Feeding Tube Complications

Author:

Colleen N.Hickey

Description

Extubation:
- Accidental or intentional
- More common with nasoenteric tubes compared with percutaneous endoscopic gastrostomy (PEG) tubes, gastrostomy tubes (G tubes), or jejunostomy tubes (J tubes)
Occlusion:
- Small diameter:
  - Most common with nasoenteric tubes
- Pill fragments
- Inadequate flushing
- Physical incompatibilities between formula and medications:
  - Adherence of formula residue to inner wall
- Essential to rule out malposition, fracture, kinking, and dislodgment
Peristomal wound infections:
- Risk factors:
  - Malnutrition
  - Stomal leak
  - Local irritation
  - Poor wound care
  - Immunosuppression
  - Diabetes mellitus
  - Poor wound healing
  - Obesity
  - Malignancy
- Excessive traction on tube:
  - Leads to delayed maturation of gastrocutaneous tract
  - Increases stoma leakage
Stoma leak:
- Problematic with distal obstruction (mechanical or dysmotility); more common with high gastric residual
- Excessive tube motion
- More likely to occur in malnourished and diabetic patients
Aspiration pneumonia:
- At risk:
  - Impaired cough/gag reflex
  - Delayed gastric emptying from ileus
  - Obstruction
  - Gastroparesis
  - Gastroesophageal reflux (frequent with large nasoenteric tube)
Diarrhea:
- Medication induced:
  - Antibiotics
  - Promotility agents
- Overgrowth of Clostridium difficile, other bacteria, or Cand ida
- High osmolar formula
- Hypoalbuminemia
Feeding intolerance:
- High residual suggests GI motility dysfunction
- Delivery is too rapid
- High osmolarity formula
- Lactose or fat intolerance
- Low-serum albumin
Uncommon complications:
- Abdominal wall hematoma
- Fistulas:
  - Hepatogastric
  - Gastrocolic
  - Colocutaneous
- Perforation (usually at time of placement)
- Injury to abdominal organs
- Pressure sores/ulcerations
- GI bleeding:
  - Esophagitis/gastritis, gastric pressure ulcers, concomitant PUD
- Gastric outlet obstruction:
  - Partial or complete obstruction at the pylorus or duodenum by part of tube or Foley catheter balloon used for temporary replacement
- Buried bumper syndrome
  - Rare but potentially serious
  - Bumper becomes lodged between the gastric wall and skin due to gastric ulceration from excessive tension
  - Usually a late complication
- Bowel volvulus around PEG tube

Pediatric Considerations
Increased risk of aspiration: Delayed gastric emptying Immaturity of lower esophageal sphincter

Diagnosis ⬆ ⬇

[Section Outline]

Signs and Symptoms
Essential Workup
Diagnostic Tests & Interpretation

Signs and Symptoms

Extubation:
- Tube removed from source
Occlusion:
- Unable to pass liquid through tube
Tube migration:
- Distal displacement of PEG tube
- Obstruction at or distal to pylorus
- Dumping syndrome
- Ischemia
- Intussusception
- Evidence of distal prolapse on external tube (if marked)
Peristomal wound infections:
- Cellulitis
- Abscess formation
- Necrotizing fasciitis
Stoma leak:
- Leakage of feedings/GI tract contents around stoma
Aspiration pneumonia:
- Cough
- Dyspnea
- Hypoxia
- Food particulate in pulmonary secretions
- Fever
Misplacement of nasoenteric tube in pulmonary tree:
- Pneumothorax
- Hydrothorax
- Pleural effusion
- Bronchopleural fistula
- Pneumonia
- Pulmonary abscess
Diarrhea:
- Frequent loose stools
- Dehydration
Intolerance to enteral nutrition:
- High residuals
- Associated with increased risk of aspiration

Essential Workup

Carefully examine the tube site and position of feeding tube within wound
For suspected tube migration, obtain a water-soluble contrast radiography of the tube to establish the tube position within the abdomen/stomach/intestine

Diagnostic Tests & Interpretation

Lab

Peristomal wound infections:
- CBC for significant infections
- Blood culture if systemically ill
Aspiration pneumonia:
- Pulse oximetry or arterial blood gas
- CBC
- Electrolytes, BUN/creatinine, glucose
- Blood and sputum culture
Diarrhea:
- Stool for white blood cells/culture/C. difficile toxin
- Electrolytes, BUN/creatinine
GI bleeding
- Serial CBC
- Coagulation studies

