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Upon completion, the reader will be able to:

• List reasons for gaining access to the gastrointestinal tract.
• Provide a brief explanation of the functions of the different sections of the gastrointestinal tract.
• List the indications for the use of a gastric tube in the patient with a gastrointestinal bleed.
• List the different types of tubes used for enteral feeding.
• Identify the different methods used for placing each type of enteral feeding tube.
• Identify the methods that can be used to confirm the placement of each tube.
• Identify the proper procedure for responding to a patient enteral tube has fallen out.

Outline

I. Abstract

II. Introduction

III. Review of GI Tract

A. Anatomy

B. Function

IV. NG Tubes/Gastric Decompression

A. Benefits of NG tube placements

B. Indications for placement

V. Gastric Decompression

A. Placement procedure

B. Confirmation of position of tube

VI. Enteral Nutrition

A. Why we need enteral tube feedings

B. Short term / Long term

C. Types of tubes

VII. NG tubes

A. Placement procedure

B. Position and use and benefits

VIII. NJ tubes

A, Placement procedure

B. Position and use and benefits

IX. G-tube

A. Placement procedure

B. Position and use and benefits

X. J-tube

A. Placement procedure

B. Position and use and benefits

XI. GJ tube

A. Placement procedure

B. Position and use and benefits

XII. Patient Care

A. Follow facility guidelines

B. Replace or not when tube is dislodged

XIII. Summary points

XIV. References

ABSTRACT

As the gastrointestinal (GI) tract is the route by which the body is supplied with water, electrolytes, and nutrients. An intact and functioning GI tract is essential for survival and optimum health. Unfortunately, there are many clinical conditions in which the GI tract is temporarily or permanently unavailable, not functioning, or damaged. In these situations, the patient’s health is seriously jeopardized. The clinician must find a way to meet the body’s needs, and this can be done by accessing the GI tract using a variety of gastric tubes. These tubes; nasogastric (NG), nasojejunal (NJ), gastrostomy (G-tube), jejunal (J-tube), and gastrojejunal (GJ-tube) are used to provide the body with nutrition, perform gastric decompression, and to evaluate/treat GI bleeding. Each of these tubes has a specific insertion technique, specific advantages and disadvantages, and complications. This article will provide a basic review of the anatomy and function of the GI tract, and discuss the use of gastric tubes for the evaluation/treatment of GI bleeding, gastric decompression and enteral nutrition. Specific radiologic techniques that are used for insertion will be discussed and described.

INTRODUCTION

There are many clinical conditions in which access to the gastrointestinal tract is desired:

• The need to provide nutrition.
• The need for gastric decompression.
• Evaluating/treating patients with gastrointestinal bleeding.

When these situations arise, the physician has at his/her disposal a variety of tubes that can be placed at various points in the gastrointestinal tract to accomplish those goals.

REVIEW OF THE GASTROINTESTINAL TRACT

The gastrointestinal (GI) tract is involved in providing the body with water, electrolytes, and nutrients.¹ In order for this to happen, food must be transferred through the GI tract, there must be a secretion of digestive juices, there must be absorption of water, electrolytes, and nutrients, and each part of the GI tract is designed to carry out one of those functions.

The GI tract starts with the mouth and the oral cavity. This is where food is introduced into the GI tract. The GI tract continues with the esophagus. This is a muscular tube that connects the oral cavity with the stomach. At approximately 2 to 5 cm above the juncture with the stomach, is the lower esophageal sphincter or cardiac sphincter. This is a ring-like band of muscle that opens or closes to let food into the stomach and keep stomach contents from moving into the esophagus. The stomach is divided into three sections: the upper part, the fundus; the middle part, the body; and the lower part, the antrum. At the end of the antrum, the stomach anastomoses with the small intestine. The connection between the stomach and the small intestine is called the pylorus, and like the esophagus, this connection is marked by a sphincter, the pyloric sphincter.

The small intestine is divided into three parts. The first part closest to the stomach is called the duodenum. This part of the small intestine is approximately 25-30 cm long, and it connects to the next part of the small intestine, the jejunum. The jejunum is approximately 2.5 m long. It connects with the terminal part of the small intestine, the ileum. The ileum is approximately 2-4 m long. In turn the ileum anastomoses with the first part of the large intestine (also called the colon), called the cecum: this connection is marked by another sphincter, the ileocecal valve. After the cecum, the large intestine is divided into the ascending colon, the transverse colon, and the descending colon. The descending colon connects with the rectum which is about 12 cm long and then is connected to the anal canal, which is approximately 2.5-4 cm long. The GI tract terminates with a sphincter called the anus.

As mentioned previously, each part of the GI tract is involved in a specific way in the digestive process:

• Mouth and oral cavity: The mouth is involved in chewing, or mastication. The purpose is to break food down into pieces small enough to pass through the esophagus and enter the stomach, moistening the food with saliva thus enhancing its formation into a bolus, and to add salivatory amylae enzyme in order to initiate digestion of food.
• Esophagus: Using strong, rhythmic, muscular contractions (peristalsis), the esophagus passes food from the mouth to the stomach. It does not have any digestive or absorptive function.
• Stomach: The stomach functions as a storage depot for food, as well as a site for mechanical and chemical breakdown of food. Gastric glands of the mucosa secrete hydrochloric acid, a hydrolytic enzymes, and mucus.
• Small intestine: The small intestine is the site where carbohydrates, fats, and proteins, electrolytes, and water are absorbed.
• Large intestine: The function of the large intestine is to absorb water and store food matter that has not been absorbed and can’t be used. The large intestine is where stool is formed.
• Rectum: This is a temporary storage area for feces.

