What is the best approach to assess and manage a blocked PEGJ (Percutaneous Endoscopic Gastrostomy with Jejunal extension) tube?

Assessment and Management of a Blocked PEGJ Tube

For a blocked PEGJ tube, the first-line approach should be simple water flushing to regain patency, followed by use of a guidewire or commercially available tube declogger by an expert if water flushing fails. 1

Initial Assessment

• Evaluate for signs of tube obstruction: resistance when flushing, inability to administer feeds or medications, or feeding pump alarms indicating blockage 1
• Check for alarming signals that might indicate buried bumper syndrome (BBS), including difficulty mobilizing the tube, leakage around insertion site when flushing, frequent feeding pump alarms, abdominal pain, or chronic site infections 1
• Assess for other complications that may mimic blockage: tube dislodgement, kinking of the tube, or inner tube migration 2

Management Algorithm for Blocked PEGJ Tube

First-Line Approach

• Attempt to flush the tube with 40-60 ml of water (drinking or still mineral water) 1
• This simple water flushing is particularly important for small-caliber tubes like jejunostomies, which are more prone to clogging 1

Second-Line Approaches (if water flushing fails)

• Use of a guidewire or commercially available tube declogger by a healthcare professional with expertise in managing enteral tubes 1
• Note: Unlike with standard PEG tubes, PEGJ tubes should NOT be rotated (only pushed in and out weekly) as this could damage or displace the jejunal extension 1

Approaches to Avoid

• Infusion with cola-containing carbonated drinks is NOT recommended due to:
  • Sugar content enhancing risk of tube contamination with bacteria 1
  • Lack of evidence-based support for this practice 1
• 8.4% w/v sodium bicarbonate solution is sometimes suggested but is not evidence-based and should be used with caution 1

Prevention of PEGJ Tube Blockage

• Implement routine water flushing (approximately 40 ml) after each feeding and medication administration 1
• Ensure proper medication administration through the tube:
  • Use liquid formulations when available 1
  • Crush tablets to fine powder and dissolve completely before administration 1
  • Flush between different medications 1
• Regular tube maintenance is essential but differs from standard PEG care:
  • PEGJ tubes should NOT be rotated like standard PEG tubes 1
  • The tube should be pushed in and pulled out weekly (approximately 2-3 cm) 1
  • Maintain proper positioning with 0.5-1 cm free distance between skin and external bolster 1

Special Considerations for PEGJ Tubes

• PEGJ tubes have higher complication rates than standard PEG tubes, including higher risk of blockage, dislocation, and buried bumper syndrome 2, 3
• One study showed PEGJ tubes were significantly more likely to develop buried bumper syndrome (32%) compared to PEG tubes (0.9%) 3
• The median duration of a PEGJ before replacement is approximately 12 months 2
• If blockage persists despite interventions, tube replacement may be necessary 2

When to Seek Specialist Help

• If water flushing and basic interventions fail to clear the blockage 1
• If there are signs of buried bumper syndrome or other complications 1
• If the patient shows signs of aspiration, infection, or other adverse events 1
• If the tube has been in place for an extended period (approaching 12 months), as this increases risk of complications 2

Remember that proper training of patients/caregivers and continuity of care after hospital discharge are key factors for successful management of enteral feeding tubes, including prevention and management of blockages 1.