Gastrostomy Tubes
INDEX
What is a Gastrostomy?
Why does my child need a
gastrostomy?
What kinds of G-tubes are there?
Which type of tube will my
child have?
What happens after surgery?
Gastrostomy Buttons
Feeding with a gastrostomy
tube
Care of a
Gastrostomy tube
Troubleshooting
A
gastrostomy is a surgically created opening directly into the stomach that
enables us to feed a child or easily remove air and fluids from the stomach.
This section
will answer your questions about why your child needs a gastrostomy, how to take
care of the gastrostomy, how to feed your child through the gastrostomy, and how
to manage some common problems with g-tubes and skin care.
Your child’s doctor will discuss
the reasons for creating a gastrostomy for your child and the surgical
procedure. Your child’s nurses will show you how to care for and feed your
child with the g-tube. There are videos and practice devices to help you
learn.
WHAT IS A
GASTROSTOMY?
A
gastrostomy is an opening through the skin on the abdomen that connects
directly into the stomach. There are two ways of making this opening. One is
called a “Stamm gastrostomy” or open gastrostomy. This means an incision or cut
is made in the skin and the abdominal wall (layer of muscle and soft tissue
that covers the stomach). This is in the middle of your child’s abdomen from
just below their ribs to just above the belly-button (umbilicus). The doctor
brings the stomach up next to the abdominal wall on the inside, and stitches it
to the wall. Then an opening is made into the stomach and the tube secured.
The tube is brought through the skin on the left side of your child’s abdomen
just below the rib cage. This tube is called a Malecot tube. The
incision is then closed with stitches just like any other incision.
The
second way of creating a gastrostomy uses an instrument called an endoscope.
This is
a long, slender tube with a light on the end that goes through the mouth, down
the esophagus or swallowing tube and into the stomach. The doctor can look
through the tube and see the inside of the stomach. A hollow needle is pushed
through the skin and abdominal wall and into the stomach. A wire is threaded
through the needle and when the doctor sees it enter the stomach, he or she
grabs it with a tool on the end of the endoscope and pulls it up the esophagus
and out through the mouth. A soft, silicone tube is then attached to the wire
and pulled down into the stomach and out through the opening in the abdominal
wall. There is a dome-like device on the end of the tube that prevents pulling
it out of the stomach.
A small
bolster is attached to the part of the tube next to the skin to hold it in
place. This type of tube is called a PEG TUBE, which stands for
Percutaneous Endoscopic Gastrostomy
A gastrostomy
is created for several reasons:
1.
A child cannot eat or drink by mouth. This may be because part of the
mouth, throat, or esophagus (tube that connects the mouth and stomach) did not
develop correctly. Other children cannot coordinate sucking, swallowing, and
breathing very well. (It’s harder than it looks!) Sometimes liquids and solids
get into the lungs instead of the stomach when these children swallow. That is
called aspiration. That is a very bad thing. These children cannot eat
by mouth until the swallowing mechanism gets better!
2.
A child cannot take in enough food or liquids by mouth to grow and
prevent dehydration. This can happen when a child has to use lots of
energy to breathe such as with cystic fibrosis, some heart defects, other lung
diseases and some metabolism problems. This can also be the case when a child
does not like things in their mouth or is very sensitive to different textures
of foods. This is called oral defensiveness. These children may eat or
drink small amounts but not enough to gain weight.
It is always
our hope that a gastrostomy is a temporary means of helping your child. When
your child is able to take in enough solids and liquids by mouth to grow
appropriately, the tube in the gastrostomy is removed and the opening closes
leaving a very small scar like a dimple on the abdominal wall. In some cases,
surgery is necessary to close the site. Each child is different, so predicting
how long they will need a g-tube is almost impossible. After your child has a
gastrostomy, your child’s pediatrician or family doctor will check their weight
frequently to be sure they are getting appropriate nutrition and determine when
they no longer need to be fed through the gastrostomy.
