What is the differential diagnosis and management for a G-tube (gastrostomy tube) leak?

Differential Diagnosis for G-Tube Leak

The most common causes of G-tube leakage are excessive tension between internal and external bolsters, peristomal infection, enlarged gastrostomy tract from side torsion, buried bumper syndrome, excessive granulation tissue, and increased gastric acid secretion. 1

Primary Mechanical Causes

• Improper bolster tension: Excessive compression between internal and external fixation devices is the leading risk factor, causing tissue necrosis and tract enlargement 1
• Side torsion of the tube: Leads to ulceration and progressive enlargement of the tract, creating a pathway for leakage around the tube 1
• Balloon deflation or incorrect volume: In balloon-type tubes, under-inflation allows tube migration and leakage; check balloon volume weekly against manufacturer specifications 1
• Incorrect tube length: Particularly with button gastrostomy devices, wrong sizing creates poor seal at the stoma site 1
• Enlarged stoma tract: Progressive widening from chronic irritation, movement, or infection creates space for gastric contents to leak 1

Buried Bumper Syndrome (BBS)

• Partial or complete gastric mucosal overgrowth over the internal bolster, occurring in 0.3-2.4% of patients 1
• Presents with peristomal leakage, immobile tube, abdominal pain, and resistance with feeding 1
• Risk factors include excessive bolster tension, malnutrition, poor wound healing, and significant weight gain from successful enteral nutrition 1
• Confirm with endoscopy or contrast study (perform in prone position to avoid false-negative results) 1

Infectious/Inflammatory Causes

• Peristomal infection: Occurs in up to 30% of cases, causing local tissue breakdown and leakage 1, 2
• Excessive granulation tissue: Vascular tissue that bleeds easily, caused by excess moisture, friction from poorly secured tube, or critical colonization 1
• Fungal skin infection: Associated with chronic moisture and leakage, creating a vicious cycle 1

Increased Gastric Output

• Increased gastric acid secretion: Directly contributes to leakage and surrounding skin breakdown 1
• Gastroparesis: Causes gastric stasis with increased residuals that overflow around the tube 1, 3
• Increased intra-abdominal pressure: From constipation, ascites, or other causes forces gastric contents around the tube 1

Patient-Related Factors

• Diabetes with poor glycemic control: Impairs wound healing and increases infection risk 1
• Immunosuppression: From corticosteroids or other medications, compromising tract integrity 1
• Malnutrition: Prevents proper tract maturation and healing 1
• Obesity: Increases tension on the tube and infection risk 1, 2

Management Algorithm

Immediate Assessment

• Check bolster tension first: Should have approximately 1 cm of play between skin and external bolster; adjust if too tight or too loose 1
• Verify balloon volume: If balloon-type tube, confirm volume matches manufacturer specifications 1
• Assess for side torsion: Stabilize tube with clamping device or switch to low-profile device if present 1
• Examine for infection: Look for erythema, purulent drainage, fever, or pain requiring antimicrobial treatment 1, 2

Skin Protection (Initiate Immediately)

• Apply zinc oxide-based barrier products (cream, paste, or film) to all exposed skin to prevent acid-induced breakdown 1
• Use foam dressings instead of gauze: Foam lifts drainage away from skin while gauze traps it and worsens maceration 1

Reduce Gastric Output

• Start proton pump inhibitors to decrease gastric acid secretion and minimize leakage volume 1, 3
• Consider prokinetic agents if gastroparesis is contributing to increased residuals 1, 3
• Address constipation to reduce intra-abdominal pressure 1

Treat Complications

• For peristomal infection: Apply topical antimicrobial agents; if no improvement in 5-7 days or systemic signs present, add oral broad-spectrum antibiotics (cephalexin 500 mg four times daily for 5-7 days) 1, 2
• For excessive granulation tissue: Apply silver nitrate cauterization directly to overgranulation, or use topical corticosteroid cream for 7-10 days with foam dressing for compression 1, 3
• For fungal infection: Treat with topical antifungal agents 1

Refractory Cases

• Do NOT upsize to larger diameter tube: This is usually ineffective and results in continued leakage around an even larger stoma 1
• Consider temporary tube removal: Remove tube for 24-48 hours to allow slight spontaneous tract closure, then replace with tube that fits more closely 1, 3
• Place new gastrostomy at different site: If all measures fail, this is the definitive solution 1

Critical Pitfalls to Avoid

• Never check gastric residuals routinely: This increases tube occlusion risk 10-fold and can worsen overflow problems 3
• Never use hydrogen peroxide after the first week: It irritates skin and contributes to stomal leaks 3
• Never assume larger tube will solve the problem: Upsizing typically worsens leakage by further enlarging the tract 1
• Never ignore difficulty mobilizing the tube: This is an alarming signal for buried bumper syndrome requiring immediate evaluation 1