Imaging

CXR:
- Nasoenteric tube position
- Aspiration pneumonia
Water-soluble contrast radiography for suspected tube migration

Diagnostic Procedures/Surgery

Endoscopy to evaluate for tube migration

Treatment ⬆ ⬇

[Section Outline]

Prehospital
Initial Stabilization/Therapy
ED Treatment/Procedures
Medication

Prehospital

ALERT
If extubation of tube has occurred, transport tube with patient to facilitate easier replacement

Initial Stabilization/Therapy

ABCs
IV fluid resuscitation for dehydration/sepsis

ED Treatment/Procedures

Extubation

Nasoenteric tube:
- Replace in ED
- Confirm position by radiograph before use
PEG tube and gastrojejunal (G-J) tube:
- Takes 4-6 wk for gastrocutaneous tract/fistula to mature
- Improper or aggressive attempt at tube replacement could lead to disruption of gastrocutaneous tract and subsequent peritonitis
- PEG tube in place >4 wk:
  - Replace in ED (may use a Foley catheter of equivalent size)
  - Confirm by water-soluble radiographic study
  - Secure catheter to abdominal wall to prevent distal migration
- PEG tube in place <4 wk:
  - Do not replace in ED
  - Risk of intraperitoneal placement
  - May need hospital admission and endoscopic tube replacement
- Surgical G tube or J tube:
  - Management similar to that for PEG tube
  - Early dislodgment within first 3 d requires emergency surgical consult and antibiotic coverage for peritonitis
  - May need endoscopic replacement if <4 wk old

Occlusion

Attempt gentle irrigation with NS, water, carbonated soda, pancreatic enzymes
If irrigation fails, replace tube
Do not use meat tenderizer

Tube Migration

If retraction of tube is possible and well tolerated:
- Secure tube externally
- Discharge home after brief trial of tube feeding
If feeding is not tolerated, or if there are signs of persistent obstruction or peritonitis:
- Admit with consult to appropriate service (surgical/GI/interventional radiology)
If external tube is cut (accidental or intentional) and the inner tube is within the abdomen:
- Inner bumper usually passes through GI tract (XR in 1 wk should be done for confirmation)
- Cases of obstruction, subsequent perforation, and peritonitis have been reported, especially in children

Peristomal Wound Infections

Local wound care
Antibiotics:
- First-generation cephalosporin (cefazolin or cephalexin)
- Ampicillin/sulbactam
- Amoxicillin/clavulanic acid
- Clindamycin (penicillin allergic)
Outpatient management for milder cases
More severe cases require surgical consult for possible drainage/debridement and inpatient care
Severe infections (peritonitis, necrotizing fasciitis) require tube removal
Prophylactic use of antibiotic before tube placement decreases wound infection (3% vs. 18%)

Peristomal Leak

Change from intermittent to continuous delivery
Decrease rate of infusion
Optimize nutritional status and glycemic control
Relieve excess tension on tube
Administer prokinetic agents (e.g., metoclopramide)
Do NOT place larger tube
Local care:
- Keep site clean and dry
- Zinc-containing barrier creams, skin protectants

Aspiration Pneumonia

Stop enteral feeding
Administer oxygen and broad-spectrum antibiotics
Endotracheal intubation with mechanical ventilation for respiratory failure and airway protection when indicated
Prevent by:
- Elevation of head of bed
- Monitoring gastric residual
- Use of continuous infusion at graduated rate
- Use of prokinetic agent

Diarrhea

Manage cause
Correct fluid and electrolyte imbalance
Try isotonic, hypotonic, or fat- or lactose-free formulas
High-fiber formula if above measures fail
Antimotility agents:
- Loperamide
- Kaopectate
- Cholestyramine