There are five
different types of devices that can be placed in a gastrostomy.The type of
device and when it can be placed will depend on how the doctor makes the
gastrostomy in the beginning.
A
gastrostomy made using the “Stamm” or “open”
procedure
will
usually 
have
a light
brown tube called a Malecot
in place
after surgery. This is a hollow catheter that has a mushroom-like tip that is
in the
stomach. Some thread or “suture” material is wrapped around the tube and then
stitched to the skin around the gastrostomy to keep it in place. This tube is
left in place for about two to four weeks. It is then replaced by another
device.
If
the Malecot tube is accidentally removed before two weeks, a Foley catheter is
placed at that time.
A Foley
catheter has a balloon on the end that is placed in the stomach.
The
balloon is
filled with water after the tube is in the stomach to keep the tube
in pla
ce.
A nipple or
crossbar
is used
on the outside to stabilize the tube.
This prevents
pulling the tube to one side and stretching the opening. It also prevents the
balloon from moving too far into the stomach and blocking the exit (pylorus).
A
gastrostomy created using the PEG technique will usually have a clear silicone
tube with a small rectangular bolster over it next to the skin. The area around
the tube, where it comes out of the skin, may be slightly red and there may be a
small amount of drainage around the tube for a few days.
In
a few cases, a low profile(flat) device usually called a gastrostomy
button can be placed using the PEG technique. Your doctor will discuss this
with you if it is a good option for your child. See the section on “Gastrostomy
Buttons” for a description of these devices and their use.
The type of
tube and method of placing it that your child’s doctor may recommend usually
depends on whether or not other things need to be done in the same surgery, and
your child’s anatomy ( body shape and structure). Many children who have
problems with feeding also have gastroesophageal reflux (GER).
This means
stomach contents come back up into the esophagus and sometimes the mouth, after
they have been swallowed. Reflux or GER, occurs when the lower esophageal
sphincter (area of higher pressure) where the esophagus connects to the
stomach does not close tightly after your child swallows, letting some things
come back up into the esophagus. This is a problem for several reasons.
1.
When swallowed food reaches the stomach, it mixes with the acid in the
stomach that is necessary for digesting (breaking down) food. The lining of the
stomach is specially equipped so it is not damaged by the acid. The lining of
the esophagus is not so equipped, so when the contents of the stomach with the
acid come back up into the esophagus, the acid burns the lining of the
esophagus. We commonly call this “heartburn.” It is not only very
uncomfortable, it can, over a long time, cause very sore areas in the esophagus
and eventually narrowed areas called strictures.
2.
If the stomach contents come up high enough in the esophagus, they can
reach the opening of the trachea, a tube that goes to the lungs. If stomach
contents get into the trachea and lungs, they are very irritating to the lung
tissue, causing coughing, flare-ups of asthma or reactive airway disease and in
some cases, pneumonia.
3.
When stomach contents come all the way back to the mouth, your baby will
“spit up”. It is possible for your child to have lots of reflux without
spitting up, but when they do, it is unpleasant for you and your child, it may
cause weight loss and creates a big laundry problem!
Before your
child’s surgeon makes a gastrostomy, he or she will want to see if your child
has reflux. Some tests may be done to see how much reflux your child has. These
may include an upper GI barium x-ray, a scintiscan, and a 24
hour pH probe. See Upper GI and scintiscan information..
If reflux
occurs often enough to cause your child not to eat or gain weight, of if your
child has pneumonias or reactive airway disease that is getting worse, your
child’s doctor may recommend a surgery to treat the reflux called a Nissen
Fundoplication. A part of the stomach is used to make the pressure
zone in the esophagus stronger and prevent reflux. An incision in the middle of
your child’s abdomen is made from just below their ribs to just above the belly
button (umbilicus). Since an incision is being made anyway, an open or Stamm
gastrostomy is done in this case.
