, but caution should be used to prevent clogging the tube in the stoma itself. Most tubes are roughly the size of a straw in diameter. Therefore the food would have to be liquidized to prevent clogging the tube. Old foods left in tubing and other apparatus can lead to infection, therefore adequate cleaning is necessary. Specific advice with respect to the type of food and the quantity required should be provided by your doctor or a dietician.
The amount of food is determined by the medical advisors and is dependent on many factors. The physician will advise the patient/family on the type of food, methods of feeding, frequency and rates.
A) Bolus Feeding
Bolus feeding is where the food is poured into the tube slowly verses by machine. Bolus feeding allows the person more freedom in that the person can be given feedings anywhere, which is nice when the person leaves the house. Bolus feeding allows for rapid feeding of formula over a relatively short period of time. Formula may be instilled using a bulbed or piston syringe or through the use of gravity flow. The feeding usually consists of no more than 250 cc's to 500 cc's per feeding and is given to the person every 4 to 6 hours. Never FORCE fluids through the PEG tube. Infuse the formula slowly and carefully to prevent abdominal cramping, nausea and vomiting, gastric distension (inflated stomach) or diarrhea. If the formula is not infused (poured) slowly, the patient is placed at a high risk for aspiration (fluid into the lungs) and the complications of pneumonia.
B) Continuous Feeding
This method is preferable for many persons because it allows for better regulation of the amount and rate of food. The feeding pump (a machine) is set up and the tubing connected to the PEG tube. The formula is infused over the prescribed period of time into the patient. Using a feeding pump to control the rate is normally better for digestion and causes fewer problems. Typically, the slower the rate of intake the better the tolerance. The risk for aspiration is also decreased because less formula is given during the prolonged period of infusion.
Which type of feeding is to be used will really be down to the individual's ability to cope with a particular feeding regime and their lifestyle. Some people find bolus feeds difficult to accept and may prefer slow continuous feeds using a pump more suitable. This is often done overnight. For some people bolus feeds delivered by a syringe work better and can help maintain a feeling of regular mealtimes. Using syringe feeds also means that food can be provided when out and about more easily. (A syringe is much easier to transport than a pump).
The person using the G-Tube and a suitable healthcare practitioner, often a dietician will develop the most suitable feeding regime. It is important that that during this process the person's lifestyle is taken into account and that a suitable compromise between an appropriate feeding regime and day-to-day activities is found. It is also possible to change feeding regimes should one become no longer appropriate.
2) Medications administered through the G-tube:
Medications may be administered through the tube utilizing the bolus feeding method. The physician or pharmacist should be consulted. Liquid medication should be preferred where possible over pills or capsules. If liquid medication isn't possible, certain tablets and pills may be crushed dissolved in 30cc to 50cc's of water. A mortar and pestle available at most kitchen stores works well for crushing pills. Formula, juice or milk may be used if the medication does not dissolve in water. Gel caps can be cut open and the contents squeezed out. Highly viscous liquids (sticky, gummy, gelatinous liquid) should be diluted with water prior to administration. Most gel caps can also be dissolved in very hot water which can subsequently be cooled down with ice cubes. It is recommended that a physician or pharmacist be consulted for questions regarding medications and/or the administration of medications, as certain medications should NOT be crushed or dissolved and certain medications should not be mixed. Following the administration of any medication, the tube must be flushed with 30cc to 50cc of water. Bulk laxatives are not given through the tube without consulting with the physician first as some laxatives may obstruct the PEG tube.
Queries regarding the use of G-tubes:
1) Can the g-tube be used at normal mealtimes?
The g-tube can be used at anytime that suits the individual. The feed can be given by attaching a syringe to the tube and pouring in the feed or by using an electric pump, so that feeds can be given without the person or helper needing to do anything during the meal. Some people choose to stick to regular mealtimes, while others use a pump and continuous feed to allow feeding to be done mainly at night. Some families find that it is nice to sit down to eat together even though one of them is getting their main meal through the g-tube. The person can sometimes be having a light snack at the same time or just a drink. Each person's routine is individual and is decided on with all their needs in mind.
2) Can the person eat some normal food or drink by mouth?
It depends on why the tube was inserted. If it was because of slow mealtimes or poor weight gain only, it is OK to continue eating and drinking as usual. In this way your mealtimes can be as long or short as you wish as you know you can top up enough calories via the tube. Some people use the g-tube mainly as "insurance" so that the person can always be sure of getting food and drink even if they don't feel like eating by mouth.
However, if the reason for having the tube is that the person has swallowing problems and aspirates on food or drinks, it is important to have advice on what is safe to take by mouth. The team may recommend that only certain amounts or types of food or drink are safe by mouth. Sometimes it is the safest option to stop taking food by mouth altogether. This is not a forever decision and the swallowing will be monitored so alterations can be made as things change.
