Gastrostomy Feeding Tube - Guidelines for the Management of Problems with

Publication: 01/09/2005  --
Last review: 07/02/2020  
Next review: 06/02/2023  
Clinical Guideline
CURRENT 
ID: 779 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

The Management of Problems with Gastrostomy Feeding Tubes

Section 1
1.1 Introduction
1.2 Scope of the guidelines
1.3 Assessment of problem gastrostomy sites
1.4 Useful contacts
1.5 Types of tubes commonly used in Leeds
1.6 Manufacturers contact details
1.7 First choice dressing list
1.8 Pictorial tools

Section 2 - Problem solving
2.1 Gastrostomy tube falls out
2.2 Suspected gastrostomy site infection*
2.3 Overgranulation of gastrostomy site*
2.4 Leaking around gastrostomy site*
2.5 Migration of gastrostomy tube
2.6 Buried bumper
2.7 Blocked gastrostomy tube*
2.8 Blocked feed port or Y-adaptor
2.9 Broken feed port or Y-adaptor
2.10 Skin sensitivity*
* The problem solving advice can also be used for jejunostomy site.

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1.1 Introduction

These guidelines apply to all hospital and community healthcare staff caring for patients who have gastrostomy feeding tubes. These guidelines should be read in conjunction with the Enteral Tube Feeding Policy (LTHT 2019) and the Trust Infection Prevention and Control Policy (LTHT 2019). These guidelines have been developed by a multi-disciplinary group from The Leeds Teaching Hospitals NHS Trust, NHS Leeds, Leeds Community Healthcare NHS Trust

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1.2 Scope of the guidelines

These guidelines are designed to help healthcare professionals manage problems with gastrostomy/Jejunostomy* feeding tubes. They describe potential problems and their possible cause related to gastrostomy/ jejunal * feeding tubes. They give information on interventions aimed at preventing the problem occurring, followed by actions to treat the problem, starting with simple interventions and moving to more intensive treatments. They recommend that interventions should be tried for 2 weeks in adults (1 week in children) before moving onto the next action. The rationale and evidence to support this practice is given and has been taken from evidence grade C & D (C = experimental descriptive studies, D = expert committee reports or opinions and/or clinical experience of respected authorities NICE 2003).

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1.3 Assessment of problem gastrostomy sites

Photographs are a helpful way of assessing problems and can be shared with other Health Care Professionals. Serial photographs enable multiple carers to assess if problems improve or deteriorate. The LTHT / LCH consent form for medical photographs must be completed. The patient and Health Care Professionals should retain a copy. One consent form covers multiple photographs.

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1.4 Useful contacts

Clinical and professional judgment should be used when using these guidelines and seek further advice as required from medical staff or the contacts list below:

Adults

  1. District Nurse
  2. Company Nurse 0808 100 1990
  3. Community Adult Home Enteral Feeding Dietitian Tel 0113 8430892
  4. Adult Enteral Nutrition Nurse Specialist 0113 2068690 or bleep 80-4727
  5. Ward J91, Level 4 Bexley Wing, St James’s Hospital. Tel (0113) 206 9191 or on call Gastro Registrar Bleep 80- 4770

Children

  1. Children’s Community Nurse Tel No: 0113 2761294
  2. Company Nurse Tel No 0808 100 1990
  3. Community Children’s Dietitian
  4. Children’s Nutrition Nurse Specialist Tel No 0113 3928309
  5. Ward L42, Leeds General Infirmary. Tel 0113 392 7442

* Company Nurse from Fresenius Kabi, 24 hour helpline Tel 0808 1001990

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1.5 Types of tubes commonly used in Leeds

Percutaneous endoscopic gastrostomy tube (PEG)

  • Fresenius Kabi, Freka - 9 & 15 Fr
  • Merck, Corpak - 12, 16 & 20 Fr

Balloon gastrostomy tube

  • Fresenius Kabi, Freka - 15 Fr
  • GBUK Enteral Ltd  (AMT) - 12, 14, 16, 18 & 20 Fr
  • ENTRAL - 12, 14, 16, 18 & 20 Fr
  • Vygon , MIC - 12, 14, 16, 18 & 20 Fr

Non balloon gastrostomy tube

  • GBUK Enteral Ltd (AMT) Capsule Monarch - 12 & 14fr

Radiological gastrostomy tube (RIG)

  • Vygon MIC 14Fr balloon gastrostomy tube placed radiologically
  • Vygon  Mic-key button 14fr

Button/low profile gastrostomy devices / (LPDG) Balloon retained buttons

  • Fresenius Kabi, Freka Button - 15 Fr
  • GBUK Enteral Ltd (AMT), Mini Button - 1, 14, 16, 18, 20 & 24 Fr
  • Vygon, MIC-key Button - 12, 14, 16, 18, 20 & 24 Fr
  • Buttons are available in various shaft lengths, 1.0 - 4.5 cm some manufacturers make 0.8 cm and 5.0 - 6.5cm shaft lengths in 14 Fr, other sizes may be available. Contact manufacturer for details

Non-balloon retained buttons (LPDG)

  • GBUK Enteral Ltd, Mini One - 14 &18 Fr
  • Entristar (Covidien) - .12, 16 & 20 Fr
  • Bard - 18 & 24 Fr

