Management of Patients with Gastrostomy Tubes (G-tubes)
Home enteral nutrition (HEN) via gastrostomy tube should be initiated only when the patient is medically stable, correct tube placement is verified, tolerance to enteral prescription is demonstrated, and the patient/caregiver has appropriate knowledge and skills to manage the tube. 1
Initial Setup and Discharge Planning
Patient Selection and Timing
- Gastrostomy feeding should be considered when patients are likely to require enteral tube feeding for more than 4-6 weeks 1
- Adults with uncomplicated gastrostomy tube placement can commence enteral nutrition within 2-4 hours after the procedure 1
- Before discharge, patients must be established on a stable feeding regimen with demonstrated ability to tolerate the volume and type of feed 1
Training Requirements
- Patients and caregivers must demonstrate competency in:
Routine G-tube Care and Maintenance
Daily Care
- Ensure proper positioning of the tube and patient (at least 30° elevation during and after feeding) 2
- Flush with 30-40 mL water before and after each feeding and medication administration 2
- Monitor for signs of infection (erythema, purulent/malodorous exudate, fever, pain) 1
- Check that external bolster is not too tight, causing pressure between internal and external bolster 1
Weekly Maintenance
- Loosen and rotate the gastrostomy tube to prevent mucosal overgrowth and reduce peristomal infections 1, 2
- Inspect the stoma site for signs of infection or skin breakdown 1
Medication Administration
- Use liquid medications when possible to reduce clogging risk 2
- Administer drugs separately from feeds with flushing before and after 1
- Avoid hyperosmolar drugs, potassium supplements, iron supplements, and sucralfate as they are more likely to cause clogs 2
Managing Common Complications
Tube Obstruction
- Prevention: Regular flushing with water (30-40 mL) before and after feeds/medications 2, 3
- Management of clogs:
- Try warm water irrigation first
- If unsuccessful, pancreatic enzyme solution can help dissolve clogs
- Mechanical devices (tube decloggers, Fogarty balloon catheters) may be used with healthcare professional assistance
- Never force flush a clogged tube as this can cause rupture or displacement 2
Site Infection
- For suspected infection, apply antimicrobial agent topically to the entry site and surrounding tissue 1
- Options include silver, iodine, or polyhexamethylene biguanide dressings (available as foams, hydrocolloids, or alginates)
- Note: Silver dressings cannot be used during MRI procedures
- If infection persists, systemic broad-spectrum antibiotics may be needed 1
- If infection still cannot be resolved, tube removal/replacement may be necessary 1
Aspiration Risk
- Position patient at minimum 30° elevation during and for 30 minutes after feeding 1, 2
- Avoid continuous overnight feeding in high-risk patients 1
- For patients with questionable gastrointestinal motility, aspirate stomach every four hours; if aspirates exceed 200 mL, review feeding policy 1
Nutritional Management
Feed Administration
- Gastric feeding (vs. small intestine) permits hypertonic feeds, higher feeding rates, and bolus feeding 1
- Starter regimens with reduced volumes are unnecessary in patients who have had reasonable nutrition in the previous week 1
- If no specialized advice is available, 30 mL/kg/day of standard 1 kcal/mL feed is often appropriate but may be excessive in undernourished or metabolically unstable patients 1
Monitoring Requirements
- Monitor fluid status, electrolytes (glucose, sodium, potassium, magnesium, calcium, phosphate) closely in the first few days after starting enteral feeding 1
- Be vigilant for refeeding syndrome, particularly in malnourished patients 1
- Regular weight monitoring and nutritional assessment to ensure adequacy of feeding regimen 3
Long-term Tube Management
- Most transorally placed bumper-type tubes can be maintained for many years with proper care 1
- There is no need to exchange tube systems at regular intervals 1
- Replacement will eventually be required due to breakage, occlusion, dislodgement, or degradation 1
- A percutaneous enteral access device showing signs of fungal colonization with material deterioration should be replaced in a non-urgent but timely manner 1
Special Considerations
- For patients with dysphagia, formal swallowing assessment must be completed before any oral intake 2
- When patients are discharged to the community on continuing enteral tube feeding, ensure all community carers are fully informed and continuing prescription of feed and relevant equipment is in place 1
By following these guidelines, healthcare providers can help ensure safe and effective management of patients with gastrostomy tubes, minimizing complications and optimizing nutritional outcomes.