GASTROSTOMY

Introduction

Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the
stomach. The tube, called a "g-tube," is used for feeding or drainage.

• A stoma created from the abdominal wall into the stomach, through which a short feeding tube is
inserted by the physician.
• It may require a small abdominal incision or it may be placed endoscopically.
• Is preferred for prolonged nutrition greater than 3-4 weeks
• Is also preferred over NGT feedings in the comatose patient because the gastroesophageal sphincter
remains intact.
• Gastrostomy is also performed to provide drainage for the stomach when it is necessary to bypass a
longstanding obstruction of the stomach outlet into the small intestine
• Surgery is performed either when the patient is under general anesthesia—the patient feels as if he
or she is in a deep sleep and has no awareness of what is happening—or under local anesthesia.
With local anesthesia, the patient is awake, but the part of the body cut during the operation is
numbed.

Purpose:

 Gastrostomy is performed because a patient temporarily or permanently needs to be fed directly

through a tube in the stomach.
 Gastrostomy is also performed to provide drainage for the stomach when it is necessary to bypass a
longstanding obstruction of the stomach outlet into the small intestine
 Congenital (present from birth) abnormalities of the mouth, esophagus, stomach, or intestines
  Sucking and swallowing disorders, which are often related to prematurity, brain injury,
developmental delay, or certain neuromuscular conditions, like severe cerebral palsy
 Failure to thrive, which is a general diagnosis that refers to a child's inability to gain weight and
grow appropriately
 Extreme difficulty taking medicines

Complications:

 Infection
 bleeding
 dislodgment of the tube
 stomach bloating
 nausea and diarrhea

(Gastrostomy is a relatively simple procedure. As with any surgery, however, patients are more likely to
experience complications if they are smokers, obese, use alcohol heavily, or use illicit drugs.)

Preparation

Prior to the operation, the doctor will perform an endoscopy and take x rays of the gastrointestinal
tract. Blood and urine tests will also be performed, and the patient may meet with the anesthesiologist
to evaluate any special conditions that might affect the administration of anesthesia.

Aftercare

Immediately after the operation, the patient is fed intravenously for at least 24 hours. Once bowel sounds are
heard, indicating that the gastrointestinal system is working, the patient can begin clear liquid feedings through
the tube. The size of the feedings is gradually increased.

Patient education concerning use and care of the gastrostomy tube is very important. Patients and their families
are taught how to recognize and prevent infection around the tube; how to insert food through the tube; how to
handle tube blockage; what to do if the tube pulls out; and what normal activities can be resumed.
Types of gastrostomy tube:

 Stamm
• It can be temporary or permanent.
• It requires either an upper abdominal midline incision or a left upper quadrant
transverse incision.
• It requires the use of concentric purse string sutures to secure the tube to the anterior
gastric wall.

 Janeway
• Use only for permanent gastrostomy.
• Same with Stamm it requires either an upper abdominal midline incision or a left upper
quadrant transverse incision.
• The Janeway procedure necessitates the creation of a tunnel(called a gastrictube) that is
brought out through the abdomen to form a permanent stoma.

 Percutaneous Endoscopic Gastrostomy (PEG)

• is a surgical procedure for placing a tube for feeding without having to perform an open
operation on the abdomen
• It is used in patients who will be unable to take in food by mouth for a prolonged
period of time.
• A gastrostomy, or surgical opening into the stomach, is made through the skin using an
a flexible, lighted instrument passed orally into the stomach to assist with the placement
of the tube and secure it in place.

PEG is done after :

• Local anesthesia (usually lidocaine or another spray) is used to anesthetize the throat.
• An endoscope a flexible tube with a camera and a light on the end) is passed through the
mouth, throat and esophagus into the stomach.
• The physician then makes a small incision in the skin of the abdomen over the stomach and
pushes a needle through the skin and into the stomach.
• The tube for feeding then is pushed through the needle and into the stomach.
• The tube then is sutured in place to the skin.

If an endoscope is unable to pass through the esophagus, then the gastrostomy can be
performed under xray guidance throught the abdominal wall. The procedure is known as
fluoroscopically guided percutaneous gastrotomy FGPG.

 The initial PEG device can be removed and replaced once the tract is well
established (10-14days after insertion). Replacement of PEG device is indicated to
provide long-term nutritional support, to replace a clotted or migrated tube, or to
enhance patient comfort. The PEG replacement device should be fitted securely to
the stoma to prevent leakage of gastric-acid
  Low-profile gatrotomy device (LPGD)-

• an alternative to PEG device

• may be inserted 3-6 months after the initial gastrotomy tube replacement.

2 types of LPGD

 Obturated device (G-Button) - have a dome tip that acts as an internal stabilizer. A
major back draw is the need for a physician to obdurate.

 Non-obsturated device (Mic-KEY)- has an external skin disk an sis inserted into the
stoma without force. A balloon is inflated to secure placement.

