What Complications Can Gastrostomy Tubes Have?

Patient Presentation
A 2-year-old female came to clinic because of increasing rhinitis, coughing and fussiness for 2 days. Her cough was wet and was worse when she was lying down. She was afebrile, was tolerating her gastrostomy tube feedings and was urinating well. She was stooling normally and had no rashes. Her older brother and father had similar symptoms. The past medical history was positive for cognitive delay and cerebral palsy.

The pertinent physical exam showed a thin female with a respiratory rate of 36 per minute, oxygen saturation of 96% on room air and otherwise normal vital signs. HEENT showed copious clear-white rhinorrhea. Her tympanic membranes looked dull but were in a normal position without fluid. Her mouth was normal. She had a few shotty anterior cervical nodes. Her abdomen was soft, but her gastrostomy tube button (GT) site looked irritated. Neurologically she was non-communicative with spasticity throughout.

The diagnosis of a child with cognitive delay, cerebral palsy, upper respiratory tract infection and an irritated GT site was made. The mother had been worried that she had an ear infection or pneumonia as she had had these problems in the past. “The GT started to leak a couple of days ago. Usually, just drying it more often works, but I started the triamcinolone cream this morning. She has an appointment with the GI doctors in 2 days so I haven’t called them about it,” the mother stated. “I think that is fine but if it gets worse you probably should call them. Probably coughing isn’t helping because then the button top can irritate the skin more too,” the pediatrician replied.

Discussion
Gastrostomy tubes (GT or GTubes) have been used to support patients for about a century. They are placed between the abdominal skin and the stomach either percutaneously or surgically. The tubes can be a standard long tube with either a bumper or inflatable balloon internally and externally they have a retention piece to hold the GT in place. A button or low profile tube are similar but extend just beyond the skin.

Reasons for GT placement include:

  • Nutritional support
  • Hydration maintenance
  • Medication management
  • Aspiration avoidance
  • Gastric stasis decompression
  • Obstruction bypass
  • Quality of life improvement for caregivers

They are very effective tools but do not always improve the quality of life for all individuals and the cost of care for a child with a GT significantly increases.

Fundoplication may be performed at the same time as GT placement to try to decrease gastroesophageal reflux and aspiration. It takes approximately 8 weeks for the GT site to heal. If the GT falls out before this, it should be replaced by the inserting specialist. After 8 weeks and with the opening visible, it is possible for other trained individuals to replace the tube. This is for most patients, but will depend on the actual individual. While healing, the site should be cleaned and monitored per the inserting specialist’s instructions. After healing, GTs should be cleaned daily with soap and water and dried thoroughly. Patients can be bathed and can swim with the GT following the instructions of the inserting specialist after the appropriate amount of time for healing.

Common problems include:

  • Leaks are relatively common and can be treated by using a gauze dressing, but if very irritated then triamcinolone cream may be helpful to decrease the inflammation. Persistent leaks may indicate a broken internal balloon or that the GT needs to be replaced.
  • Granulation tissue that can build up near the GT is also usually treated with triamcinolone cream but other options include stomahesive power, silver nitrate, cryotherapy and if recalcitrant, surgical debridement.
  • Cellulitis should be treated with topical or oral antibiotics as appropriate. Methicillin-resistant Staphlococcus aureus is the most common cause.
  • GTs can become blocked also. Small amounts of saline or water can be instilled and after a period of time (~30 minutes) flushing can be attempted. If it cannot be cleared then it needs to be replaced. There usually are two lumens – one for nutrition and one for medications. Liquid medication is preferred to be used in the GT. After using a lumen, 5-10 cc should be flushed to try to keep the lumen open.
  • Buried bumper can result from pulling on the GTs, so attention should made to not put traction on the GT. Surgery is usually needed to fix this problem.
  • Abdominal distention can result from too much air and can be easily fixed by connecting the extension tubing and allowing air to escape. Buttons usually have a valve that must be opened to allow venting.