3) What if the person is thirsty?
In some cases it is OK to drink normally. If the team has said that the person cannot drink by mouth, then fluids added via the g-tube will reduce thirst.
4) What will it feel like while the person is being fed?
Most people don't notice anything at all. If an attempt is made to feed a person too quickly they will soon complain of feeling sick, just as they would if they ate too much, too quickly. If this happens, then the rate of feeding is easily reduced or stopped.
5) Will the person still feel hungry, and then full after a feed?
Yes. The stomach will still fill and empty in the normal way, giving the usual sensations of hunger and satisfaction.
6) How should food or formula be handled?
The caregiver should thoroughly wash their hands with soap and water before preparing formula/food and having contact with the patient. Formula should be given at room temperature (too hot or cold would make patient uncomfortable). Unused formula and blenderized foods should be refrigerated. Refrigerated formula and blenderized food should be warmed to room temperature over a 30 minute period before feeding. NEVER heat the solution as this could increase the growth of bacteria. In hotter climates, ice may be placed in the outside pocket of the full canister or bag for overnight feeding, but be conscious of the discomfort caused to the patient, as some people with buttons find cold fluid going into their stomach quite uncomfortable.
7) In what position should the patient be fed?
The patient should be fed in an upright position (at least 30 degrees) and remain in an upright position for 30 to 60 minutes following the feeding. This minimizes the possibility of aspiration (inhaling food into the lungs) and its inherent complications (pneumonia). Over-distention, where the abdomen becomes super inflated, should be avoided by careful attention to the rate of feeding flow and the development of abdominal bloating. The doctor will recommend the measurement of feeding and the flow to be used.
8) What is the purpose of the alarm on the pump?
The alarm may sound to let you know the pump is running on the battery instead of the power point. It also warns of a blockage in the flow (check to make sure the clamp and roller brake are off), a kink in the tube (check under the person, also the tube between the canister and where it enters the pump), and that the canister is empty of formula.
9) Will the G-tube hurt?
There may be some discomfort from gas/air or adjusting to the liquid foods. There will be slight discomfort at the incision site after the operation but this can be dealt with using ordinary painkillers. Once it has healed the person will hardly feel it is in there.
10) Will people know that the individual has a G-tube?
The tube is very small and is hidden by clothing, so nobody will notice it unless it is show to others. PEG tube holders are made by Dale Medical and NelMed and are available from suppliers.
Dale Tube Holder
11) How much time will it take to care for the G-tube?
Usually G-tubes need very little maintenance. They need to be kept clean but a bath or shower does most of this for you.
12) What does a "good" stoma look like?
Ideally, the site should be flat, dry and not tender or excessively red. If the site is red, oozing profusely or has a foul odor, you might have an infection. Consult your physician.
13) How should I clean the stoma?
The first week there is more care than afterwards since surgery has been performed. Sterile gloves, gauze etc., must be used to clean the area thoroughly around the wound. The nurses and doctor will instruct you in this procedure and will usually give you a booklet to take home with you. The incision will heal but of course remains open since the tube is through it. Afterwards the incision has healed; daily care of the G-Tube site is simple. The area around the stoma and under the tube flange should be cleaned daily with warm tap water and a tissue or gauze. A mild soap can be used to remove any small crusts. Allow it to dry completely. Some people carefully use a hair dryer to speed drying. There is no need to use saline (salt water) or sterile liquids - clean tap water is fine.
14) What sort of dressing should be used?
Ideally, none. The site thrives on fresh air and a daily shower or bath.
15) Will the G-tube leak?
Occasionally the tube may pull away from the abdominal wall resulting in leakage around the insertion site. Most G-tubes leak a small amount but this is easily taken care of with a little damp cotton. The fluid that leaks out from the stomach can irritate the skin around the tube so it is important to clean any leaks. If skin irritation is noticed apply a little protective cream or a prescription skin barrier for protection. Normally, the degree of leakage is very small and it will not be enough to mark or stain clothes. Leakage may also occur if the stoma site (incision) enlarges in the patient with poor nutrition A tube that leaks more than a little, probably needs replacing because the balloon is leaking or it is not the correct size.
16) What is proud flesh?
Occasionally the development of what is referred to as granulation tissue or "proud flesh" will occur. This is basically skin that grows around and sticks out from the stoma site. The use of hydrogen peroxide to clean the stoma site can lead to the growth of granulation tissue. Treatment is simple and painless. When it becomes bothersome, you can get rid of most of it by cauterizing the flesh with silver nitrate. This devitilizes or burns away the tissue and in a few days, it sloughs off. Your Gastroenterologist prescribes the silver nitrate in the form of a caustic pencil or applicator sticks that look like long matchsticks.