In some cases,
it is possible to do the Nissen Fundoplication using a laparoscope. It is not
necessary to make the incision in the middle of the abdomen when a laparoscope
is used. This generally makes recovery from surgery easier. If your child also
needs a g-tube, this will be done with the PEG technique. Your child’s doctor
will discuss which procedure will be best for your child.
If your child
has no evidence of reflux, a PEG tube can be done. This does not require an
incision and your child will recover more quickly. Occasionally, the way your
child’s ribs and internal organs are placed makes this difficult and an open
gastrostomy is still necessary even without reflux.
If your child has a Malecot tube,
there will be stitches keeping the tube and crossbar if used, in place. A gauze
dressing is wrapped around the tube sometimes to keep it from moving around or
pulling on the sides of the opening. Pulling the tube to one side or another
tends to stretch the opening and make it bigger. This allows stomach fluids to
leak out onto the skin. If there is no crossbar holding the tube in place, a
nipple will be used when the dressing is removed, to hold the tube in place and
prevent pulling to one side or accidental removal.
The g-tube is
usually placed to “gravity drainage” which lets the secretions from the stomach
drain out through the tube. The GI Tract (stomach and intestines) tends
to work very slowly for a short time after surgery. We drain secretions out
until the stomach and intestines start to work and move the secretions through
normally. When this happens, we will begin to feed your child. We will know
your child’s GI tract is working when the amount of drainage is very small and
your child has a bowel movement or passes gas.
After we begin
feedings, the tube will usually be placed “up to burp” between feedings. This
means a syringe is placed on the end of the tube and it is hung up in the air
over the baby’s stomach to let any air that is in the stomach escape. As your
child’s GI tract starts to work better, we will gradually decrease the amount of
time the tube is left “up to burp” as long as they are not gagging with feedings
or needing to burp.
The average
hospital stay for a child that has a Nissen fundoplication done along with an
open gastrostomy is usually 3 to 5 days.
If your child
has had a PEG tube placed, the tube may be placed to gravity drainage for a
short period. It will then be placed “up to burp” until they are doing ok with
feedings and then the time the tube is up to burp will gradually be decreased
until you are able to feed your child and then cap the tube off completely
between feedings.
The average
hospital stay for a child having a PEG tube placed is 2 days.
After the
gastrostomy has had some time to heal, we may be able to change either type of
tube to a low-profile (flat) device called a gastrostomy button. If your
child had a Stamm gastrostomy, this can usually be done two to four weeks after
surgery. If your child had a PEG tube placed, this needs to remain in place for
8-12 weeks before it is changed. The additional time is required because the
stomach is not stitched to the abdominal wall when a PEG tube is placed.
Changing the tube too soon may allow the stomach to fall away from the abdominal
wall causing stomach contents to spill into the abdominal cavity. This is a
very serious problem that requires immediate surgery to correct.
There
are two kinds of buttons or low-profile devices. There are many
manufacturers that make each kind. We use buttons manufactured by the BARD
company and Medical Innovations Corp. (MIC) but the same type of button can be
obtained from other vendors.
The biggest
difference between the buttons is the internal (inside the stomach) part of the
button. The Bard button has a dome-like shape on the inside. The MIC button
has a balloon that is inflated with water after it is placed in the stomach.
Either button can be placed in the clinic when you return for an out-patient
visit with the doctor that placed the original tube. Placement does not require
returning to surgery. A local anesthetic is used to decrease discomfort which
is very short-lived.
Both types of
buttons have feeding tubes that connect to the button when you feed your child
and are removed when the feeding is done. The MIC button has a locking
mechanism that prevents accidentally removing the feeding tube during a
feeding.. The Bard button feeding tube fits securely but does not lock in
place.