Learning Point
GT Complications include:

  • Intra-procedural
    • Bleeding
    • Bowel perforation
    • Cardiorespiratory arrest
    • Collapsed lung
    • Death
    • Esophageal tear
    • Hemoperitoneum
    • Intraoperative laceration
    • Pneumoperitoneum
  • Post-procedural
    • Abscess
    • Bleeding
    • Death – related or unrelated to GT
    • Diaphragmatic dysfunction
    • Fever
    • Fundoplication wrap failure
    • Gastric prolapse
    • Gastric pseudopolyp
    • Gastric residue
    • Gastric separation
    • Gastroesophageal reflux
    • Gastrointestinal blockage
    • GT problems
      • Buried bumper
      • Dislodged
      • Leakage
      • Migration
      • Obstruction
      • Pulled out, intentional
      • Removal, re-operation or relocation
      • Malfunction – clogging, breaking
    • Hernia
    • Hospital admission
    • Intussuception
    • Megacolon
    • Nasogastric tube obstruction
    • Obesity
    • Pain
    • Pancreatitis
    • Perforation of stomach wall
    • Pneumonia
    • Prolonged oxygen use
    • Pseudotumoral proliferative gastric mucosa
    • Rectus sheath hematoma
    • Respiratory insufficiency
    • Sepsis
    • Stomach flu
    • Tract dehiscence
    • Ulcer
    • Unstated infection including chest
    • Urinary tract infection
    • Volvulus
    • Viscus rupture
    • Wound dehiscence
  • Stoma-related
    • Abscess
    • Cellulitis
    • Delayed closure of site after GT removal
    • Fistula
    • Granuloma
    • Pain
    • Skin
      • Infection
      • Irritation
      • Necrosis
    • Stomal herniation
  • Patient feeding
    • Abdominal distention
    • Aspiration
    • Aspiration pneumonia
    • Bloating
    • Constipation
    • Cramping
    • Delayed gastric emptying
    • Delayed feeding
    • Diarrhea
    • Electrolyte imbalance
    • Emesis
    • Ileus
    • Gastroparesis
    • Problems with feeding/medication administration
    • Malnutrition
    • Nausea
    • Retching

Questions for Further Discussion
1. What are the pros and cons of percutaneous versus surgical placement of a GT?
2. If a GT is dislodged, how long before the site can start to close up?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Nutritional Support

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

McSweeney ME, Smithers CJ. Advances in Pediatric Gastrostomy Placement. Gastrointest Endosc Clin N Am. 2016 Jan;26(1):169-85.

Kapadia MZ, Joachim KC, Balasingham C, Cohen E, Mahant S, Nelson K, Maguire JL, Guttmann A, Offringa M. A Core Outcome Set for Children With Feeding Tubes and Neurologic Impairment: A Systematic Review. Pediatrics. 2016 Jul;138(1). pii: e20153967.

Fuchs S. Gastrostomy Tubes: Care and Feeding. Pediatr Emerg Care. 2017 Dec;33(12):787-791.

Yap BK, Nah SA, Chen Y, Low Y. Fundoplication with gastrostomy vs gastrostomy alone: a systematic review and meta-analysis of outcomes and complications. Pediatr Surg Int. 2017 Feb;33(2):217-228.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are Potential Complications of Large for Gestational Birthweight?

Patient Presentation
A newborn male, term, infant was born to a G2P2, Pacific Islander female by an uncomplicated pregnancy and vaginal delivery. Gestational age had been confirmed by a 21 week ultrasound. Because of increased fundal height measurements, the mother had been monitored by ultrasound in the third trimester and a birth weight of around 4300g had been expected. There was no gestational diabetes but the mother’s other child was large for gestational age (LGA).

The pertinent physical exam showed a large male with birth weight of 4430 grams (98%), head circumference of 37 cm (98%) and length of 53 cm (90%) and was symmetric. HEENT was normal. His clavicles were intact. There was no heart murmur. His spine was normal. The rest of his examination was normal.

The diagnosis of a LGA male was made, most likely due to genetic disposition. He was monitored by glucose protocol because of the risk of hypoglycemia but never needed intervention. His was breastfed and was discharged at 2 days with a 5% decrease in birth weight.

Discussion
Infant size at birth is determined mainly by genetics, but also pregnancy and environmental factors. Large for gestational age (LGA) is defined as a mean weight > 2 standard deviations above the weight for gestational age or above the 90th percentile on growth charts (or ~4000 g on WHO growth charts). Macrosomia is a term used for a term infant who is > 4000g.

Risk factors for LGA infants includes:

  • Male infant
  • Maternal
    • Genetic disposition
    • Hispanic ethnicity
    • Diabetic
    • Multiparity or grand parity
    • Obesity
  • History of previous LGA infant

Prenatal ultrasound is very helpful for antenatal management. First trimester fetal ultrasound is excellent for determining gestational age. Fetal abdominal circumference 1-2 weeks before anticipated delivery (before 40 weeks gestation) is also excellent at determining fetal weight. After 40 weeks gestation it is not accurate for determining fetal weight.