Instant feedback: The GI tract is responsible for handling approximately 9 Liter of fluid every day, 1.5 Liter from ingested fluids, the remainder being gastric juices and mucous. Almost all of this (except for approximately 1.5 Liter) is absorbed by the small intestine, and if there can be serious consequences if this absorptive process is disrupted.

NASOGASTRIC TUBES/GASTRIC DECOMPRESSION

The prophylactic placement of a polyvinyl chloride or polyurethane catheter, a nasogastric (NG) tube, or another type of gastric tube after abdominal surgery has become, in many hospitals, routine. After abdominal surgery bowel motility is often compromised and/or slowed, and this can cause serious clinical complications. The NG tube is placed with the objectives of:

• Reducing abdominal distention.
• Speeding up the return of bowel function.
• Preventing aspiration.
• Decreasing nausea and vomiting.
• Decreasing the risk of aspiration.
• Decreasing the chance of wound dehiscence and hernia.
• Decreasing the chance of wound separation and infection¹⁴

There is evidence that prophylactic placement of a NG tube can be helpful,¹⁵ but there is also some evidence that gastric decompression does not accomplish those goals.^16,17

Hematemesis, the vomiting of blood, is almost always caused by bleeding in the upper GI tract, and gaining access to the stomach can provide important diagnostic information to the treating physician (e.g., localizing the bleeding to the upper GI tract, indicates the severity and presence of ongoing bleeding, clearing the stomach prior to endoscopy), and provides clinical benefit to the patient.² This can also be accomplished by passing a polyvinyl chloride or polyurethane catheter, a nasogastric tube, through the nose and into the stomach.

Notice the amount of air in the stomach. This film is an example of the need for gastric decompression.

Indications for the placement of a NG tube:

• Decompress the stomach by aspiration of gastric contents (blood, fluid, air).
• Analysis of gastric substances to assist in the clinical diagnosis.
• Introduction of fluids (lavage fluid, activated charcoal, tube feeding, medications).

Instant feedback: Although NG intubation has in the past been routinely performed when patients present with gastrointestinal bleeding, positive effects have not been clearly proven.

Gastric Decompression

This is a commonly used NG tube which runs from the nose into the stomach and is routinely used for the removal of gastric fluids and stomach decompression. When deemed necessary, this tube can also be placed orally. The oral gastric (OG) tube is frequently placed in patients with facial fractures or sinusitis.

The catheters most commonly used as NG tubes for stomach decompression are of various sizes: number 16 French and number 18 French are the most commonly placed. (Note: The French scale is a scale that is used to denote the size of catheters. One French unit equals 0.33 mm, so an 18 French nasogastric tube is approximately 6 mm)

The preferred method for placing a NG tube is at the bedside with the patient in a semi-upright position. The NG tubes are generally placed by the attending clinician or trained nursing staff. In order to ensure proper placement, the length of tube that must be inserted should be pre-determined. This is done by taking the end with the access ports and placing it at the tip of the patient’s nose. Extend the tube up to the ear lobe, then make a bend and extend it down to the xiphoid process, that point should be marked on the tube.³ Although this method of estimation is not foolproof, it is sufficient for the initial placement.

After confirming the oral cavity is empty, flexion of the cervical spine will help ensure the NG tube progresses down the esophagus toward the stomach. Always keep spine precautions in check if the patient has a known or suspected spinal injury. Manual stabilization of the head is required to help prevent potential injury to the patient. You should liberally coat the first six inches of the access end of the tube with a water-soluble lubricant which contains a local anesthetic. Insert the tube into the nostril and advance it down to the nasopharynx. Coughing at this point may indicate passage of the tube into the trachea. If this is suspected, remove or partially withdraw the tube and reinsert it once the patient is comfortable. When the tube is at the pharynx, the patient can be offered a glass of water, and when he/she is swallowing, the tube can be advanced into the stomach. If the physicians have ordered the patient to have nothing per mouth (NPO), the patient may take dry swallows to help the tube advance. The method just described of placing an NG tube requires an alert and cooperative patient. When a patient has limited ability to participate due to trauma or illness, the NG or OG tube can still be placed by the clinician or nursing staff at bedside. If possible, the patient’s head should be tucked with the chin toward the chest. This manipulation will help prevent the tube from advancing into the airway and the lung. When cervical flexion is ill advised, the patient can be log rolled onto their left side maintaining full spine precautions.

Once the tube has been advanced to the marked point, it is time to confirm the position of the tube; it should be located in the fundus of the stomach. This is a critical step in the process as incorrect placement of a NG tube can be dangerous: pneumothorax, hydrothorax, pleural effusions, pneumonia, aspiration of gastric contents, and other complications have resulted from a poorly placed nasogastric tube.⁴

Reviewing the literature, it is noted that checking the position of the tube can be done by many different methods:

• Auscultation technique: 30-60 cc of air is injected through the NG tube while the abdomen is ausculated, the act of listening to sounds made by internal organs. If the tube is in the stomach, the passage of air should be heard by placing a stethoscope over the stomach. Although useful, this method has been shown to be unreliable.⁵
• Aspiration of gastric contents: Gastric contents are aspirated and visually inspected. Again, this method is not reliable; pleural fluid can, at times, take on the appearance of gastric contents.
• pH testing: Gastric contents are aspirated and the pH level is checked. Gastric fluid has a pH of 1 to 4; intestinal fluid has a pH of 6 to 7. Unfortunately, there is not much quality research that addresses the accuracy of this method.⁶ As well, the pH of the gastric content aspirated can vary due to medications, age, and gender, also the test itself is subjective when it is done using litmus paper.⁷
• Carbon dioxide measuring: There are several ways to check for carbon dioxide in the NG tube. Capnometry is simple and appears to be very accurate.⁸ In this method, an end-tidal carbon dioxide detector is attached to the proximal end of the nasogastric tube and the presence (or absence) of carbon dioxide can be confirmed. This test is limited by the availability of the equipment.
• Water testing: The proximal end of the tube can be submerged in water, and if bubbling is seen, this may be an indication that the tube is in the lung. However, this method cannot be relied on to affirm proper tube placement.
• Magnet tracking: A small magnet is affixed to the distal end of the nasogastric tube prior to insertion and the position of the tube is ascertained by an external sensor array attached to a computer. One author notes this technique to be 100% reliable.⁹ Again this technique is limited by the availability of the equipment.
• Abdominal radiograph: An abdominal radiograph that includes the fundus of the stomach may be taken to confirm proper tube placement.

