What are the common complications of Gastrostomy (G) and Gastrojejunostomy (GJ) tubes and how are they managed?

Common Complications of G and GJ Tubes and Their Management

The most common complications of gastrostomy (G) and gastrojejunostomy (GJ) tubes include peristomal infection, tube dislodgement, leakage around the tube, buried bumper syndrome, and mechanical tube failure, with management focusing on proper wound care, appropriate tube positioning, and prompt replacement when necessary. 1

Peristomal Infections

Presentation and Risk Factors

• Occurs in up to 30% of cases (most common complication of transoral gastrostomy placement)
• Most infections (>70%) are minor, with <1.6% requiring aggressive treatment 1
• Risk factors: diabetes, obesity, poor nutritional status, immunosuppressive therapy 1
• Signs: erythema, purulent/malodorous exudate, fever, pain 1

Management

1. Daily inspection and sterile dressing changes until granulation occurs (usually days 1-7) 1
2. Apply antimicrobial agent topically to entry site and surrounding tissue 1
3. For persistent infections:
   • Obtain swab for microbiological examination (bacterial and fungal) 1
   • Initiate oral broad-spectrum antibiotics for 5-7 days 1
   • For systemic signs, switch to IV antibiotics with local wound care 1
   • If infection persists despite treatment, remove/replace the tube 1
4. For peritonitis, surgical intervention may be required 1

Buried Bumper Syndrome

Presentation and Risk Factors

• Occurs in 0.3-2.4% of gastrostomy patients 1
• Presents with peritubal leakage/infection, immobile tube, abdominal pain, resistance with formula infusion 1
• Risk factors: excessive tension between internal/external bolsters, malnutrition, poor wound healing, weight gain 1

Prevention and Management

1. Prevention:

   • Allow approximately 1 cm of play between skin and external bolster 1
   • Push tube 2-3 cm ventrally and pull back during dressing changes 1
   • Weekly maintenance should include loosening and rotating the tube 2

2. Management:

   • Confirm diagnosis endoscopically or radiographically (perform contrast study with patient in prone position) 1
   • Remove buried gastrostomy tube with external traction and place new tube through existing tract or nearby site 1
   • For completely covered bumpers, electrosurgical incisions may be necessary for endoscopic removal 1

Tube Leakage

Causes and Management

1. Causes: gastric outlet obstruction, constipation, excessive cleansing of site 1
2. Management:
   • Address underlying cause (treat constipation, gastric outlet obstruction) 1
   • Apply stoma adhesive powder or zinc oxide to prevent skin irritation 1
   • Use foam dressing rather than gauze (lifts drainage away from skin) 1
   • Treat associated fungal infections with topical antifungal agents 1
   • For refractory cases: remove tube for several days to allow stoma approximation or place new gastrostomy at different site 1

Tube Dislodgement and Mechanical Failure

Incidence and Types

• Accidental removal occurs in 1.6-4.4% of cases 1
• GJ tubes have higher rates of obstruction, migration, dislodgement, and leakage than G tubes 3
• Mechanical failure includes clogging, cracking, deterioration 4

Management

1. For dislodged tubes:

   • Replace through existing tract if mature (typically >4 weeks old)
   • For immature tracts, urgent replacement is necessary to prevent tract closure
   • Balloon-type replacement tubes are commonly used for blind replacement 1

2. For mechanical failure:

   • Replace tube endoscopically, radiologically, surgically, or at bedside depending on tube type 1
   • For balloon-type tubes, check water volume weekly and replace every 3-4 months due to balloon degradation 1
   • Administer water flushes (30 mL) before/after feedings and medications to prevent clogs 2

Aspiration

Incidence and Risk Factors

• Procedure-related aspiration: 0.3-1.0% of cases 1
• Post-procedure aspiration more common (up to 15% in some studies) 1
• Risk factors: supine position, sedation, neurologic impairment 1

Prevention and Management

1. Prevention:

   • Maintain head elevation at minimum 30° during and for 30 minutes after feeding 2
   • Consider conversion to GJ tube for patients with recurrent aspiration 1
   • Schedule nebulizer treatments away from feeding times 2

2. Management:

   • For aspiration pneumonia, follow American Thoracic Society and European Respiratory Society guidelines 2
   • Monitor for signs of hypoxia and hypotension 1

Special Considerations for GJ Tubes

1. Higher complication rates than G tubes:

   • More frequent tube replacements required (mean 2.2 replacements per patient) 5
   • Higher perforation risk, especially in patients <10kg (3.1% vs 0.1% in ≥10kg patients) 6

2. Common complications specific to GJ tubes:

   • Tube displacement (most common reason for replacement) 5
   • Clogged tubes 5
   • Cracked tubes or ruptured balloons 5
   • Bowel perforation (most occurring within 30 days of placement) 6

3. Management approach:

   • Regular monitoring and maintenance
   • Consider alternative long-term enteral access for children requiring >1 month of feeding 5
   • Exercise caution in patients <10kg due to increased perforation risk 6

Rare but Serious Complications

1. Fistulous tracts (gastrocolocutaneous fistulas):

   • May present with stool leaking around tube or formula-like diarrhea 1
   • Management: usually removal of tube and allowing fistula to close; surgery rarely required 1

2. Gastric ulcer/hemorrhage (0.3-1.2% of cases):

   • Caused by peptic ulcer disease, traumatic erosion, or ulceration beneath internal bolster 1
   • Prevention: avoid excessive lateral traction and tension between bolsters 1

3. Fungal tube infection:

   • Can cause tube degradation and failure (up to 70% by 450 days) 1
   • Consider polyurethane tubes which may be more resistant than silicone 1

Proper tube care, positioning, and regular maintenance are essential for preventing complications and ensuring successful enteral nutrition delivery through G and GJ tubes.