Similar to SGA infants having “catch-up” growth, LGA babies do show “catch-down” growth over time most of which is in the first 3 months of life especially for head circumference and length. However, LGA babies then show slower weight changes and long term consistently have higher BMI and subcutaneous fat. One study found, “The growth patterns of LGA preterm-born children are distinctly different from other preterm or full term children. In particular, we found substantially greater weight gains and relatively higher BMIs is among them, which added to their already increased metabolic risks based on their gestational age.”

Learning Point
For infants and children being LGA increases the risks for:

  • Asphyxia
  • Cognitive impairments
  • Congenital malformations and genetic syndromes – a review of overgrowth syndromes can be found here
  • Cardiomyopathy
  • Fetal death rates are higher in babies weighing > 4000 g in diabetic mothers, and > 4250g in non-diabetic mothers
  • Electrolyte disorders – hypocalcemia, hypoglycemia
  • Hematological problems – iron deficiency, polycythemia
  • Infant of a diabetic mother risks, can be reviewed here
  • Labor complications
    • Prolonged labor
    • Shoulder dystocia
    • Brachial plexus injuries
    • Clavicle or humerus fractures
  • Meconium aspiration
  • Obesity and overweight
  • Persistent pulmonary hypertension
  • Renal vein thrombosis
  • Respiratory distress syndrome

For mothers includes:

  • Hemorrhage
  • Increased Cesarean section deliveries
  • Infection
  • Lacerations – perineal, vaginal, cervical

Questions for Further Discussion
1. What are common problems for an infant who is small for gestation age? A review can be found here
2. What monitoring and treatment must be done for infants who are LGA?
3. What defines grand parity vs multiparity?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Birth Weight

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lawrence EJ. A matter of size: Part 2. Evaluating the large-for-gestational-age neonate. Adv Neonatal Care. 2007 Aug;7(4):187-97.
Taal HR, Vd Heijden AJ, Steegers EA, Hofman A, Jaddoe VW. Small and large size for gestational age at birth, infant growth, and childhood overweight. Obesity (Silver Spring). 2013 Jun;21(6):1261-8.

Bocca-Tjeertes IF, Kerstjens JM, Reijneveld SA, Veldman K, Bos AF, de Winter AF. Growth patterns of large for gestational age children up to age 4 years. Pediatrics. 2014 Mar;133(3):e643-9.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are The Potential Complications of a Tracheostomy?

Patient Presentation
A 4-year-old male came to clinic with increased respiratory secretions for the past 24 hours. He had a tracheostomy and the secretions were increased in amount and were thicker and yellowish in color instead of white. He had problems sleeping the night before because of coughing, which had continued into the daytime. He did not have problems breathing after suctioning but needed it at least hourly and often more. He also had copious clear rhinorrhea. He was uncommunicative, but his mother didn’t believe he was having any pain. He was afebrile, and was urinating and stooling as usual.

The past medical history was positive for a currently unidentified neurological condition where he had hypotonia, decreased strength and cognitive deficits. He had a tracheostomy and a gastrostomy tube placed around 1 year of life after multiple episodes of hospitalization for respiratory infections and failure to thrive. During that hospitalization, he needed chronic ventilatory support. Since that time he had been hospitalized 2-3 times/year for respiratory infections and pulmonary toilet. He had a decannulation attempt the previous year that failed because of general intolerance. The family history was positive for an adoptive brother who had congenital heart disease.

The pertinent physical exam showed a thin male with a respiratory rate of 42/minute, heart rate of 98 beats/min, with a normal blood pressure and temperature. His saturation was 90%. Weight had increased ~250 grams from an office visit 5 weeks ago. HEENT showed copious clear rhinorrhea, clear throat, and dull tympanic membranes bilaterally without fluid. His trach cannula was in place and the stoma was clear without erythema or granulation tissue. Lungs were quite coarse with fluid that moved with coughing. He had no specific wheezing or decreased breath sounds. His abdomen was soft and non-tender with a gastrostomy tube in place. The stoma site showed normal skin tissue. Neurologically, he was uncommunicative but would follow the examiner with his eyes. He had hypotonia and decreased strength. After he was suctioned, his saturation increased to 94%.

The work-up included a chest radiograph that was normal for the patient and without specific focal consolidation. A tracheostomy culture and gram-stain was sent. Some gram-positive cocci in pairs were seen along with increased polymorphonuclear cells.