Formula Intolerance

Prokinetic agents promote gastric emptying

Medication

Amoxicillin/clavulanic acid (Augmentin): 500-875 mg (peds: 25-45 mg/kg/24 hr) PO q12h
Ampicillin/sulbactam: 1.5-3 g (peds: 100-200 mg/kg/24 hr) IV q6h
Cefazolin (Ancef, Kefzol): 500 mg-1 g (peds: 25-100 mg/kg/24 hr) IV q6h
Cephalexin (Keflex): 250-500 mg (peds: 25-50 mg/kg/24 hr) PO q6h
Cholestyramine: 2-4 g (peds: >6 yr 80 mg/kg q8h) PO q6-12h
Clindamycin: 150-300 mg (peds: 5-10 mg/kg) IV q6h
Kaopectate: 30 mL (peds: 3-6 yr old, 7.5 mL; 6-12 yr old, 15 mL) PO after each loose bowel movement up to 7 times per day
Loperamide (Imodium): 4 mg initially, then 2 mg (peds: 1 mg q8h if 13-20 kg; 2 mg q12h if 20-30 kg; 2 mg q8h, if >30 kg not to exceed 6 mg/d) PO up to 16 mg/d
Metoclopramide: 5-10 mg (peds: 0.1-0.2 mg/kg to max 0.8 mg/kg/d) PO/IV/IM q6h (30 min before feeds and every night)

Follow-Up ⬆ ⬇

[Section Outline]

Disposition
Follow-up Recommendations

Disposition

Admission Criteria

PEG tube extubation within 1 wk of placement
Surgical G tube or J tube extubation within 3 d of placement
Significant peristomal wound infection
Aspiration pneumonia
Diarrhea associated with dehydration
Active GI bleeding
Peritonitis

Discharge Criteria

Successful replacement of extubated feeding tube

Issues for Referral

GI, surgical, or IR consult for feeding tube replacement when cannot be placed successfully in the ED

Follow-up Recommendations

Primary care or GI follow-up for recurrent feeding tube complications

Pearls and Pitfalls ⬆ ⬇

Radiography should be used to confirm placement of all feeding tubes
Do not attempt replacement of a newly placed PEG tube, G tube, or J tube in the ED

Additional Reading ⬆ ⬇

BlumensteinI, ShastriYM, SteinJ. Gastroenteric tube feeding: Techniques, problems, and solutions . World J Gastroenterol. 2014;20(26):8505-8524.
Huclt, SpicakJ. Complications of percutaneous endoscopic gastrostomy . Best Pract Res Clin Gastroenterol. 2016;30(5):769-781.
Rahnemai-AzarAA, RahnemaiazarAA, NaghshizadianR, et al. Percutaneous endoscopic gastrostomy: Indications, technique, complications and management . World J Gastroenterol. 2014;20(24):7739-7751.
TintinalliJE, StapczynskiJS, MaOJ, et al., eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed.New York: McGraw-Hill; 2016.

The authors gratefully acknowledge Jennifer L. Kolodchak for his contribution to the previous edition of this chapter.

Codes ⬆

ICD9

536.40 Gastrostomy complication, unspecified
536.49 Other gastrostomy complications
996.79 Other complications due to other internal prosthetic device, implant, and graft
536.42 Mechanical complication of gastrostomy
536.41 Infection of gastrostomy
536.4 Gastrostomy complications

ICD10

K94.20 Gastrostomy complication, unspecified
T85.518A Breakdown (mechanical) of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
T85.528A Displacement of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
T85.598A Other mechanical complication of other gastrointestinal prosthetic devices, implants and grafts, initial encounter
K94.22 Gastrostomy infection
K94.23 Gastrostomy malfunction
K94.29 Other complications of gastrostomy

SNOMED

473177008 Obstruction of nasogastric tube (disorder)
443181001 Obstruction of percutaneous endoscopic gastrostomy tube (finding)
473160008 Migration of nasogastric tube (disorder)
426032000 Malfunction of gastrostomy tube (disorder)
407547003 Stoma seal leaking (finding)
442858008 Infection of gastrostomy site (disorder)

section name header

Basics ⬇

Pediatric Considerations

Diagnosis ⬆ ⬇

Lab

Imaging

Diagnostic Procedures/Surgery

Treatment ⬆ ⬇

ALERT

Extubation

Occlusion

Tube Migration

Peristomal Wound Infections

Peristomal Leak

Aspiration Pneumonia

Diarrhea

Formula Intolerance

Follow-Up ⬆ ⬇

Admission Criteria

Discharge Criteria

Issues for Referral

Pearls and Pitfalls ⬆ ⬇

Additional Reading ⬆ ⬇

Codes ⬆