What is an EJ (Ewald) tube?

What is an EJ (Ewald) Tube?

An EJ (Ewald) tube is a type of orojejunal (OJ) tube that is inserted through the mouth into the jejunum for enteral feeding and/or gastrointestinal decompression when gastric feeding is not possible or contraindicated. 1

Types and Terminology

EJ tubes fall within the broader category of enteral access devices that can be classified based on:

1. Entry point:

   • Natural orifice access: Through mouth (orojejunal/OJ) or nose (nasojejunal/NJ)
   • Artificial access: Through abdominal wall (percutaneous)

2. Placement method:

   • Blind placement: Without visualization
   • Endoscopic guidance: Using endoscopy for visualization
   • Image guidance: Using fluoroscopy, ultrasound, or other imaging

Placement Techniques

EJ tubes can be placed using several techniques:

• Blind placement: Traditional method but has lower success rates
• Endoscopic guidance:
  • Drag-and-pull method: A suture is attached to the tube end and pulled into position using grasping forceps 1
  • Over-the-wire technique: Guide wire is placed into the jejunum first, then the tube is passed over it (94% success rate) 1
• Assisted placement devices:
  • Bedside magnet (95% success rate in small studies)
  • Electromagnetic transmitter with bedside monitor
  • Gastric electromyography using EKG leads 1

Clinical Applications

Indications

• Enteral nutrition when gastric feeding is contraindicated:

  • Severe gastroesophageal reflux with aspiration risk
  • Gastroparesis or gastric outlet obstruction
  • Post-bariatric surgery requiring enteral access 2
  • Pancreatitis (multiple studies show improved outcomes compared to parenteral nutrition) 1

• GI decompression:

  • Small bowel obstruction
  • GI fistula
  • Concurrent feeding and decompression 1

Advantages of Jejunal Feeding

• Decreased length of hospital stay
• Reduced infectious complications
• Lower overall healthcare costs compared to parenteral nutrition 1

Comparison with Other Jejunal Access Methods

EJ vs. PEJ (Percutaneous Endoscopic Jejunostomy)

• PEJ: Direct primary access to jejunum through abdominal wall
• Advantages of PEJ over EJ:
  • Longer tube patency
  • Lower rate of tube dysfunction (19% vs 36% requiring intervention)
  • Better for long-term jejunal feeding (>4 weeks) 2

EJ vs. PEG-J (PEG with Jejunal Extension)

• PEG-J: Jejunal extension tube placed through an existing gastrostomy
• When to use PEG-J:
  • Patient already has PEG in place
  • Temporary jejunal access needed
  • Direct PEJ placement technically difficult 2

Practical Considerations

• EJ tubes require more frequent replacement than percutaneous options
• Tube dysfunction is common with orojejunal tubes
• For long-term jejunal feeding needs, direct PEJ is preferred over EJ tubes due to lower reintervention rates 2
• Modern techniques using ultra-thin endoscopes and steel guidewires have improved placement success rates 3

Complications and Limitations

• Inadvertent displacement back into stomach (common with drag-and-pull method) 1
• Tube clogging (reported in 4% of cases) 4
• Inadvertent removal (reported in 16% of cases) 4
• Limited evidence supporting bedside placement devices 1

For patients requiring long-term jejunal feeding, transitioning from an EJ tube to a more permanent solution like PEJ should be considered to reduce complications and reinterventions.