The diagnosis of an upper respiratory tract infection with increased secretions was made. The mother was concerned about being able to care for the child because her husband was out of town and her backup nursing staff was not available. “I’m not sure that I can really take care of him, along with his brother by myself. I don’t want him to be hospitalized, but he needs to be watched all the time,” she said. The pediatrician called his pulmonologist who agreed with the mother. “He gets sick pretty quickly and he probably would be okay if there was nursing care, but I don’t feel comfortable with her being alone. She’s very good and if she is worried, then I know I should be worried too,” the pulmonologist said. Over the night, the patient’s clinical course worsened slightly and he need very frequent suctioning and 2 liters of oxygen/minute by trach cuff. He still remained afebrile. Over the next 2 days, he was slowly weaned off the oxygen and the secretions decreased in amount. He was discharged home.

Discussion
In the past, indications for tracheostomy were often because of infection, but today are more often due to need for chronic airway support and/or ventilation. Many more children and infants are having tracheostomies placed. Decannulation rates for these children are low due to concomitant complex chronic disease such as neurological, pulmonary and congenital heart diseases. Co-morbidies are common with 3-4 being average, and frequently also including chronic technology such as gastrostomy tubes or ventriculoperitoneal shunts. Approximately 8% of children do not survive the hospitalization where the tracheostomy is placed. It is believe this is not specifically due to the tracheostomy, but is secondary to underlying medical conditions. About 15-20% of children with tracheostomies have a tracheostomy-related complication and many have frequent hospitalizations. Frequent hospitalizations are often due to respiratory issues (50.8% with pneumonia accounting for 15.4%) and neurological and otolarygological problems accounting for 8.4% each in a 2015 study.

Decannulation is highly individual and many children will need the tracheostomy for their lifetimes. In general before a decannulation attempt, there should be no ventilatory support needed for at least 3-6 months, no aspiration events, no need for supplemental oxygen, no need for elective surgery in the near future necessitating intubation, and co-morbidies that have resolved or are improved. Patients who are being considered for decannulation often will have a trial of capping the trach during the day and night, and/or have the tracheostomy tube downsized. All have some type of formal airway assessment usually by laryngoscopy to evaluate the overall airway and to detect potential problems such as granulation tissue in the airway. A favorable direct airway evaluation is a good predictor of decannulation success.

Learning Point
Potential complications of tracheostomy include:

  • Early complications
    • Air leak
      • Pneumothorax
      • Pneumomediastinum
      • Subcutaneous emyphasema
    • Airway obstruction
      • Decannulation, accidental
      • Mucous plugging
    • Hemorrhage
      • Aberrant vessels
      • Innominate artery
      • Thyroid gland
    • Pulmonary edema
    • Respiratory arrest
    • Surrounding tissue injury
      • Cricoid cartilage
      • Esophagus
      • Recurrent laryngeal nerve
    • Tube placement injuries
      • Main bronchus cannulation
      • Tracheal tear/fistula
  • Delayed complications
    • Airway obstruction
      • Decannulation, accidental
      • Mucous plugging
    • Hemorrhage
      • Stomal
      • Tracheal mucosa
      • Tracheo innominate fistula
    • Swallowing or speech problems
    • Stomal problems
      • Granulation tissue
      • Tracheocutaneous fistula
    • Tracheal lesions
      • Granuloma, suprastomal or distal
      • Suprastomal collapse
      • Subglottic stenosis
    • Tracheoesophageal fistula

Modified from Watters, 2017.

Questions for Further Discussion
1. What is the general formula for sizing an endotracheal tube or tracheostomy tube?
2. What are the treatments for stomal granulation tissue?
3. What special problems may infants or young children have with development because of a tracheostomy?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tracheal Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Yaneza MM, James HL, Davies P, Harrison S, McAlorum L, Clement WA, Kubba H. Changing indications for paediatric tracheostomy and the role of a multidisciplinary tracheostomy clinic. J Laryngol Otol. 2015 Sep;129(9):882-6.

Zhu H, Das P, Roberson DW, Jang J, Skinner ML, Paine M, Yuan J, Berry J. Hospitalizations in children with preexisting tracheostomy: a national perspective. Laryngoscope. 2015 Feb;125(2):462-8.

Watters K, O’Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope. 2016 Nov;126(11):2611-2617.

Watters KF. Tracheostomy in Infants and Children. Respir Care. 2017 Jun;62(6):799-825.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

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