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.
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.
GT Complications include:
- Bowel perforation
- Cardiorespiratory arrest
- Collapsed lung
- Esophageal tear
- Intraoperative laceration
- Death – related or unrelated to GT
- Diaphragmatic dysfunction
- Fundoplication wrap failure
- Gastric prolapse
- Gastric pseudopolyp
- Gastric residue
- Gastric separation
- Gastroesophageal reflux
- Gastrointestinal blockage
- GT problems
- Buried bumper
- Pulled out, intentional
- Removal, re-operation or relocation
- Malfunction – clogging, breaking
- Hospital admission
- Nasogastric tube obstruction
- Perforation of stomach wall
- Prolonged oxygen use
- Pseudotumoral proliferative gastric mucosa
- Rectus sheath hematoma
- Respiratory insufficiency
- Stomach flu
- Tract dehiscence
- Unstated infection including chest
- Urinary tract infection
- Viscus rupture
- Wound dehiscence
- Delayed closure of site after GT removal
- Stomal herniation
- Patient feeding
- Abdominal distention
- Aspiration pneumonia
- Delayed gastric emptying
- Delayed feeding
- Electrolyte imbalance
- Problems with feeding/medication administration
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?
- Disease: Gastrostomy Tubes | Nutritional Support
- Specialty: Gastroenterology | Surgery
- Age: Toddler
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.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa