Clogged G-tube

Background

• The percutaneous gastrostomy tube (PEG) is commonly indicated in:
  • patients with impaired ability to tolerate PO for caloric supplementation, hydration, frequent enteral medication dosing
  • oropharyngeal or esophageal obstruction
  • major facial trauma
  • passive gastric decompression
  • mechanical apposition of the stomach to the abdominal wall to prevent hiatal herniation.
• Most PEGs are 18F to 28F and may be used for 12-24mo

Clinical Features

• G-tube can be clogged with medications or feeding solution
• Inability to pass feeds or aspirate from g-tube

Differential Diagnosis

G-tube Complications

• Clogged G-tube
• Displaced G-tube
• Infected G-tube
• Leaking G-tube

Evaluation

• Clinical diagnosis
• Attempts should not be made to clear tube if uncertain position/integrity of tube

Management

Mechanical Interventions

• Attempt to milk back cheesy precipitants, if the tube is pliant
• Gentle back-and-forth flushing with saline: be patient, continue pumping back and forth (even if you feel no forward flow or change) for a few minutes
  • This will often dislodge just enough residue to allow for a proper flush
• Use guidewire or small stylet in proximal tube
  • Do not attempt to clear subcutaneous portion of tube with guidewire or stylet secondary to to risk of puncture of tube, injure the pt, or create a tube leak.
• Use fogarty catheter to clear obstruction
  • Use a No 4 embolectemy cath for a 10-12F tube or a No 5 embolectemy cath for a 14F tube
  • Insert until obstruction met, then inflate and deflate and then continue insertion. Stop insertion just proximal to internal opening of feeding tube. Inflate and deflate while withdrawing catheter. Repeat as necessary.
  • Do not withdraw with balloon inflated because the tube and catheter will move together as a unit
  • Confirm position/integrity of tube with contrast radiography after procedure
• Attempt to flush with warm water
  • The smaller the syringe used, the greater the force that can be applied (pascal's principle)
  • Catheters are prone to aneurysm and rupture (especially Broviaks) therefore, always confirm tube integrity with contrast radiography if this method is used

Pharmacologic Interventions

• Coca-cola has not been shown to be superior to water and may result in precipitants and further blockage
• Meat tenderizer and cranberry juice no better than warm water
• Use commercially available declogger (Bionix), Clog Zapper
• Use catheter to instill pancreatic enzymes and allow 30-60 minutes to dissolve obstruction, then flush with water
  • Crush 1 pancrelipase tab (lipase, amylase, protease) to fine powder
  • Crush 1 non-enteric sodium bicarbonate 324mg tab to fine powder
  • Dissolve powder mix in 5 cc warm water to achieve activated pancrelipase ~pH 8 sln

Complications

• Catheter perforation, aneurysm, or displacement
• Internal catheter leak
• Stomach perforation

Imaging

• Ensure patency and placement with KUB with 20-30ml of water soluble contrast

See Also

• G-tube complications

References

Authors

Matthew, Neil Young, Kevin Lu, Tim Horeczko, Ross Donaldson, Claire