Once the NG tube position has been confirmed, the tube should be secured to the bridge of the nose with surgical tape. If possible and approved by the facility and clinician, the skin should be prepped with tincture of benzoin to help the tape adhere. There is commonly a significant length of un-advanced NG tube extending from the patient’s nose. This is frequently secured to the endotracheal (ET) tube on a vented patient or the hospital gown to reduce the chance of the tube being inadvertently pulled out.

The exact incidence of incorrectly placed NG tubes is not known, but one review of the literature noted that placement failures occurred in 1.9% to 89.5% of adults and in 20.9% to 43.5% in children10 but as mentioned previously, it can be catastrophic. Given the limitations of the bedside methods of determining placement, a radiographic exam is preferred.¹¹ The NG tubes are visible on an abdominal film, and the proper position can be confirmed.

Instant feedback: Although there have been many attempts in the literature to determine an accurate and safe method of determining gastric tube placement, none of these methods is 100% foolproof. Although exposure to radiation is always a concern, given the possibility of serious consequences when a gastric tube is misplaced, an abdominal radiograph should be considered the standard of care for determining proper tube placement.

ENTERAL NUTRITION

Malnutrition and a poor clinical outcome are associated.¹² Some patients cannot meet their nutritional needs through oral feedings and at that point the clinician may decide on one of several different tubes for enteral nutrition. They may be critically ill, they may have had head or neck surgery, there may be a permanent neurological impairment that prevents safe and complete use of the gastrointestinal tract, they may be malnourished or have increased metabolic demands or they may be, for a variety of reasons (e.g., old age, dementia) they are unable to feed themselves. The patient may also be considered a high risk for aspiration when eating by mouth or there could be other medical conditions (e.g., gastroparesis, gastroesophageal reflux disease) that require nutritional support. In these situations, the technique of enteral feeding can be used. Enteral feeding can play a role in both short-term rehabilitation and long-term nutritional management. The extent of its use ranges from supportive therapy, in which the tube supplies a portion of the needed nutrients, to primary therapy, in which the enteral feeding tube delivers all the necessary nutrients. Mechanical obstruction is the only absolute contraindication to enteral feeding.

Enteral feeding is accomplished by gaining access to the GI tract by using a variety of tubes. Once access has been gained, feeds can be administered as a bolus intermittently or as a continuous infusion. Short-term feeding (less than 6 weeks) can be accomplished by placing a nasoenteral tube into various parts of the GI tract; if the patient requires nutritional support beyond 6 weeks, it is advisable to gain more comfortable and/or more direct access to the GI tract through the skin.¹³ Enteral feeding can be accomplished using a nasogastric tube, nasojejunal tube, a gastrostomy tube, a jejunostomy tube, or gastrojejunostomy tube.

Instant feedback: Although enteral nutrition is widely accepted and the technique is standardized, controversy remains over when and in whom to use it and the actual clinical benefits.

ENTERAL FEEDING TUBES

Nasogastric Feeding Tubes

The large bore NG tubes that are placed for gastric decompression are seldom used for enteral feeding. These tubes are too large for comfort and there is the risk of nasal tissue damage and necrosis from the pressure of the tube if they are left in for a long period of time.

More commonly, a 5-10 French polyurethane NJ tube is used for short-term NG tube feedings. The NJ tube is commonly packaged with a pre-inserted stainless steel stylet or guidewire. This tube must be flushed with saline or water to activate the lubricant and allow for ease in removal or manipulation of the stylet. The NJ tube is very pliable and most frequently it is advanced with the use of the stylet to prevent buckling. Prior to tube feedings, the stylet should be removed and the tube flushed to assure it is functioning. The disadvantage to the small diameter feeding tube is its tendency to clog if not properly flushed post use. This tube can be inserted in the nose and advanced to the stomach using the techniques described for the bedside placement of NG tubes. Once placed, the position can be confirmed by an abdominal film. These tubes can also be placed with an endoscope, using fluoroscopy or ultrasound guidance. Patients with sustained head trauma, maxillofacial injury, or anterior fossa skull fracture should have NG, OG, and NJ tubes placed under the guidance of fluoroscopy. Inserting these tubes blindly has the potential of passing the tube through the criboform plate, thus causing intracranial penetration of the brain and potentially serious injury.

Instant feedback: Intermittent gravity feeding is preferred for NG feedings because the stomach can act as a reservoir.

Nasojejunal Feeding Tubes

This is a commonly used NJ tube which advances from the nose to the ligament of Treitz in the jejunum or the third portion of the duodenum. This tube can also be placed orally, if warranted.