Additional items

  • GBUK Enteral - EnPlug to prevent the closure of existing stoma        
    Pack of 10,12,14 &16fr x 4cm = EN-PLUG-S; 
    Pack of 10,12,14 &16fr x 7cm = EN-PLUG-L                                           
    Pack of 18 & 20 Fr x7cm= EN-PLUG-XL
  • Clinifix on  prescription from GP or for Leeds Adult enteral feeding patients available via delivery as contract item
  • Statlocks on prescription from GP

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1.6 Manufacturers details

Abbott Nutrition

0800 252882

Bard

01293 529555

Covidien, Kangaroo

02030 271757

Fresenius Kabi

01928533533

EnteralUK

01757 282945

Medicina

01204 695050

Corpak Medsystems uk

0800 1444480

Nutricia Advanced Medical Nutrition

01225 751098

Vygon (UK) Ltd

01793 748800

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1.7 Example of dressing choices

All dressings available on FP10. LTHT pharmacy stock some products listed and others available for NHS supplies through materials management.

Barrier Film 

  • Soft white or yellow paraffin ointment
  • Cavilon 1ml foam applicator 5x1ml Ref: 3343E from 3M
  • Cavilon 28ml spray bottle  Ref: 3346E from 3M

Cleansing Agents 

  • Cooled boiled water
  • Sodium chloride 0.9% pods (irripod) 25 x 20ml
  • Sodium chloride 0.9% aerosol (irriclens) 1 x 240ml

Foam Dressing 
Light absorbency:

  • Mepilex Border Lite

High absorbency - adhesive:

  • Mepilex XT 10cm2

Higher absorbency - self adhesive
Border Comfort 10cm x10cm

Dressing Packs
Sterile dressing pack specification 35 (non-woven) Community Patient Pack (inc. gauze, disposal bag, sterile fluid & paper towel)
Gauze Swabs and Padding
Specification 28 sterile fabric swab (Topper 8) 7.5cm2
(packs of 5)
Specification 28 non-sterile fabric swab 10cm2
(packs of 100)

Absorbent Pads Mesorb

Antimicrobial cleansing agents

  • Chlorhexidine gluconate solution 4%
  • Octenisan for infants and children

Antimicrobial dressings, ointments and cream

Low exudate wounds

Kendall Excilion AMD Antimicrobial IV sponges (5cm x 5cm) PIP code 230-5951

Kendall Antimicrobial Foam dressing (AMD) Pip code 347-0697

Iodosorb Ointment 10g
Trimovate (antifungal & antimicrobial)

Topical steroid preparations for overgranulation - apply thinly
Hydrocortisone 1% cream / ointment (mild)
Fluroxycortide (Haelan) cream / ointment (moderate)
Fluroxycortide (Haelan) tape 7.5 x 50cm
Mometasone / (Elocon) cream / ointment (Potent)
Fucibet cream (steriod and antimicrobial)

Protective pastes and seals
Orabase protective paste 30gm tube Ref: 129730 (Convatec)
Pelican paste 100 Ref: 130101 (Pelican Healthcare)
Dansac seals Ref:070-20 (Dansac)
Contact Tissue Viability for advice on the feasibility of using antimicrobials on: (0113) 2069207 or LTCT (0113) 3055099

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1.8 Pictorial Tools

  1. Daily care of gastrostomy site (G tube & PEG tube)
  2. Changing a balloon gastrostomy tube (G tube)
  3. Changing a balloon button gastrostomy
  4. Management of a leaking gastrostomy site
  5. Management of overgranulation
  6. Management of infected gastrostomy site
  7. Changing the Y-adaptor on a Corflo PEG
  8. Changing the dual port on a Freka PEG/JEJ tube


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Problem

Possible cause

Prevention

2.1. TUBE FALLS OUT The gastrostomy site starts to close when the tube falls out. In
5-10 minutes it can close down 2-4 Fr sizes and in 1-12 hours it can close over.

see - Accidental removal of a gastrostomy tube

Tube pulled out.

Tube damaged or worn out.

Take care that tube does not get pulled or caught when moving and handling the patient.

For small children and confused patients dress in clothing so the tube is not visible to reduce risk of them pulling the tube.

For balloon type tube or buttons:
the balloon has deflated or burst.

Check tube or button is correctly positioned, if loose or looks more prominent check volume of water in balloon is correct.
Ensure the balloon volume checks are carried out as recommended by discharging guidelines

 

Ensure patient has a spare tube, tape and lubricating gel.

 

Action

Rationale

FOR ADULTS
Less than 4 weeks since initial formation of gastrostomy site
Less than 4 weeks since initial formation of gastrostomy site:

  1. Insert a Foley catheter or balloon gastrostomy (if available) into the stoma to maintain the tract. DO NOT USE TUBE.
  2. Contact ward J91 at St James's Tel (0113) 206 9191/2068291 or Adult Enteral Feeding Nurses on 80-4727/ 68690
  3. A tubogram MUST be arranged in Radiology to confirm position of or replace the emergency tube.
  4. If resistance on insertion of tube STOP and refer to contact details above
  5. As the Gastrostomy site is less than 12 weeks old DO NOT attempt to replace the emergency tube used ie: Foley catheter. Use contact details above to request an appropriate gastrostomy tube is inserted.


 .

 

 

 

 

If the tube falls out before the stoma site is fully healed there is a risk of placing the new tube into the peritoneal cavity. X-ray and contrast will confirm the tube is in the stomach.

