In this section
Balloon tubes (long and short) can usually be replaced by trained staff or parents with experience in this area. In the Emergency department, this should only be attempted by senior medical staff (Fellow or Consultant).
Non-balloon, low profile tubes are normally replaced under anaesthetic using endoscopy to confirm position. This type of device should NOT be replaced acutely. However, as with the removal of any gastrostomy device, some form of replacement tube needs to be reinserted within 4 hours.
In general, the original tube should be replaced. If there is damage to the tract or if the tract is now too tight, a different tube or Foley catheter should be used.
Care must be taken with the length of the tube reinserted. The skin flange should be tightened to keep the tube snug, but not so tight as to cause pressure necrosis.
During Hours: Contact the Gastrostomy Service Nurse Coordinator.
After hours: The Nursing Supervisor can access the stores cupboard in the Gastroenterology Department on the 9th floor. If a gastrostomy tube is obtained after hours, the Gastrostomy Service Nurse Coordinator must be informed the following day so stocks may be replenished.
All balloon gastrostomy devices have two lumens on the skin side of the tube. One is for gastric access for feeds and the other is for inflation of the balloon. Check that the balloon inflates easily and does not leak before inserting the new tube.
Reinsertion of a gastrostomy tube can be painful. Analgesia should be considered prior to commencing any procedure. Appropriate analgesics include parenteral opioid and rectal paracetamol. Topical application of viscous lignocaine to the gastrostomy site is another option. Consider also sedation eg with nitrous oxide, which can assist with the process of reinsertion.
The device and skin around the gastrostomy tract need to be clean but not sterile.
With the balloon deflated, apply a little water-based lubricant to the balloon part of the tube. Insert the lubricated tube into the tract smoothly. It should be a snug fit and a little twist sometimes helps. Excessive resistance should not be encountered. If it is, then insertion may be at the wrong angle. It is possible to make a false passage or insert into the peritoneal cavity.
Inflate the balloon with water:
If using a Foley catheter, insert approximately 5 cm (can vary according to size of patient), inflate the balloon, then pull back until there is resistance.
Tube position should always be checked by attempting to aspirate gastric fluid and testing with litmus paper.
If firm resistance is encountered or several attempts are required to insert the tube, position should be checked with a dye study.
If there is any doubt about the placement of the tube, contact the on-call Gastroenterologist to discuss whether an x-ray or dye study is necessary
If tube placement is confirmed, feeding can restart immediately. However, if there is doubt about position and there is a delay in obtaining confirmatory imaging, patients may require intravenous fluids. The fluid status of patients MUST be assessed, and appropriate fluids given.
If the patient becomes unsettled whilst recommencing feeds, consider the following complications:
If either of these is suspected, cease feeds and contact the on-call Gastroenterologist.
For practical issues during working hours, the Gastrostomy Service Nurse Coordinator or the dedicated Stomal Therapist can be contacted via switchboard. At other times, contact the on-call Gastroenterology Consultant or general Surgery Registrar.