Some clinicians believe that enteral nutrition delivered to the small bowel is a better choice than feedings delivered to the stomach, and will place a NJ feeding tube. This type of feeding tube is more difficult to place than a NG tube¹⁸, but its proponent’s say that it decreases the risk of aspiration, may provide more calories, and the feeding schedule will be subject to fewer interruptions. However, both the jejunum and the stomach can be safely used to deliver calories, the differences between the two types of tubes are minimal, both can be effective, and the decision as to which one to use depends on the skill of the practitioner and the potential tolerance of the patient.^{19, 20} The NJ tube can be placed using an endoscope²¹ or by using fluoroscopy²² (one study indicated that these techniques were equally effective²³). When choosing fluoroscopy the practitioner must weigh the exposure to radiation, the need for transport to the radiology department, patient safety, and cost. Some practitioners have reported success by placing the NJ tube in the stomach and allowing it to spontaneously move into the small bowel²⁴ and magnetically guided tubes have also been used as well.²⁵

This is an example of an abdominal film taken to confirm the placement of a bedside placed NJ tube.

Placing the NJ tube blindly at the bedside, a technique that is difficult and often unsuccessful²⁶, requires considerable skill. The success rate for passing the NJ tube beyond the pylorus has been reported to be from 15 to 92%.²⁷ Many hospitals have established protocol for the placement of the NJ feeding tube bedside. After the tube is placed into the abdomen via the nose, the stylet is removed. Administering prokinetic drugs such as metoclopramide, cisapride, and erythromycin may be beneficial in positioning the NJ tube beyond the pylorus by increasing peristalsis. Positioning the patient onto their right side could also initiate the tube toward the pylorus. Abdominal films are then obtained at timed intervals. If peristalsis has not advanced the NJ tube to the jejunum within the allotted time determine by the clinician, the patient will most likely need to have the NJ tube positioned under fluoroscopy by a radiologist. As previously mentioned, it is advisable to have NJ tubes placed under fluoroscopy guidance in patients with known head trauma, maxillofacial injury or anterior fossa skull fracture. If the patient has known or suspected sinusitis, the NJ tube should be advanced orally. The oral jejunal (OJ) feeding tube placement will help prevent further irritation or inflammation of the sinuses.

The method for placing the NJ feeding tube in radiology starts with the patient supine on the fluoroscopy table. The patient’s chin should be tucked toward the chest; those patients with a known or suspected cervical spine injury would not be able to comply and manual stabilization of the head is essential to prevent potential injury to the patient. A water-soluble lubricant or a lubricant with a local anesthetic is routinely placed on the access end of the tube and in the patient’s nares. The stylet or guidewire is generally within a few inches of the tip of the tube when it is advanced through the nare into the nasopharynx. Coughing or the vent alarm sounding could indicate the tube has advanced into the trachea. If this should occur, the tube should be withdrawn and insertion reattempted when patient is more comfortable and stabilized. The tube should be directed posteriorly, aiming the tip of the tube parallel to the nasal septum and superior surface of hard palate. If possible, the patient should take a few dry swallows to help advance the tube. If the patient is unable to swallow, the tube should be advanced using fluoroscopy to confirm the tube advances in the esophagus and not into the lung. When in the tip of the tube is beyond the trachea and is in the esophagus, the tube can be rapidly advanced into the fundus where it will usually loop and pass into the antrum.

The stylet may be advanced to the tip of the tube at this point. Occasionally the patient may need to roll on his/her right or left side in order for the tip of the tube to be advanced; this is due to the fact that in the supine position the fundus is more anterior than the pylorus. For some patients, gastric decompression could be necessary to help with the tube placement. During the course of the exam, the radiologist will manipulate the NJ tube by pulling back or advancing the stylet or guidewire or possible the tube itself. Once the tip is at the pylorus, the tube will be advanced into the duodenum and the stylet is usually held at the opening of the pylorus as the tube alone is advanced. This method will decrease the rigidity of the tube and allow it to advance more easily in the curve of the duodenum. If the tube curves back into the stomach a small amount of contrast or air can be introduced through the tube in order to outline the position of the pylorus and the first portion of the duodenum. The contrast can actually stimulate peristalsis and advance the tube further. Once the tube has been advanced into the first portion of the duodenum, the stylet may be reinserted to the tip to help advance the tube. The desired position for the NJ tube is with the tip at the ligament of Treitz in the jejunum or the third portion of the duodenum.

This spot film taken during the fluoroscopic placement of an NJ tube demonstrates the guidewire located within the tube. The NJ tube appears to be kinked in the fundus of the stomach, but when the guidewire was removed and the tube flushed with water it was functioning properly, thus demonstrating the importance of the removal of the guidewire and flushing the tube while the patient is still on the fluoroscopy table.

When the NJ tube is in proper position, the stylet should be removed and the NJ tube secured to the bridge of the nose with surgical tape or similar product. The skin prep, tincture of benzoin, may be applied to the bridge of the nose to help the tape adhere. The tube should be flushed with saline or water to assure the tube is functional. This step is also advisable to prevent any contrast that might have been used during the placement of the tube from hardening and plugging the thin tube. A spot film or an abdominal film may be taken for documentation of the tube position.

This abdominal film is a good example of a properly placed NJ tube with the distal tip located at the ligament of Treitz.

Instant feedback: The NJ tube is an alternative method of nutritional support for patients that require short term feeding intervention. It is recommended for patients that are at risk for feeding aspiration or gastric motility dysfunction. Pump-controlled intermittent or continuous feeding is recommended.