More than 4 weeks since initial formation of gastrostomy site:

  1. Insert a Foley catheter or balloon gastrostomy (if available) into the stoma.
  2. If balloon gastrostomy tube used and you are competent to undertake Gastrostomy tube changes, check aspirate. Use for feeding if position confirmed with pH of 1-5. If there are any concerns about the position of the tube then refer to radiology.
  3. If a foley catheter used DO NOT use tube, refer patient to the gastro reg on call or the Enteral feeding nurses using contact details above (a balloon gastrostomy tube will then be inserted for feeding).
  4. If a Foley catheter used DO NOT attempt to replace this tube if the Gastrostomy site is less than 12 weeks old. Use contact details above to request an appropriate gastrostomy tube is inserted.

 

More than 12 weeks since initial formation of gastrostomy site:

  1. Undertake the placement of the gastrostomy tube if you are competent to do so.
  2. For advice and support or if unable to place the gastrostomy tube, use contact details above

 

FOR CHILDREN
Less than 4 weeks since initial formation of gastrostomy site:
1.Insert ENplug, NG tube smaller Fr than tube displaced, suction, urinary or balloon gastrostomy tube/button into the stoma to maintain the tract..
2. If resistance on insertion of tube STOP and refer to Paediatric surgeon on call (Bleep 1490 or 1234) or contact ward L42 at Leeds Children’s Hospital on 0113 3927442 / 3927542 for surgical advice.
3. The surgeon will assess and place a gastrostomy tube and may arrange a tube-o-gram in radiology to confirm position of the gastrostomy tube. Do NOT use until position in the stomach has been confirmed
4 - 12 weeks since initial formation of gastrostomy site:
1. Insert ENplug, NG tube smaller Fr than tube displaced, suction, urinary or balloon gastrostomy tube/button into the stoma to maintain the tract.
2. If balloon gastrostomy tube used and you are competent to undertake gastrostomy tube changes, check aspirate. Use for feeding if position confirmed with pH of 1-5. If there are any concerns about the position of the tube then refer to surgeon and or radiology for tube-o-gram.
3. If a urinary or Malecot catheter used DO NOT use tube, refer patient using contact details above and a balloon button/tube will then be inserted for feeding.
More than 12 weeks since initial formation of gastrostomy site:
1. Undertake the placement of the gastrostomy tube if you are competent to do so.
2. For advice and support or if unable to place the gastrostomy tube contact:

  • For hospital patients: contact the Children’s Nutrition Nurse Specialist Enteral Feeding on ext 28309 or bleep 80-2180. Out of hours contact on call Paediatric Surgery Registrar Bleep 80- 1490 or 80-1234
  • In the community, parents/carer to contact Children’s Community Nurse or School Nurse. If tube replacement is not possible insert enteral plug and secure in place with tape
  • Refer to Children’s Nutrition Nurses Monday - Friday 9am to 5pm to find out if they have capacity to see and replace the tube on PANDA unit.
  • Out of hours contact Ward L42 on 0113 3927442. The nurse will contact the on call Paediatric Surgery Registrar Bleep 80- 1490 or 80-1234 who will advise on where the patient can be assessed and have insertion of a replacement tube. This may be the Children’s Accident and Emergency (A&E) at Leeds Children’s Hospital..

3. Assess the patient’s ability to meet their nutritional and fluid requirements via the oral route to identify the urgency for gastrostomy replacement. If the patient can take some diet or fluid by mouth and no urgent medications are due, then the patient may be able to wait with EN plug in situ until the next morning for community or nutrition nurse to replace the tube.
4. Patients should bring their spare button/tube to the hospital with them to be replaced

 

 

 

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Problem

Possible cause

Prevention

2.2. SUSPECTED INFECTION OF THE GASTROSTOMY SITE

Indications:
red, inflamed, hot, radiating cellulitis, pus, exudate, sometimes unpleasant smell.

Patient colonized prior to insertion of gastrostomy.

MRSA Policy LTHT weblink: nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?id=1744

Poor asepsis at insertion. Contamination of the tube / insertion site.
e.g. poor hand hygiene when caring for gastrostomy; patient scratching gastrostomy site.

Dressing on the gastrostomy site can provide a moist warm environment ideal for bacterial growth.

Leaking stoma site causing damage to surrounding skin.

On going prevention
Keep clean and dry.
Cleanse daily with Normasol if patient is in hospital or
mild soap and water at home. Your healthcare professional may advise a different cleansing agent.
Leave gastrostomy site uncovered.

IF FUNGAL (YEAST) INFECTION SUSPECTED SEE SECTION 2.10 SKIN SENSITIVITY
ACTION 5.

 

 

 

Action

Rationale

1. Assess the patient and gastrostomy site. Take photograph (see 1.4) or use paper tape measure to assess and document extent of the cellulitis/erythema.

See Tissue Viability manual - NHS Leeds, Clinical Guideline for the Assessment of Wounds in Adults and Children.

Test any exudate / leakage with pH paper to identify possible cause of leakage — pH 1-5 indicates gastric acid,
pH 7-8 leakage is more likely to be serous fluid / pus or peritoneal fluid. Indicating infected gastrostomy site or misplaced tube.

If systemically unwell go to action 2 and 3.

Clean gastrostomy site daily with Normasol if patient in hospital, mild soap and water in the community. Your healthcare professional may advise a different cleansing agent if required.