17) What other complications might there be?
Occasionally, the skin around the stoma can become sore or infected, or it can get a bit hardened. It is therefore important to look at the stoma when cleaning it and let your nurse/doctor look at it if you are concerned. Stomach ache, bloating or diarrhoea can also occur if too much food is put into the stomach too quickly. This may happen if the stomach is not used to large volumes. A feeding regime should be discussed with your doctor or a dietician so that tolerance can be gradually built up.
18) Does the feeding tube ever need to be replaced?
The feeding tube does not last a life time. They typically have a life span of about 6-12 months so it is important to understand they may have to have it pulled out and a new one inserted. If there is substantial drainage but flushing can be easily done, there is a good possibility a replacement tube is needed.
19) What happens if the tube comes out?
This is unlikely as the tube is secured either by a little water filled balloon or a small plastic disc. As the hole is only a fraction of this size, the tube cannot pull out until the balloon is deflated, which is only normally done to renew the tube. If the tube ever does come out - don't panic. Place a clean dry towel over the stoma to absorb drainage. If there is an extra on hand, replacement of a button can often be done at home if the caregiver has received training. Otherwise calling a doctor or visiting the hospital emergency room is in order. In either case, it is a good idea to have an extra tube on hand. Remember though, the key to quick and easy replacement of a button of any variety is speed! It only takes a few short hours for the stoma to close up. If this happens, surgery may be required to reopen the stoma.
20) What if the tube becomes plugged?
This is most often caused by the build up of formula residual in the lumen (internal space or opening that exists within the gastrostomy tube). Tube blockage may be prevented with the routine practice of flushing the tube after each use. The tube should be flushed at least once daily. Although water is good, coke or other carbonated beverages are even better. If blockage occurs the tube should be irrigated using a large bulbed syringe. Be careful to avoid excessive force while irrigating because the tube could rupture. Milking the tube may help dislodge the obstruction. Should these attempts to remove the obstruction fail, notify the physician immediately.
21) What about oral hygiene?
Good mouth care is imperative in preventing problems, especially with patients who are provided with total nutritional support through the PEG tube. Daily brushing of the patient's teeth, gums and tongue should be done. Mouthwash may be used with patients who retain a gag reflex. The patient's lips should be moistened with water and, if necessary, lubricated with petroleum jelly to prevent cracking.
22) How is the equipment cleaned?
After each feeding, flush the tubing with lukewarm water to clear the tubing and wash away any particles that might clog the tube. Remember to not flush the tubing with chilled water. If you use a canister type apparatus to hold the formula, scrub the inside with a brush and warm sudsy water. Plastic bags such as those for the Kangaroo pump (and similar pumps) are designed to be used for 24 hours then thrown away. Some people clean them thoroughly then use them for another 24 hours but caution must be exercised when doing this, as the threat of infection exists. Flushing the tubing with boiling water helps get rid of stubborn particles (after the tubing is removed from the patient!). Some people advocate the use of a carbonated drink such as Coca Cola to clean the tubing. Running a small amount through the tubing may help remove crusted formula.
23) Venting the tube
You may need to vent -- remove excess air or fluid from -- your child's g-tube. Your child's doctor will tell you if this is needed. Following are two ways to vent your child's g-tube.
1) Attaching the g-tube to a drainage device, such as a mucus trap or drainage bag, will provide constant venting. A Sims connector (cut at the third ridge of the long end) will fit the g-tube and drainage tube together.
2) To vent the tube as needed, you may connect a catheter-tip syringe to the g-tube to aspirate the excess air or gastric fluid from the stomach. Use this method for bloating, distension or gagging. If this is a repeated need, contact your child's doctor.
24) What can be done about abdominal gas?
Trapping of gas in the stomach is sometimes a side effect of tube feeding. Massaging of the abdomen can sometimes help, as can bending the knees up to the chest. Also try rolling onto one side or other to allow the gas to be dispersed. Should the patient experience bloating prior to or following any feeding, the patient's stomach and intestinal tract should be decompressed. Decompression is easily accomplished by removing the feeding adapter cap from the tube and allowing the PEG tube to be open to air. Encouraging the patient to cough will expedite the removal of excessive air. It is a good idea to put the bolus tube into the PEG before the patient cough's or burps to prevent the contents from splattering out all over.
A G-tube does not necessarily stay in forever and should the person's ability to safely take sufficient calories orally return, the gastrostomy can easily be removed and will quickly heal leaving only a very small scar.
The care of the tube and the feeding sound like a lot of work, but it really isn't. At first you may feel that you will never remember all of the steps necessary for each procedure!! It is a good idea to take notes and develop a checklist to use for the first week or so but you will find that you will quickly be able to do it from memory.