Gastrostomy Feeding Tubes

As mentioned previously, if enteral feedings are needed for a period of time beyond 6 weeks, tubes inserted through the nose are not appropriate, more direct access to the GI tract is needed, and a gastrostomy tube is an option for providing nutritional support for patients who are not at risk for aspiration. A gastrostomy tube is a polyurethane or silicone feeding tube that is inserted through the abdominal wall laprascopically, by an open surgical technique, or more commonly by using an endoscope. The surgical technique is seldom used.²⁸

The percutaneous endoscopic gastrostomy (PEG) technique is the one most often used. In this procedure, sedation and analgesia are administered and an NG tube is placed. The stomach is distended with air, a medication that decreases intestinal movement (e.g., glucagon) is given, and an endoscope is inserted.²⁹ The position of the endoscope in the stomach can be seen through the abdominal wall because of the very strong light at the end of the endoscope and the proper site for insertion of the tube can thus be determined. The most common method of placing a gastrostomy tube with the endoscope is by using the pull-through method.³⁰

In the pull-through method, a skin incision is made through the abdominal wall. A guide wire with a suture attached is advanced through the gastric puncture site into the stomach. The suture is grabbed by a snare inside the endoscope and pulled up through the esophagus. The endoscope is removed leaving the guide wire in place. The G-tube is then attached to the suture on the guide wire. By applying tension on the guide wire, the G-tube will be pulled through the mouth, esophagus and out through the abdominal wall. A pliable mushroom or bumper low-profile tube is generally used. The endoscope is once again inserted to visualize the interior of the stomach and check for bleeding. Although this is the most common method for placing a G-tube with the endoscope, a patient’s condition could warrant a push-through method. The push through method is frequently used on patient’s who have esophageal disease. In the push-through technique, an incision is made through the abdominal wall into the stomach. A guide wire is placed through the incision into the stomach. The tract is dilated and the G-tube is pushed through the abdominal wall over a guide wire into the stomach. The tube is held in place by a saline or water inflated balloon or by a retention flange.

This is a pliable mushroom or bumper low-profile tube that is commonly placed by endoscope. By applying tension on the guide wire, the G-tube was pulled through the mouth, esophagus and out through the abdominal wall.

However, despite the popularity of endoscopic PEG tube placement, fluoroscopy has often been successfully used to place gastrostomy tubes. The guidewire and catheter techniques used in interventional radiology are an alternative to the PEG tube placement when the distal esophagus is occluded by a stricture or tumor. In this push through method, a nasogastric tube should be inserted prior to the procedure. This allows barium to be instilled through the NG tube the day before so the transverse colon can be visualized under fluoroscopy during the procedure and perforation by the needle can be avoided.

This is a commonly used G-tube which advances through the abdominal wall into the stomach and is routinely used for long term enteral feedings.

The most common pre-procedural orders should include:

• Coagulation status should be recent or repeated if the most current lab results were abnormal. The following lab tests are commonly ordered:
  • CBC
  • PT
  • PTT
  • Platelets
• Subcutaneous heparin should be held until after the placement of the G-tube.
• Intravenous (IV) heparin, coumadin, and aspirin should be held until lab results are within the normal range.
• The patient should be kept nothing by mouth (NPO) after midnight the day before the exam.
• An informed surgical consent should be obtained by the attending Radiologist.

A combination of conscious sedation and local anesthetics are used to provide patient comfort. In some cases, general anesthesia may be indicated. The patient is closely monitored for any signs of discomfort and the anesthetics modified if warranted. An ultrasound examination of the epigastric region is performed to localize the superior epigastric artery and the left hepatic edge. This is marked on the patient’s skin. The left upper quadrant (LUQ) is prepped and draped in a sterile fashion. Any fluid in the stomach is withdrawn through the NG tube and air is than introduced to distend the stomach. The gastric distention caused by the air allows the potential access site to be visualized via the fluoroscope. It also brings the anterior gastric wall in contact with the abdominal wall while displacing the colon and small bowel inferiorly. As with all procedures, preferences and techniques vary according to the attending Radiologist.

The above image is of a low profile G-tube which sits flush to the skin. It is available in diameters from 14 French (4.67mm) to 24 French (8mm) with various stoma lengths. This type of G-tube comes with an extension set for gastric feeding and decompression. The low profile tube is frequently used for infants or children.

The method commonly used for the placement of a G-tube involves the placement of gastropexy anchors or T-tacks. Percutaneous gastropexy involves the placement of a threaded metal or nylon fastener into the stomach through a needle that is passed through the skin into the stomach. These fasteners will help to appose the anterior gastric wall to the anterior abdominal wall. Routinely three T-tacks are placed in a triangular configuration. A needle is then inserted through the abdominal wall and into the gastric lumen within the area of the positioned T-tacks. This is usually at the horizontal portion of the greater curvature. Placement can be affirmed by using a contrast medium and by air aspiration. Oblique and lateral fluoroscopy is often extremely helpful in confirming the location of the needle in the gastric lumen. A guide wire is passed through the needle and the needle is withdrawn. Utilizing fluoroscopy, the wire should conform to the gastric outline which confirms its location in the stomach.

In this film you can see the outline of the balloon and the barium entering the stomach.

Dilators of increasing size are introduced over the guide wire to increase the size of the opening or stoma until the tract is large enough to accommodate the diameter of the intended G-tube. The use of angioplasty balloons can achieve the same affect. A peel-away catheter or sheath is placed into the stomach over the guidewire. This sheath should be a bigger diameter than the G-tube that will be placed. Once the sheath is in position, the G-tube is passed through the sheath over the wire into the stomach. The sheath is peeled back as the G-tube is advanced into position. The wire is removed and the placement of the tube is confirmed by injecting a small amount of contrast.³¹ Once confirmed, the internal anchoring or retention balloon is inflated with saline or water.