Either: Apply 1 or 2 Excilion (Kendall) AMD 5 x 5cm (pre cut) dressing to exit site and change daily.

Or: Apply Iodosorb ointment to site in conjunction with a suitable dressing

. Apply daily for 7-14 days.  The tube can be used for multiple applications. Contraindicated in children


The same AMD foam dressing can be re-applied for up to 7 days, change sooner if strike through is visible.

pH indicator strips assess pH of leakage and help identify possible causes of redness and inflammation
pH indicator strips should be single patient use

 

 

 

AMD dressings are impregnated with PHMB (polyhexamethylene biguanide HCI) a widely used low allergenic antiseptic


Iodosorb is readily available from hospital pharmacy or GP

Reduces bacterial colonisation, however where systemic infection is present this will need treating with systemic antibiotics

 

 

Problem

Possible cause

Prevention

2.2. CONTINUED SUSPECTED INFECTION OF THE GASTROSTOMY SITE

 

 

 

Action

Rationale

2. If stoma site does not improve after 3-5 days and infection is spreading, there is cellulitis or patient pyrexial, refer for medical advice because systemic antibiotic treatment is required for more severe infections, especially if the patient is pyrexial.

Most common organism is staphylococcus aureus, suggest 5 day course of flucloxacillin (doxycycline if penicillin allergic or clarithromycin if over 65 years old and penicillin allergic.. If known to be MRSA positive use doxycycline. See guideline for further information

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3. Swabs recommended if not responding to treatment.

Antibiotic selection influenced by MRSA colonization / infection status and swab results. Discuss with microbiologist.

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Problem

Possible cause

Prevention

2.3. OVERGRANULATION (hyper-granulation) TISSUE

Overgranulation occurs when there is an
extended inflammatory process.

Trauma
Friction around stoma site may be caused by seat belts or clothing rubbing against the tube. Tube being dragged or pulled.

Check the external fixation device is correctly positioned close to the skin. Ensure tube is looped and taped securely or positioned above stoma site to prevent friction.

It is pink moist cauliflower like tissue which appears around the stoma site.

Poor fitting tube

Check tube / button fits correctly, For buttons re-measure stoma site length and change if necessary.

The stoma site may be constantly wet, bleeds easily on contact and is prone to infection.

Colonisation Increasing levels of bacteria causes an inflammatory reaction

Oxygen
Restricting the air to the stoma site may increase the risk of colonisation, such as the use of hydrocolloid or occlusive dressing.

Keep stoma site clean and dry, use a soft non- woven gauze or cotton buds (DO NOT use cotton wool balls, as fibres tend to stick to stoma site).

 

For persistant/ recurrent overgranulation Reassess and start at action 1.

 

Action

Rationale

  1. Assess the patient and gastrostomy site (see
    2.2, action 1).
  2. Consider Salt treatment- warn the patient that there may be some discomfort associated with the application.

See step by step pictorial guide 9 within this guideline for details on how to apply.

If not appropriate for Salt treatment opt for topical steroid treatment.


Thinly apply 1% Hydrocortisone cream / ointment (mild steroid) twice a day for 10-14 days. If there is exudate, apply in conjunction with a suitable dressing.

This is a low cost, readily available and effective treatment for overgranulation.

Ointment recommended for dry areas and cream recommended when there is exudate present. Corticosteroids reduce inflammation, as
overgranulation is thought to be associated with an abnormal inflammatory response.
Steroids are not licensed for the treatment of overgranulation, and the responsibility rests with the prescriber.

Help to reduce colonisation and thus reduce inflammation.

2. If not responding change to Fluroxycortide (Haelan) cream / ointment (moderate steroid). Thinly apply twice daily for 10-14 days or Fluroxycortide (Haelan) tape. Cut tape 1cm2 larger than the area to be covered, cut star keyhole and apply and then change daily.

Cut dotted lines:

Star keyhole dressing improves contact with overgranulation.

 

Problem

Possible cause

Prevention

2.3. CONTINUED OVERGRANULATION (hyper-granulation) TISSUE

 

 

 

Action

Rationale

3. If not responding to action 2 change to Mometasone (Elocon) cream/ointment (potent steroid). Thinly apply once daily. Use for up to 2 weeks maximum and review.

 

Use with caution in children

5. If not responding to steroid cream, consider using silver nitrate. This should only be done by an experienced practitioner.

Protect surrounding skin with soft white or yellow paraffin/ cavilon barrier film and then apply silver nitrate pencil 75% or 95%, every 3-4 days until the tissue has completely sloughed. A suitable dressing can be applied to absorb any exudate (see action 1).

Soft white or yellow paraffin acts as a barrier and protects the skin from the silver nitrate. Silver nitrate cauterizes the overgranulation and stops bleeding.

6. If no or poor response to silver nitrate, increase application of silver nitrate to alternate days (Monday, Wednesday & Friday) and thinly apply Hydrocortisone 1% or Fluroxycortide (Haelan) cream twice a day in between applications.

Using both silver nitrate and topical steroids together
in cases of resistant overgranulation has shown to be effective.

7.If not responding to the above treatments please contact Children’s Nutrition /community nursing team or Adult Enteral Feeding Nurses, Home Enteral Feeding Dietitian or Company nurse

 

8. If no response to the above please refer to the Tissue Viability Service. The referral form is available from Leeds Health Pathways for LTHT patients.

