How should a leaking gastrostomy tube be addressed?

Management of Leaking Gastrostomy Tube

Address the underlying mechanical cause first—check and adjust bolster tension to maintain 0.5-1 cm of play between the external bolster and skin, verify balloon volume matches manufacturer specifications, and assess for tube mobility to rule out buried bumper syndrome. 1

Immediate Assessment Algorithm

Step 1: Check Mechanical Factors

• Bolster tension: Excessive compression between internal and external bolsters is the leading cause of G-tube leakage, causing tissue necrosis and tract enlargement. 1 Ensure approximately 1 cm of play between the skin and external bolster. 2
• Tube mobility: The tube should advance inward at least 2 cm (ideally 5-10 cm) without resistance. 1 Any difficulty mobilizing the tube is an alarming signal for buried bumper syndrome requiring immediate endoscopic evaluation. 1
• Balloon volume: For balloon-type tubes, verify the balloon contains the correct volume per manufacturer specifications—deflation or incorrect volume allows tube migration and leakage. 1
• Side torsion: Assess whether the tube is being pulled laterally, as this causes ulceration and progressive tract enlargement. 1

Step 2: Rule Out Buried Bumper Syndrome

• Buried bumper syndrome occurs in 0.3-2.4% of patients and presents with peristomal leakage, immobile tube, abdominal pain, and resistance with feeding. 1
• If the tube cannot be mobilized or rotated, perform urgent endoscopy or contrast study (in prone position to avoid false-negatives) to confirm diagnosis. 1

Skin Protection and Local Management

Immediate Skin Barrier Measures

• Apply zinc oxide-based barrier products to all exposed peristomal skin to prevent acid-induced breakdown. 1
• Use foam dressings instead of gauze—foam lifts drainage away from the skin whereas gauze traps it against the skin, worsening maceration. 2, 1
• Avoid placing overlying gauze with tape or abdominal pads, as these retain moisture and injure surrounding skin. 3

Treat Associated Infections

• Peristomal bacterial infection: Occurs in up to 30% of cases. 2 If diagnosed early, oral broad-spectrum antibiotics for 5-7 days may suffice. 2
• Fungal infection: Treat with topical antifungal agents to break the moisture-driven irritation cycle. 2, 1

Medical Management to Reduce Leakage Volume

Acid Suppression

• Start proton pump inhibitor therapy to decrease gastric acid secretion and minimize leakage volume. 1 This reduces both the amount of leakage and the caustic nature of the drainage.

Address Increased Gastric Output

• Gastroparesis: Consider prokinetic agents if gastroparesis is contributing to increased residuals and overflow. 1
• Constipation: Address constipation aggressively to reduce intra-abdominal pressure that forces gastric contents around the tube. 1

Critical Pitfalls to Avoid

• Do NOT upsize the tube—replacing with a larger-diameter tube is usually ineffective and typically worsens leakage by further enlarging the tract. 2, 1
• Do NOT routinely check gastric residuals—this increases tube occlusion risk 10-fold and can worsen overflow problems. 1
• Do NOT use hydrogen peroxide after the first week—it irritates the skin and contributes to stomal leaks. 1
• Do NOT ignore difficulty mobilizing the tube—this is an alarming signal for buried bumper syndrome requiring immediate evaluation. 1

Advanced Interventions for Refractory Cases

When Conservative Measures Fail

• Conversion to gastrojejunostomy: Consider converting the gastrostomy tube to a gastrojejunostomy tube as an alternative treatment option. 2
• Wound and ostomy nurse consultation: These specialists are invaluable resources and often serve as primary managers for leaking gastrostomy sites. 2

Endoscopic Interventions

• Argon plasma coagulation (APC): For persistent leakage in mature gastrostomy tracts, circumferential fulguration of the mucosa surrounding the tube with pulsed APC at 50 W and 1 L/min flow rate has shown success, with complete resolution occurring between 2-6 weeks. 4
• Through-the-scope clips: Can be applied if the inner orifice remains enlarged after APC to obtain better closure. 4

Last Resort Options

• Temporary tube removal: In refractory cases, remove the gastrostomy tube for several days to allow the stoma to approximate more closely. 2
• New site placement: Occasionally the tube must be removed and a repeat gastrostomy placed at a new site. 2

Special Considerations

Early vs. Late Leakage

• Small peristomal drainage during the first week after PEG placement is expected and normal. 1
• Persistent chronic leakage indicates underlying tract pathology requiring the interventions outlined above. 1

Patient-Specific Factors

• Hyperglycemia: Elevated blood glucose impairs wound healing—optimize glycemic control to promote tract repair. 1
• Risk factors for complications: Patients with diabetes, obesity, poor nutritional status, or those on chronic corticosteroid/immunosuppressive therapy are at increased risk for infection and leakage. 2