The G-tube should also be flushed with water. The skin tissue at the site of the G-tube should be thoroughly cleaned, an antibiotic ointment and dressing applied. Wound care should be observed until the newly established tract is healed. The tract is usually healed and considered established in 2-3 weeks. A survey of the literature shows that this technique has a very high success rate and compared to the PEG technique, there are fewer deaths and complications.^32,33,34 Complications include peritonitis, gastric perforation, hemorrhage requiring transfusion, deep stoma infection, septicemia, aspiration, minor wound infection, peristomal leakage, and tube dislodgement.³⁵ Compared to nasogastric enteral feeding, a G-tube appears to be superior in terms of improving the patient’s nutritional status.³⁶

It is easy to visualize the G-tube radiographically, but once contrast is added the position of the G-tube is easily confirmed.

Jejunostomy Feeding Tubes

These are commonly used J-tubes which advance through the abdominal wall directly into the jejunum and would be routinely used for long term enteral feedings. The red robinson catheter needs to be sutured to the skin to maintain position. The clear silicon J-tube is held in position with a small saline filled retention balloon.

A Jejunostomy tube is a time-proven method of providing nutritional support; a feeding tube is placed directly through the abdominal wall into the jejunum. It is particularly useful in patients who are at high risk of aspiration of feedings delivered to the stomach, patients with non-functional stomachs, patients with esophageal carcinoma or chronic pancreatitis, and patients who have had a total gastrectomy.^37,38 The classic technique of placing a J-tube is the direct percutaneous endoscopic method. An anti-peristaltic drug is given and an endoscope is placed into the stomach and on into the jejunum. The powerful light at the end of the endoscope is used to ensure that the endoscope is in the proper position and to identify the proper insertion site. Once the appropriate site has been located, a needle is passed through the abdominal wall and into the jejunum. The needle is visualized with the endoscope, the tip of it is grabbed with a snare, and the jejunum pulled into and held up against the abdominal wall. A trocar is placed over the needle and advanced into the jejunum and the jejunostomy tube is passed through the trocar.³⁹ Although this technique has a relatively high success rate, it is not simple or easy to do. The jejunum cannot be opacified, it is mobile and difficult to maintain in the proper position during the procedure, and it is easily decompressible.^40,41

An alternative method for placing a J tube is by utilizing fluoroscopy. For this interventional radiology procedure the ordering physician should follow the pre-procedure orders mentioned in the section on G tube placements. The attending radiologist will obtain a surgical consent. The procedure starts with an anti-peristaltic drug and conscious sedation being administered. A small catheter is advanced from the nose or mouth to the proximal jejunum using the technique described earlier for placing a NJ tube. Once the tube is positioned in the jejunum, air is administered through the catheter. The tip of the catheter can be visualized in this air-filled loop of the jejunum, using AP, lateral, and oblique fluoroscopy, and the position adjusted if indicated. The tip of the catheter needs to be in a portion of the jejunum that is relatively close to the anterior abdominal wall. Lateral fluoroscopy is essential to determine the anterior location. When the tip is in a sufficient location, the skin is prepped and draped in a sterile fashion.

A local anesthetic is administered and the jejunum is punctured with a needle that is preloaded with a Cope suture anchor. The anchor is pushed into the jejunum using a guide wire, and when it is retracted to the skin the jejunum is secured to the abdominal wall. An additional puncture with a second needle is made in the same incision next to the existing guide wire. A second guide wire is introduced and that needle is then removed. A series of dilators of increasing increments are advanced over that guide wire to expand the diameter of the tract to accommodate the size of the J-tube that is being placed. An angioplasty balloon can also be used to dilate the tract. A peel-away sheath is positioned over the second guide wire. The J-tube is then advanced over this guide wire through the sheath. The sheath is pulled apart as the tube is advanced. The J-tube position is checked by injecting a small amount of contrast. Both an AP and lateral fluoroscopic view is routinely utilized to verify the position of the tube. Once placement is confirmed the guide wires are removed and the tube is secured to the skin using the threads from the anchors. The site should be cleaned and an antibiotic ointment and dressing applied. Wound care should be observed until the newly established tract is healed. Despite the advancements made in the percutaneous endoscopic or fluoroscopy placed J-tubes, the majority of these tubes are still placed surgically. Radiology frequently replaces the J-tube if it has been inadvertently dislodged or occluded.

Contrast is first injected to confirm the Cope suture anchor is in the jejunum and once the position is confirmed the J-tube is advanced into position over the guidewire, the balloon is filled, and contrast is injected once again to confirm proper placement of the J-tube.

A high success rate has been reported and a lower incidence of complications (e.g., injury to adjacent organs, intraperitoneal leakage and subsequent peritonitis) is likely.^42,43,44 However, although the use of a J-tube is clearly a standard technique, some doubt seems to remain about the safety and effectiveness of jejunal feedings as opposed to feedings delivered higher in the GI tract,⁴⁵ and its safety and effectiveness in general.⁴⁶ As well, significant complications (e.g., bowel perforation, bowel obstruction, skin site infections, pneumatosis intestinalis, and intra-abdominal jejunostomy leak) have been reported.⁴⁷

Instant feedback: To limit the risk of aspiration with small bowel feeding, the feeding port of the J-tube should be placed close or beyond the ligament of Treitz. Pump controlled feeding infusions are recommended with a J-tube.

Gastrojejunostomy Feeding Tubes

This is a commonly used GJ tube. Notice the inflated balloon which will be positioned in the stomach and will help secure the tube in the proper position.