 

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Problem

Possible cause

Prevention

2.4. LEAKING STOMA SITE

Indications:
Leakage of gastric contents - tests positive to acid pH 1-5 with pH paper.

A small amount of mucus discharge is normal and tests neutral, pH 7 with pH paper.
Leakage may also be caused by a displaced tube see 2.5. migration of tube through pylorus.

Stoma site stretched by tube being pulled.

Ensure patient is in suitable feeding position and the tube is positioned above or to the side of the stoma site. Not tucked in under pants.

Misplaced tube NPSA/2010/RRR010

Check that tube is in correct position.

Tube migrated through the pylorus and balloon or disc is blocking the pyloric sphincter.

Ensure external fixation plate in correct position. If it is too slack the tube may migrate into the stomach allowing leakage of gastric contents. Gently pull back on tube until you feel internal disc / balloon against stomach wall.

Increase intra abdominal pressured due to excessive coughing (eg. chest infection)/ ventilation or straining (eg. constipated)

Constipation may cause gastric outflow obstruction and stomach contents may ‘back-flow’ through the stoma site.

Delayed gastric emptying.

Hole in tube.

 

 

Check for constipation and treat.

 

Check and treat

Clamp tube in different position.

 

Action

Rationale

1. If leakage occurs within the first week  following initial placement of gastrostomy tube, stop feed and refer to medical staff immediately.

For adults contact ward J91 at St James's Tel (0113) 206 9191/2068291 or Adult Enteral Feeding Nurse 68690/80-4727  For children ward L42 LGI Tel (0113) 392 7442)

Risk of feed leaking into the peritoneal cavity and causing peritonitis NPSA/2010/RRR010.

2. Check tube for damage, especially near exit site. Place white tissue under tube, flush tube with coloured liquid e.g. blackcurrant juice, observe for any leakage. If tube damaged arrange for replacement or repair

To ensure tube intact and identify if there is a hole in tube. Blackcurrant different colour to stomach contents.

3. Test leakage with pH paper - see section 2.2 action 1. Apply soft white or yellow paraffin or Cavilon spray / wipe to surrounding skin and then apply Orabase /Pelican paste generously around the tube.

A suitable key hole foam dressing can also be helpful to maintain traction between internal disc / balloon and external fixing device. Reapply the Orabase / Pelican paste with cotton bud or cavilon sponge when leakage soaks through the dressing. Ensure tube is looped and taped to prevent further stretching of the stoma site. Every 24 to 72 hours, clean off gently and reapply. Alternatives to tape

To identify if leakage is gastric acid or infection.
Soft white or yellow paraffin or Cavilon wipes / spray are barriers and protect skin from excoriation by gastric acid. Orabase / (for small amount of leakage) Pelican paste ( for large amount of leakage) creates
a seal around the tube, reduces leakage, promotes, granulation and is a barrier. The leakage will gradually reduce; it usually takes 4-10 days for the stoma site to close around the tube. DO NOT stop treatment until leakage has stopped for a few days.

 

Problem

Possible cause

Prevention

2.4. CONTINUED
LEAKING STOMA SITE

For balloon tubes
Water in the balloon may be lost through osmosis.

For balloon tubes Document every 2 weeks or as advised by your healthcare professional. The balloon is inflated with the recommended amount of water by the manufacturer.

 

Action

Rationale

4. If the stoma site is very enlarged and a balloon gastrostomy tube/ button is in situ, remove tube/button for 1-2 hours (or more if needed). Then replace the tube (the same tube can be replaced).

To promote shrinkage of stoma size. Placing a larger Fr size tube to stop leakage is not recommended. Larger tubes are heavy and stretch the stoma site and tend to make the problem worse.

5. Discuss use of Ranitidine or Omeprazole with GP or medical staff.

Ranitidine & Omeprazole increase pH of gastric acid and reduces tissue damage

6. Discuss use of Metoclopramide with GP or medical staff.

Metoclopramide promotes gastric emptying.

7. If bile leaking around stoma site stop feeding and refer to surgeon / gastro team / GP.

May have an intestinal obstruction.

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Problem

Possible cause

Prevention

2.5. MIGRATION OF TUBE THROUGH PYLORUS

Peristalsis pulls tube into small bowel, which may block gastric outlet causing vomiting and leakage of gastric secretions from the stoma site.

Tube not anchored securely to the abdominal wall, so it may be accidentally dislodged.

Ensure tube securely looped and taped in position.

Fixation device has moved from usual position.

Check external length correct and fixation device is close to skin. You can feel the internal balloon or disc against the stomach wall when the tube is gently pulled back.

 

Action

Rationale

1. Stop the feed immediately. Secure tube to abdominal wall. Check external length of the tube and test on pH paper for acid reaction of (pH 1-5).

Use to prevent further displacement.
To check if tube is in the stomach.

2. For balloon tubes

Aspirate tube and test for gastric acid, pH 1-5 on pH paper.

Deflate the balloon and withdraw to 6cm mark. Re-inflate the balloon with recommended amount of boiled cooled / sterile water by the manufacturer and gently pull back until tension felt against the stomach wall. Slide the fixation device to skin level. Aspirate tube and test for gastric acid, pH 1-5 on pH paper. Consider replacing tube with a button low profile device (LPDG).

For PEG tubes
Pull back on the tube and place the fixation device in the usual position. Replace fixation device if loose. Aspirate tube and test for gastric acid, pH 1-5, measure and document external length from the exit site from the stoma to start of the feed port. Check external fixation device securely holds the tube, replace if necessary.

For all tubes
If tube slips through fixation device, once it is correctly positioned in the stomach, wrap tape around tube below the fixation device to secure.

Deflating the balloon will allow the tube to be pulled back through the pylorus into the stomach.

To ensure the tube is in the stomach prior to feeding.

It may be possible to pull the internal fixation device through the pylorus. If aspirate bile stained and / or pH 6-8 tube likely to be in duodenum / jejunum.

 

To prevent fixation device sliding up the tube.

3. If unable to pull back into stomach, contact company nurse or seek medical advice.

The tube’s internal disc / balloon may be trapped in pyloric sphincter.

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Problem

Possible cause

Prevention

2.6. BURIED BUMPER SYNDROME
The internal disc of the PEG becomes embedded in the stomach wall and the stomach lining grows round it. This can block the tip of the gastrostomy tube.

Indications:
Leakage from the stoma site associated with flushing the tube with water and / or feed administration.
Unable to freely advance the tube 1-3cm and / or rotate.
Patient experiences pain when tube is advanced and / or rotated.

PEG tube not rotatied daily
PEG tube not advanced and rotated  weekly.

Advance tube 1-3 cm into stomach and turn the tube in a complete circle at least weekly and no more than once a day

Fixation device too tight.

Position fixation device close to skin.
Adults 1cm from the skin. Children 0.5cm from skin.

 

For further details see Freka PEG gastrostomy guide for patients and carers page 5 Fresenius Kabi.

 

Action

Rationale

2. Check if tube flushes easily and test pH of aspirate to confirm tube is in stomach. If unable to advance/ rotate tube or is painful to do, then buried bumper is suspected. For adults contact company nurse / HEF Dietitian  or Ward J91 at St James's Tel (0113) 206 9191/2068291 or Adult Enteral Feeding Nurses 68690/80-4727

For Children contact children’s community nurse or children’s nutrition nurse for further advice.

If buried bumper confirmed arrange for tube to be changed in next 1-2 weeks.

The nurse can assess the tube and confirm if buried bumper is suspected.

It is safe to use the tube providing that the pH test confirms that the tube is in the stomach and there is no resistance when the tube is flushed.

2. If tube is blocked and unable to clear the blockage and buried bumper suspected contact the hospital.

To arrange for tube replacement.

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Problem

Possible cause

Prevention

2.7. BLOCKED TUBE
Indications:
Tube stiff to flush.

Unable to flush water through tube.

Connectors are pushed out of tube when feeding or flushing tube.

Unable to push connector into tube.

Medications mixed with feed.
Not flushing or inadequate flushing of tube before and after medications and feed.

Flush with water before and after medicine and feed.
Use at least:
1-2ml for infants
5-10ml for children
30ml for adults

Crushed or dispersible tablets not well dispersed in water.

Multiple medications mixed together or given one at a time and NOT flushed in between.

Flush using a push pause technique, this creates turbulence within the tube and flushes more effectively
Use liquid medicines or dispersible tablets
If there is a build up of feed inside of the tube,
it may be useful to flush with soda water on a regular basis as the bubbles may help to prevent build up of feed.

Buried bumper (see 2.6).
Balloon burst and blocks end of tube.

PEG tube’s internal fixation device becomes embedded in stomach wall (see 2.6).

 

Action

Rationale

1. Flush with warm water, carbonated water or soda water, using 60ml syringe. Do not use cola, diet cola, lemon or pineapple juice on blockages caused by medication.

Bubbles may loosen blockage. Cola / juice are acidic and can make blockages worse especially if blocked by drugs.

2. Blockage may be aspirated out of tube. Oscillate syringe plunger back and forth and squeeze the tube between finger and thumb. Try using a smaller size syringe e.g. l0ml to flush.

Wrap a cloth warmed using hand hot water round the tube.

To loosen the blockage. Smaller syringe exerts a greater pressure, observe for tube bulging and do not use excessive force
Warmth may soften the blockage.

3a. For PEG tubes, Place towel or bowl under tube, remove feed port* and clamp. Rub tube between thumb and forefinger massaging the tube. If near stoma site undo fixation device and massage tube. Replace end and flush with cooled boiled / sterile water (if blocked by Omeprazole or Lanzoprazole, flush with l0ml or 8.4% sodium bicarbonate and leave for 15 minutes in hospital or soda water in community). Repeat a few times until blockage clearsConsider the use of Creon 10,000 units or 1 scoop of Pancrex mixed with 10 ml sodium bicarbonate 8.4% if this blockage is related to feeding.

To squeeze build up / medication out of the tube. To irrigate the tube and dilute build up of feed / medication.
8.4% sodium bicarbonate or soda water will dissolve the omeprazole granules.

Note when untwisting the threaded skirt from the feed port of a Corflo PEG be aware that it may cause the internal bumper to deflate. Avoid pulling the tube and replace as soon as possible.

Sodium bicarbonate takes a few minutes dissolve and activate the  enzymes in the   Creon

4. For balloon tubes and buttons
Remove tube / button and replace with new Gastrostomy tube/button (see pictorial tools 2/3).

Balloon tubes can safely be changed at home providing patient, carer or nurse trained how to do this.