Both
buttons have a valve on the inside that keeps stomach contents from coming out
through the button even when it is open. The valve on the Bard button will
eventually wear out and let stomach contents escape through the button when the
outside tab is open. The button needs to be replaced when this happens. The
Bard button should only be replaced by a physician or nurse trained in this
process. When drainage occurs from the center opening on the button you should
call your doctor’s office to arrange to have the button changed.
A Bard button
will generally need to be changed every 6-12 months but may last 3-4 years.
The valve on
the MIC button works slightly differently but generally does not wear out. The
balloon on the MIC button will eventually spring a leak or burst and then the
button needs to be changed. This can be done at home if you are comfortable
doing this. Because the balloon can be deflated, the button is easy to remove
and replace with a new one. The staff will show you how to do this if your
child has a MIC button. MIC buttons generally need to be replaced every 4-6
months.
After your child has had a g-tube
placed and the GI tract is working again, you may begin to feed your child. If
your child does not aspirate when they swallow, you may still give food and
liquids by mouth. The type and amount of formula your child will need to
receive through the tube will depend on his/her weight, age and amount they are
able to take by mouth. One of our dieticians will assist you in deciding what
type of formula and how much to give your child.
We try to give
each child bolus feedings because that is most like the way the rest of
the family eats. This means we give enough formula over a short period for your
child to feel full and satisfied for several hours. The amount will depend on
your child’s age but is usually 4-8 ounces over a 20 minute period.
A bolus
feeding is given by attaching a feeding tube to the button, if your child has
one. Then a catheter tip syringe is placed in the end of the tube and
1-2 ounces of formula is poured into the syringe and allowed to slowly run into
your child’s stomach. As the formula infuses, more is added to the syringe
until the full feeding is given. One ounce of water is then poured into the
syringe to flush all the formula from the tubing. It may be necessary to use
the plunger on the syringe to push the last bit of water from the tubing if you
are using a gastrostomy button. The tubing is then disconnected if your child
has a button. If your child has any kind of tube, the end is closed or plugged
until the next feeding.
Some children
do not tolerate bolus feedings. There are many different possible reasons for
this, but some children have long episodes of gagging and or vomiting whenever
more than 1-2 ounces of formula are in the stomach. If your child can only
tolerate very small, slow feedings, it is often better to use a pump to give
your child a very slow, continuous feeding. This enables your child to take in
the amount of fluids and calories they need and frees you from spending all day
and night trying to feed your child. Often, children who need pump feedings
will get most of their formula at night while they sleep so they can be
disconnected from the pump during the day to play and do normal childhood
activities. Your child’s doctor and dietician will help you work out a feeding
schedule that works for you and your child.
Feedings pumps
use a bag to hold the formula with tubing that runs through the pump and then
connects to your child’s g-tube or button. You are able to set the exact speed
to infuse the formula and the total amount to give. There are portable pumps to
use when you are away from home which are in a backpack for easy carrying.
The buttons and tubes really require very little special
care. If your child has a PEG tube, a button or a foley catheter in place, you
should wash around it with a mild soap (whatever you bathe the baby with) and
water. Keep the skin around the tube as clean and dry as possible. It is not
necessary to keep gauze dressings or other coverings over the buttons or tubes.
While your
child has a Malecot tube in, you should be sure the stitches and crossbar are
moved as little as possible. If a small scab forms on the skin where the tube
comes out of the stomach, do not scrub it off. Let it dry and fall off.
After the
Malecot is replaced or one week after a PEG tube is placed, you may begin to
give your child baths in the tub. They may also swim in a chlorinated pool. It
is possible that small amounts of bath or pool water may seep into the stomach
around the tube. Almost everyone has swallowed bath or pool water at some time
in their childhood with no problems.
The buttons
should sit flat against the skin and turn easily. As your child grows, the
abdominal wall may get thicker and it may be necessary to use a longer button.
Signs that the button is too tight include the tabs on the Bard button curling
up, the edges of the MIC digging into the skin, red marks on the skin where the
button has been that do not go away when the button is turned, or the button
feeling tight when you turn it.