Parts of PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Mushroom catheter tip and Internal bumper-secures the tube against the stomach wall

External Catheter/bumper- keeps the catheter in place

Tubing Adaptor - is in place between the feeding

Clamp or plug- used to close or open the tubing

Difference between NGT and PEG

NGT PEG
 Needs to be  Lasts for months
reinserted  Long term use

 Temporary  Decrease chances for infecton and

aspiration
GASTROSTOMY TUBE PLACEMENT:

 Surgical opening is sutured tightly around the tube or catheter to prevent leakage.
 Care of this opening before it heals requires surgical asepsis.
 The catheter has an external bumper and internal inflatable retention balloon to maintain placement.
 When tract is establish (about 1 month), the tube or catheter can be removed or reinserted for each feeding.
 Alternatively, a skin level tube can be used that remains in place.
 A feeding set is attached when needed.

TESTING FEEDING TUBE PLACEMENT:

 Before feedings, tube placement is confirmed by radiography, particularly when a small bore has been
inserted or when client is at risk for aspiration.
 After placement is confirmed, the nurse marks the tube with indelible ink or tape at its exit point from the
nose and document tubing for baseline data.
 Nurse is responsible for verifying tube placement before each intermittent feeding and at regular intervals
(e.g. at least once per shift) when continuous feeding are being administered.

METHODS TO CHECK TUBE PLACEMENT:

1. Aspirate gastrointestinal secretions.

o Small bore tubes offer more resistance than large bore tubes and are more likely to collapse when
negative pressure is applied.
o Gastric secretions tend to be a grassy green, off white or tan color.
o Intestinal fluid is stained with bile and has a yellow o brownish green color.

2. Measure the ph of aspirated fluid.

o This is the recommended method to determine the tube placement.
o Testing the ph can help distinguish gastric from respiratory and intestinal placement.

Gastric
-Acidic
-pH of 1 to 4
-pH will be high as 6 if client is receiving medications that control gastric acid

Small intestine
-pH equal to or higher than 6

Respiratory
- Alkaline
-ph of 7 or higher
- pH as low as 6, there is slight possibility of respiratory placement
-pH higher than 6, radiologic confirmation of tube location needs to be considered, especially in clients
with diminished cough and gag reflexes
3. Ascultate the epigastrium while injecting 5 to 2o ml of air.
o Air injected to stomach produces whooshing, gurgling or bubbling sounds over epigastrium and the
upper left quadrant.
o In predicting placement, this is less reliable than pH testing.

4. Confirm the length of the tube insertion with the insertion mark.
o If more of tube is exposed, the position of the tip should be questioned.

 Radiographic verification of tube placement is the most effective method

 Repeated X ray studies are not feasible in terms of cost
 Nurses should:
 Ensure initial radiographic verification of small bore tubes.
 Aspirate contents when possible and check their acidity.
 Closely observe client for signs of obvious distress.
 Consider tube dislodgement after episodes of coughing, sneezing and vomiting.

GASTROSRTOMY TUBE CARE:

 A small dressing can be applied over the tube outlet and gastrostomy tube can be held in place by a thin
strip of adhesive tape that is first place around the tube and then firmly attached to abdomen.
 Dressing protects the skin around the incision from leakage of gastric acid and spillage of feedings
 The nurse verifies the tube’s placement, assesses residuals and rotates the tube or stabilizing disk once
daily to prevent skin breakdown.
 Some gastrostomy tubes have balloons that are inflated with water to anchor the tube in stomach
 Adequacy of balloon inflation is checked weekly by deflating the balloon using luer tip syringe.

GASTROSRTOMY SKIN CARE:

 It requires a special care because it may become irritated from the enzymatic gastric juices that leak around
the tube.
 If left untreated, the skin becomes macerated, red, raw, and painful.
 The nurse washes the area around the tube with soap and water daily, removes any encrustation with saline
solution, rinses the area well with water and pats it dry.
 Once the stoma heals and drainage ceases, a dressing is not required.
 A long term gastrostomy requires a special dressing or stabilization device to protect the skin around the
tube from gastric secretions and to help the tube secure in place.
 Skin at the exit site is evaluated daily for skin breakdown, irritation, excoriation and presence of drainage or
gastric leakage.
 Nurse encourages the patient and family to participate in this inspection and in hygiene activities.
 If skin problems do occur, an enterosomal therapist or wound care specialist can be of assistance.

Possible Nursing Diagnosis:

 Imbalanced nutrition, less than body requirements related to enteral feeding problems.
 Risk for infection related to presence of wound and tube
 Risk for impaired skin integrity at tube site
 Ineffective coping related to inability to eat normally
 Disturbed body image related to presence of tube
 Risk for ineffective therapeutic regime management related to knowledge deficit about home
care and the feeding procedure

Central Luzon Doctors’ Hospital Educational Institution

San Pablo Tarlac City

Gastrosto
my
Prepared By:
Gonzales,Chryzl

Mercado Jericson

BSN IV-A
 Prepared To:

Mrs.Gloria Dulay RN MSN

(I.C.U. Clinical Instructor)