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Problem

Possible cause

Prevention

2.8. BLOCKED FEED PORT / Y-ADAPTOR END

Feed and / or medication blocking the adaptor.

Flush with water before and after medicine and feed.

Not flushing before and after feeds and medication.

Use at least:
1-2ml for infants
5-10ml for children
30ml for adults
Flush using a push pause technique, creates turbulence in the tube and flushes more effectively.
Use liquid medicines or soluble tablets.
Wash end of PEG tube port with warm water at least weekly.

 

Action

Rationale

1. To unblock Y-adaptor
Close clamp on tube, attach syringe of water, hold tube over a bowl and open other cap and flush.

To clean the inside of the Y adaptor end and remove the blockage.

2. To change Y-adaptor (feed port) on PEG tubes
When changing Y-adaptor always close the clamp.

Remove feed port or Y-adaptor and replace with a new one.

Spare Y-adaptors/feed ports are available from Home Care delivery service. Ensure patient always has a spare Y-adaptor and knows the type and Fr size of PEG tube.

Contact community dietitian / company nurse to add to home delivery stock list.

The hospital stocks spare Y-adaptors for: Children - ward 42, LGI.

Adults –To contact Endoscopy department

The hospital stocks spare Y-adaptors for: Children - ward 42, LGI.
Adults –To contact Endoscopy department
See step by step guide in this guideline for how to change a Corflo PEG end


(https://www.fresenius-kabi.com/gb/documents/Gastrostomy_Feeding_Care_Guideline.pdf).
For balloon tube remove tube and replace with a new tube (see section 2.1 action 1 & pictorial tools).

Do Not remove if new gastrostomy site (less than 12 weeks from placement).

Seek medical advice.

To prevent leakage and maintain the internal fixation disc.

To change the end.

Freka PEG ends are colour coded Fr 9 = yellow, Fr 15 = blue & Fr 20 = purple.

 

 

 

 

The feed port is fixed to the tube and it cannot be removed

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Problem

Possible cause

Prevention

2.9. BROKEN FEED PORT OR Y-ADAPTOR END OR UNABLE TO DISCONNECT GIVING SET FROM FEED PORT I Y-ADAPTOR END.

General wear and tear. Connecting giving set too tight.

Do not over tighten when connecting feed giving set.

 

Action

Rationale

1. To change Y-adaptor on PEG tubes
When changing end always close the clamp.

Remove feed port or Y-adaptor and replace with a new one.

To prevent leakage and maintain the internal fixation disc.

Spare Y-adaptors/feed ports are available from Home Care delivery service. Ensure patient always has a spare Y-adaptor and knows the type and Fr size of PEG tube.
Contact community dietitian / company nurse to add to home delivery stock list.
The hospital stocks spare Y-adaptors for: Children - ward 42, LGI.
Adults –To contact Endoscopy department
See step by step guide in this guideline for how to change a Corflo PEG end
For Freka PEG see gastrostomy guide for patients and carers ( https://www.fresenius-kabi.com/gb/documents/Gastrostomy_Feeding_Care_Guideline.pdf).

For balloon tube remove tube and replace with a new tube (see section 2.1 action 1 & pictorial tools).

To change  Freka PEG feed port note they  colour coded Fr 9 = yellow, Fr 15 = blue & Fr 20 = purple.

 

The feed port is fixed to the tube and it cannot be removed.

Do Not remove if new gastrostomy site (less than 12 weeks from placement).
Seek medical advice.

Risk of peritonitis.

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Problem

Possible cause

Prevention

2.10. SKIN SENSITIVITY Indications: skin dry, redness, itching, but no infection or exudate.

Sensitivity to cleanser eg. soap.

Sensitivity to Silicone or polyurethane tubes.

Yeast infection, skin may have red spotty skin rash sometimes spots have white flaky top and may have malodour.

Sensitivity to tapes or dressings.

Keep clean and dry.
Cleanse daily with normasol if patient is in hospital or
Non sensitive soap and water at home. Your healthcare professional may advice a different cleansing agent.

Leave gastrostomy site uncovered.

 

Action

Rationale

1. Identify cleansing solution used and advise to clean with water only and check for improvement after one week.

May have sensitivity to cleansing solution.

2. Apply emollient 1-2 times a day.

To moisturise the skin.

3. Apply barrier film i.e. Cavilon spray or 1ml sponge applicator. Apply daily initially and then reduce to alternate days.

Cavilon will leave a clear plastic coating on the skin and does not sting.

4. Apply 1% hydrocortisone cream (mild steroid) apply 1-2 times a day, for a week. If not responding change to Fluroxycortide (Haelan) Cream (moderate steroid). (Steroids are not recommended if infection is suspected).

To reduce skin sensitivity.

5. Suspected yeast infection - send a swab
Apply topical Nystatin, or Miconazole cream
- apply twice daily. Review after 10-14 days.

To treat fungal infection.

 

Steroid and antifungal cream / ointment is useful when infection and inflammation
co-exist.

6. Suspected yeast infection and inflammation Apply Nystataform-HC or Trimovate cream / ointment.

7. Suspected sensitivity to tube
Patch test by taping / bandaging a section of the same make of tube to the skin of the forearm. Check site after 2 days initially, if no reaction replace and leave for up to a week then recheck skin. Contact HEF/Dietitian/company nurse/children’s nutrition nurse  for a sample of tube to use.

To test for sensitivity to the tube.

8. Refer to dermatologist.

For further investigation.