A GJ tube is a dual lumen tube that is inserted through the abdominal wall. One lumen is open to the stomach and the other lumen is open to the jejunum. These tubes are used when patients need nutritional support, but the stomach cannot be used and there is also a need for gastric decompression. A single lumen GJ tube is also available when direct access to the stomach is not required for gastric drainage or the administration of medications. GJ tubes were first introduced approximately four years after the introduction of PEG tubes, and there is much less clinical experience with their use.⁴⁸ These tubes are appropriate for patients with severe gastroesophageal reflux disease and oropharyngeal dysphagia, patients with gastroparesis or functional gastric dysmotility caused by sepsis, pancreatitis, or narcotic therapy, or who are status-post pancreaticoduodenectomy.^49,50 They are commonly placed via endoscopy, but fluoroscopy can be used, as well.⁵¹ One study noted that using fluoroscopy to place GJ tubes resulted in a higher success rate and fewer complications when compared to the percutaneous technique.⁵² Although these tubes have their proponents and appear to be of some clinical value, several authors have reported high rates of complications (e.g., more hospital days, bowel obstruction, intussception, lack of weight gain, aspiration, mechanical tube problems) and the need for more frequent tube replacement.^53,54

The access to the stomach for a radiology placed GJ tube utilizes the same method as discussed in the G-tube section. The clinician and attending radiologist would adhere to the same pre and post procedure protocols. The patient is sedated and local analgesic is applied. The patient’s LUQ is prepped and draped in a sterile fashion. As with the G-tube, an interventional radiologist will utilize ultrasound to locate the edge of the liver and mark the skin appropriately. The radiologist will use catheters, guide wires, T-tacks, peel-away sheaths, contrast and fluoroscopy to properly place and position the GJ tube. With the GJ tube placement, the guide wire is advanced through the stomach into the proximal jejunum whereas the guide wire for the G-tube stays in the stomach during the initial placement. Once the tract is dilated, a peel-away sheath is positioned into the stomach. The GJ tube is then advanced through the sheath over the guide wire. The sheath is pulled apart as the tube is advanced. When properly positioned, the tip of the GJ tube should be in the proximal jejunum and the inflated retention balloon located within the stomach. The length of the GJ tube is longer than the G-tube to accommodate the tip being placed into the jejunum. After the stoma site is thoroughly cleaned, an antibiotic ointment and dressing is applied.

The guidewire was advanced through the stomach into the duodenum toward the jejunum, one the guidewire was in the proper position the GJ tube was advanced over the guide wire. Proper position is with the retention balloon positioned in the stomach and the distal end of the tube placed in the jejunum.

Instant feedback: All medications administered through enteral feeding tubes should be in liquid form. The introduction of crushed pills through a NG tube, NJ tube, J-tube, G-tube or PEG tube, or GJ tube greatly increases the risk of occluding or clogging of the tube which may result in the need for replacement.

CARE OF THE PATIENT WITH A GASTRIC TUBE

Each caring facility should have policies and procedures in place for the care and handling of the different enteral feeding tubes. A few points should be kept in mind when providing direct patient care for an individual with an enteral tube. The patient and his/her caregivers must be conscientious of the tube at all times. It can be inadvertently pulled out when tugged on. This could occur either consciously or subconsciously by the patient or during positioning of the patient. The patient should be encouraged to leave the tube alone. The attending physician may have to write an order for physical restraints, if this is not possible. A patient may need to be positioned in a specific way (e.g., a patient receiving gastric enteral feedings may need to have his/her head elevated to a certain height) during tube feedings. The nursing staff and physician should be attentive to the type of enteral tube and its specifications for use. If the need arises for handling the tube, observe the rules of universal precautions and uses gloves (non-sterile gloves are acceptable). Always flush the tube with water after use to prevent occlusion from medications or feedings hardening in the tube.

When a caregiver is working with a patient that has a G tube, a J tube, or a GJ tube the skin should be inspected regularly for signs of an infection or any breakdown of the skin. The retention balloon should also be checked weekly. If a gastrostomy, jejunostomy, or gastrojejunostomy tube falls out do not try and replace it. Instead, cover the stoma with a dry, sterile dressing and notify a nurse and/or a physician immediately. It is recommended the tube be replaced by trained staff within a few hours to prevent the stoma or tract from closing. If a nasogastric or nasojejunal tube falls out do not try and replace it; notify the attending physician. Generally, these tubes do not need to be replaced as emergently.

SUMMARY POINTS

When the need for nutritional support becomes apparent for either short-term rehabilitation or long-term nutritional management, the NG, NJ, G, J, and GJ tubes would provide a safe alternative to oral feedings. There are several methods of placing the enteral feeding tube. These include surgical, bedside, under fluoroscopy by a radiologist or by a gastroenterologist utilizing an endoscope. The method used for placement and the type of tube placed is usually determined by the patient’s nutritional needs and physical condition.

• There are many clinical conditions in which access to the gastrointestinal tract is desired:
  • The need to provide nutrition.
  • The need for gastric decompression.
  • Evaluating/treating patients with gastrointestinal bleeding.
  
  
• The gastrointestinal (GI) tract is involved in providing the body with water, electrolytes, and nutrients. In order for this to happen, food must be transferred through the GI tract, there must be a secretion of digestive juices, there must be absorption of water, electrolytes, and nutrients, and each part of the GI tract is designed to carry out one of those functions.
  
• The small intestine is the site where carbohydrates, fats, and proteins, electrolytes, and water are absorbed making it an important area for enteral feedings.
  
• The GI tract is responsible for handling approximately 9 Liter of fluid every day, 1.5 Liter from ingested fluids, the remainder being gastric juices and mucous. Almost all of this (except for approximately 1.5 Liter) is absorbed by the small intestine, and if there can be serious consequences if this absorptive process is disrupted.
  
