A 73 y.o. woman comes to the ED with abdominal pain and leakage around her G tube site after having it replaced in the ED 2 days earlier.
where is the foley placed in the ED?
The Foley was placed into the jejunum in the ED and when the balloon was blown up it caused an obstruction. There are multiple complications of both NG tubes and gastrostomy tubes.
For NG tubes, the most serious complication is placing them in the brain. This can occur with basilar skull fractures or in patients who have had transphenoidal hypophysectomies. In general, NG tubes are avoided in cases with facial fractures.
The other complications of NG tubes include placement in the lung which can cause a pneumothorax, bronchopleural fistulas, intravascular penetration, esophageal perforation, retropharyngeal abscess from perforation of a piriform sinus , and failure of the lower esophageal sphincter to close if the tube is coiled there.
this patient developed a delayed pneumothorax
NG or gastrotomy tube blockage- treatment is one 325 mg sodium bicarbonate tablet, one viokace tablet (10,440 USP units of lipase) and 5 cc of water. Introduce this into the tube and clamp for 30 minutes.
Gastrostomy tube complications include colocutaneous fistulas. The tube is placed endoscopically with a needle passed through the endoscope into the abdominal wall. A wire is passed and the G-tube is placed over the wire. Occasionally, the colon overlies the stomach when the stoma is created and a fistula results.
A colocutaneous fistula can develop if there is bowel between the stomach and skin
Skin infections can occur at the stoma site; and necrotizing fasciitis has been reported. A more common complication is replacing a G tube which has just been placed. The new tube may go directly into the peritoneum which is why if the tube is less than 4 weeks old care should be taken in replacing it.
A percutaneous gastrostomy can become loose in the first 4-6 weeks after placement. Generally, the tube is secured and tightened to the abdominal wall. If it becomes loose gastric contents and air will enter the peritoneal cavity and cause peritonitis. If the pt is not septic a trial of IV antibiotics and being placed on NPO status with gastric suctioning can be done after resecuring the tube. However, for about 72 hours after a PEG placement pneumoperitoneum is considered normal making it difficult to determine if a bowel perforation has occurred.
For about 72 hours after a PEG placemnt pneumoperitoneum is considered normal.
Hint: If there is a parastomal leak and the tube is in good position, DO NOT use a bigger tube size to replace it. The best thing to do is take the tube out and allow the stoma to close partially; then use the same sized tube.
If you are faced with a G tube which has become dislodged; rapid replacement is best because the stoma will close necessitating an endoscopic procedure to replace it. If the stoma is already small it can be dilated with serial dilators passed over a wire. (thal Quick chest tube dilators work well)
Our patient returned with a bowel obstruction because the balloon of the Foley was blown up in the jejunum. On her return a formal Gtube with a baffle was placed and the problem resolved.
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