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Provenance

Record: 779
Objective:

These guidelines apply to all staff who are caring for adults and children who have a gastrostomy feeding tube in place in hospital and the community.

Clinical condition:

Gastrostomy Feeding Tube

Target patient group: Adults and children who are at risk of developing complications with their gastrostomy feeding tube in hospital and the community.
Target professional group(s): Secondary Care Doctors
Allied Health Professionals
Secondary Care Nurses
Adapted from:

Evidence base

Gastrostomy management
Gauderer MWL, Ponsky JL, Izant RJ. (1980) Gastrostomy without Laparotomy: A percutaneous endoscopic technique Journal of Paediatric Surgery 15:872
Khair J. (2003) Managing home enteral tube feeding for children. British
Journal of Children’s Community Nursing. 8(3): 116-126.
Leeds Community Tissue viability service. How to choose the correct dressing (2015) detail.aspx?ID=2559

Good Practice Guideline – Managing Complications at Abdominal Enteral Feeding Tube Exit Sites in Adults_(2013) National Nutrition Nurses Group
Evidence base

Leeds Community Tissue viability service. How to choose the correct dressing (2015) detail.aspx?ID=2559

Leeds Guideline for the Prevention and Management of Wound Infection in Adults and Children (PL 193) (2010) detail.aspx?ID=2029

Guideline for Wound Management (2014) detail.aspx?ID=1423

Leeds Teaching Hospitals NHS Trust (2015) Enteral Tube Feeding Policy.
detail.aspx?ID=162

Leeds Teaching Hospitals NHS Trust (2014) Guidelines for percutaneous endoscopic gastrostomy (PEG) placement.
detail.aspx?ID=159

Leeds Teaching Hospitals NHS Trust (2014) Guidelines for the Replacement of a Gastrostomy Tube and On-going Care for Adults and Children detail.aspx?ID=1510

National Institute for Clinical Excellence (2012) Healthcare-associated infections: Prevention and control in primary and community care. London: March 2012 NICE CG139.1.3 Enteral feeding.  

National Institute for Clinical Excellence (2006) Nutrition support in adults. London: Quick reference guide Feb 2006 NICE.13,14,21&22.

National Patient Safety Alert (2010) Rapid response report NPSA/2010/RRR010: Early detection of complications after gastrostomy.

North Bristol NHS Trust. Care of the umbilical granuloma. December 2005 Journal of Wound Care 2013 Jan 22(1):17-18,20 Treatment for hypergranulation at gastrostomy sites with sprinkling salt in paediatric patients.
Sanders DS, Carter MJ, Silva JD, McAlinson ME, Willemse PJ, Bardham KD. (2001) Percutaneous endoscopic gastrostomy: a prospective analysis of hospital support reuired and complications following discharge to the community. European Journal of Clinical Nutrition; 55, 610-614.

Stroud M, Duncan H, Nightingale J. (2003) Guidelines for Enteral Feeding In Adult Hospital Patients. Gut; 52 (Suppl VII); vi1-vii12.

White R, Bradnam V. (2015) Handbook of Drug Administration via enteral feeding tube. 3rd Edition British Pharmaceutical Group, Pharmaceutical Press, London. 1-57.
Sriram K et al (1997) Prophylactic locking of enteral feeding tubes with pancreatic enzymes. American Society of Enteral and Parenteral Nutrition, 21, 6, 353-356.
Buried bumper syndrome
Liscomb GR et al (1994) Blocked gastrostomy tubes. The Lancet, 343, 801- 802.

Vautier G, Scott BB. (1994) Blocked gastrostomy tubes. The Lancet, 343, 1105.
Overgranulation / infection / wound healing
Burkholder B. (2000) Topical corticosteroids — an update. Current problems in dermatology; 12, 222-225.

Dunford C. (1999) Hypergranulation tissue, a review of the formation, causes and management of hypergranulation tissue. Journal of Wound Care, November, 8, 10, 506 — 507.

Ip M, LaiLui S, Poon VKM, Lung I, Burd A. (2006) Antimicrobial activities of silver dressings: an in vitro comparison. Jounal of Medical Microbiology. 55, 59-63.

Johnson S. (2007) Fluroxycortide (Haelan) Tape for the treatment of overgranulation tissue. Wounds UK 3,3, 70-74.

Leak K, Johnson S. (2007) managing the complications og Percutaneous endoscopic gastrostomy (PEG) sites: Allevyn Ag in clinical use. Poster presented at Wounds UK, Harrogate, Nov 2007.

Leak K. (2002) Changing wound care practice: management of percutaneous endoscopic gastrostomy sites. 27-30.

Leak K. (2002) PEG site infections: a novel use for Actisorb Silver 220. British Journal of Community Nursing, 7,6, 321-325.

Leaper D. (1996) Antiseptics in wound healing. Nursing Times; September 25,
North Bristol NHS Trust. Care of the umbilical granuloma. December 2005 Aneurin Bevan Health Board Paediatric Enteral Service February 2012
Rollins H. (2000) Hypergranulation tissue at gastrostomy sites. Journal of Wound Care, March, 9, 3, 127-129. Warrener, L. Spruce, P. (2012) Managing overgranulation tissue around gastrostomy sites. British Journal of Nursing, 2012 (Tissue viability Supplement), Vol 21, No 5, S14 - S24.

Document history

LHP version 2.0

Related information

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