• The NG tube is placed with the objectives of:
  • Reducing abdominal distention.
  • Speeding up the return of bowel function.
  • Preventing aspiration.
  • Decreasing nausea and vomiting.
  • Decreasing the risk of aspiration.
  • Decreasing the chance of wound dehiscence and hernia.
  • Decreasing the chance of wound separation and infection.
  
  
• Indications for the placement of a NG tube:
  • Decompress the stomach by aspiration of gastric contents (blood, fluid, air).
  • Analysis of gastric substances to assist in the clinical diagnosis.
  • Introduction of fluids (lavage fluid, activated charcoal, tube feeding, medications).
  
  
• Although NG intubation has in the past been routinely performed when patients present with gastrointestinal bleeding, positive effects have not been clearly proven.
  
• The French scale is a scale that is used to denote the size of catheters. One French unit equals 0.33 mm, so an 18 French nasogastric tube is approximately 6 mm.
  
• The incorrect placement of a NG tube can be dangerous: pneumothorax, hydrothorax, pleural effusions, pneumonia, aspiration of gastric contents, and other complications have resulted from a poorly placed nasogastric tube.
  
• Checking the position of the NG tube can be done by many different methods:
  • Auscultation
  • Aspiration of gastric contents
  • pH testing
  • Carbon dioxide measuring
  • Water testing
  • Magnet tracking
  • Abdominal radiograph
    
• Although there have been many attempts in the literature to determine an accurate and safe method of determining gastric tube placement, none of these methods is 100% foolproof. Although exposure to radiation is always a concern, given the possibility of serious consequences when a gastric tube is misplaced, an abdominal radiograph should be considered the standard of care for determining proper tube placement.
  
• Enteral feeding can be accomplished using a nasogastric tube, nasojejunal tube, a gastrostomy tube, a jejunostomy tube, or gastrojejunostomy tube.
  
• Although enteral nutrition is widely accepted and the technique is standardized, controversy remains over when and in whom to use it and the actual clinical benefits.
  
• The large bore NG tubes that are placed for gastric decompression are seldom used for enteral feeding. These tubes are too large for comfort and there is the risk of nasal tissue damage and necrosis from the pressure of the tube if they are left in for a long period of time.
  
• A 5-10 French polyurethane NJ tube can be used for short-term NG tube feedings. The disadvantage to the small diameter feeding tube is its tendency to clog if not properly flushed post use.
  
• Intermittent gravity feeding is preferred for NG feedings because the stomach can act as a reservoir.
  
• While placing the NJ feeding tube, coughing or the vent alarm sounding could indicate the tube has advanced into the trachea.
  
• The desired position for the NJ tube is with the tip at the ligament of Treitz in the jejunum or the third portion of the duodenum.
  
• The NJ tube is an alternative method of nutritional support for patients that require short term feeding intervention. It is recommended for patients that are at risk for feeding aspiration or gastric motility dysfunction. Pump-controlled intermittent or continuous feeding is recommended.
  
• A gastrostomy tube is a polyurethane or silicone feeding tube that is inserted through the abdominal wall laprascopically, by an open surgical technique, or more commonly by using the percutaneous endoscopic gastrostomy (PEG) technique.
  
• The most common pre-procedural orders for a G-tube, J-tube, and a GJ tube should include:
  • Coagulation status should be recent or repeated if the most current lab results were abnormal. The following lab tests are commonly ordered:
    • CBC
    • PT
    • PTT
    • Platelets
  • Subcutaneous heparin should be held until after the placement of the G-tube.
  • Intravenous (IV) heparin, coumadin, and aspirin should be held until lab results are within the normal range.
  • The patient should be kept nothing by mouth (NPO) after midnight the day before the exam.
  • An informed surgical consent should be obtained by the attending Radiologist.
    
• A survey of the literature shows that the method of placing a G-tube using the gastropexy anchors technique has a very high success rate and compared to the PEG technique, there are fewer deaths and complications.
  
• A J- tube is a time-proven method of providing nutritional support; a feeding tube is placed directly through the abdominal wall into the jejunum. It is particularly useful in patients who are at high risk of aspiration of feedings delivered to the stomach, patients with non-functional stomachs, patients with esophageal carcinoma or chronic pancreatitis, and patients who have had a total gastrectomy.
  
• Despite the advancements made in the percutaneous endoscopic or fluoroscopy placed J-tubes, the majority of these tubes are still placed surgically. Radiology frequently replaces the J-tube if it has been inadvertently dislodged or occluded.
  
• To limit the risk of aspiration with small bowel feeding, the feeding port of the J-tube should be placed close or beyond the ligament of Treitz. Pump controlled feeding infusions are recommended with a J-tube.
  
• GJ tubes are used when patients need nutritional support, but the stomach cannot be used and there is also a need for gastric decompression.
  
• Although GJ tubes have their proponents and appear to be of some clinical value, several authors have reported high rates of complications (e.g., more hospital days, bowel obstruction, intussception, lack of weight gain, aspiration, and mechanical tube problems) and the need for more frequent tube replacement.
  
• All medications administered through enteral feeding tubes should be in liquid form. The introduction of crushed pills through a NG, NJ, G-tube or PEG tube, J-tube, or a GJ tube greatly increases the risk of occluding or clogging of the tube which may result in the need for replacement.
  
• If a gastrostomy, jejunostomy, or gastrojejunostomy tube falls out do not try and replace it. Instead, cover the stoma with a dry, sterile dressing and notify the physician immediately. It is recommended the tube be replaced by trained staff within a few hours to prevent the stoma or tract from closing.
  
• If a nasogastric or nasojejunal tube falls out do not try and replace it; notify a nurse and/or the attending physician. Generally, these tubes do not need to be replaced as emergently.

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