If your child
has a MIC-KEY button, we will show you how to check the water in the balloon.
No other special care is necessary.
If there is
drainage around your child’s tube or button:
If your child
has a malecot tube, small amounts of drainage are common. Be sure the tube is
secured with the crossbar or nipple and not pulled to one side.
If your child
has a foley catheter or PEG tube, check to see if the balloon or dome on the end
of the tube inside the stomach is next to the stomach wall by gently
pulling on the tube until you feel resistance. The bolster or nipple should
rest lightly on the skin on the outside with the tube in this position.
If your child
has a MICKEY button, check to be sure there is 5cc of water in the balloon. If
you get no water out of the balloon, remove the button and check to see if the
balloon has burst or is leaking. Change the button if the balloon is not
holding water.
If your child
has either button, check to be sure the fit is correct. If the button is too
long and sticks out from the skin or can be pulled out away from the skin, the
balloon or dome on the inside is not sealing the inside of the opening well.
Call one of the G-tube nurses to see if a different size button would work
better.
If the button
seems very tight, sinks into the surrounding skin and does not turn easily, it
may be too short. Call one of the G-tube nurses for help.
If you see
bright red or pink tissue growing around the gastrostomy, there is often thick,
yellow drainage too. See below.
Whenever there
is drainage around your child’s tube or button, the most important thing is to
protect the skin. If the drainage contains stomach juices, it is very acidic
and very irritating to skin. Even if there are not stomach juices in the
drainage, the constant moisture on the skin can be irritating. Use some sort of
barrier cream on the skin around the tube or button. Desitin, zinc oxide,
Sensicare or similar creams work best. Antibiotic creams such as Neosporin or
Bacitracin wash off very easily and do not protect the skin well. You may use
a small gauze pad on top of the cream to absorb drainage and protect clothing.
If there is
bright red tissue growing up around the tube:
Granulation tissue is made by everyone to heal wounds. When
there is a foreign object, such as a g-tube, in our body we make granulation
tissue to try and heal the area and get rid of the invader! Because the tube
does not go away, often the body keeps making extra tissue which grows up the
tract or tunnel we have made into the stomach and eventually pops out around the
tube on the outside. This tissue is red or deep pink, shiny, and bleeds very
easily. There is also a thick, yellow drainage that comes from this tissue. It
is not a sign of infection, but a natural byproduct of this kind of tissue.
Granulation
tissue is best treated by using a medicine called silver nitrate. This should
be applied by a doctor or nurse the first time. You will be shown how to do
this if more than one application is necessary.
Some children
make lots of granulation tissue. In those cases, it may be helpful to use a
cream called Triamcinolone to prevent granulation tissue from growing.
Granulation
tissue may cause lots of drainage around the tube. It is very important to
protect your child’s skin from the irritation that this drainage may cause. Use
a heavy barrier cream such as Desitin, zinc oxide or Sensicare. You may use a
small gauze pad over this to protect clothing.
If the skin
around the tube is red:
The most common cause of a red,
rash-like appearance on the skin around the tube or button is from irritation
caused by moisture or drainage. Use a barrier cream such as Desitin or zinc
oxide.
If your child
complains of itching around the tube and there is a raised, bright red rash
around the tube, this may be caused by a yeast infection. Lotrimin (chlortrimazole)
or Nystatin cream will usually treat this. Call your doctor or one of the
G-tube nurses before starting to use one of these medicines.
Very rarely,
children develop an infection in the tissue just underneath the skin around a
tube. This is called cellulitis. There is no drainage associated with this but
the skin has a red “sunburned” appearance and feels hot to touch. Children
usually complain of much discomfort when this area is touched. This infection
should be treated with an antibiotic. Contact your child’s doctor or one of the
G-tube nurses if you are concerned about this.
If your child
vomits or gags with feedings:
Cyndi Bishop, R.N.
Anita Shelley, E.T.
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