Troubleshooting and managing feeding-tube and insertion site problems in adults

Suggested management of feeding-tube and insertion site problems associated with gastrostomies and jejunostomies is given in Troubleshooting and management of feeding-tube and insertion site problems in adults. Information is also available from the New South Wales Agency for Clinical Innovation website. Expert advice can be obtained from a stomal therapy service, a clinical nutrition nurse, a gastroenterologist trained in tube management, ostomy associations and companies that manufacture the equipment. For some patients, the feeding tube may be replaced in the community by the patient, carer or trained staff; however, some patients may require hospital transfer in order to replace the feeding tube.

Table 1. Troubleshooting and management of feeding-tube and insertion site problems in adults
Agency for Clinical Innovation (ACI), 2015

Practitioner information sheet
leakage around tube skin irritation (redness, bleeding, soreness, swelling or ooze) granulation tissue dislodged tube blocked tube
leakage around tube
Possible cause: ‘kinking’ of tube
preventive strategies	ensure appropriate stabilising device is used and check tube frequently
management	straighten and inspect tube for damage; replace tube if damaged [NB1]
Possible cause: excessively large boluses
preventive strategies	ensure dietetic assessment to determine appropriate feeding regimen
management	decrease bolus volume (feed and/or water flushes) and increase feed frequency or energy density of formula—seek advice from dietitian
Possible cause: tube migration into stomach
preventive strategies	adjust flange or external retention device so that it is sitting 0.2 to 0.5 cm from the skin (ensure snug fit with balloon against abdominal wall)—there are centimetre markings on the tube
management
Possible cause: diameter of tube too small
preventive strategies	avoid side torsion or excessive tension on tube and ensure appropriate stabilising device is used—seek advice from stomal therapy service and/or a clinical nutrition nurse or gastroenterologist trained in tube management
management	use dressings and barrier wipes to protect skin dressings should be absorptive and remove moisture from skin (eg a foam dressing) if possible, avoid replacing with a larger tube, which results in tissue breakdown and a larger stoma adjust flange or external retention device so that it is 0.2 to 0.5 cm from the skin (ensure snug fit with balloon against abdominal wall)—there are centimetre markings on the tube tube may need to be replaced, ideally at a different site [NB1]
Possible cause: tube perished
preventive strategies	regularly inspect tube for splits or cracks, discolouration, or irregular beading of tube ensure only appropriate substances are administered via tube
management	replace tube [NB1]
Possible cause: balloon deflated
preventive strategies	check balloon volume
management	refer to manufacturer’s guidelines replace tube if balloon has burst or is leaking [NB1]
Possible cause: buried bumper syndrome (suspect if tube cannot be advanced or rotated in stoma or there is increased leakage, if patient has abdominal pain, or if feeds cannot be infused through tube)
preventive strategies	avoid excessive tension between external and internal bolster
management	replace tube, normally via endoscopy [NB1]
skin irritation (redness, bleeding, soreness, swelling or ooze)
Possible cause: leakage around tube (see above for possible leakage causes)
preventive strategies	avoid excessive tension on tube and ensure appropriate stabilising device is used—seek advice from stomal therapy services, a clinical nutrition nurse or a gastroenterologist trained in tube management
management	dry the skin and apply barrier wipe around the site—seek advice from stomal therapy service or ostomy association on the most appropriate barrier wipe and dressing options
Possible cause: cellulitis, candidiasis (thrush), abscess or folliculitis
preventive strategies	ensure skin is protected if tube is leaking
management	collect skin or wound swab—antimicrobial therapy may be required (see the Antibiotic guidelines) if the tube is colonised with Candida species, the tube should ideally be replaced, and antimicrobial therapy given [NB1]
granulation tissue
Possible cause: excessive tube movement, moisture, infection, ill-fitting device
preventive strategies	maintain cleanliness of area keep site free of moisture prevent excessive movement by securing the external retention device with a 0.5 cm gap from skin check disc daily and ensure correct fit
management	ensure correct fit of tube—external disk should be 0.5 cm from skin apply a foam or hypertonic dressing and change daily short-term use of corticosteroid (if infection is not suspected) apply silver nitrate or other topical coagulant (styptic) daily until improved—seek advice from stomal therapy services or a clinical nutrition nurse
dislodged tube
Possible cause: tube pulled out, burst balloon, tube breakdown, external bumper or disc inadvertently removed
preventive strategies	ensure tube is appropriately secured for cognitively impaired patients, distractions (eg an activity apron) may prevent tube being pulled out
management	replace tube as soon as practical to prevent tract closure if tract is mature (established for longer than 1 month), PEG tube can be reinserted without endoscopy [NB1] if tract is immature (established for less than 1 month), contact endoscopy unit if a replacement PEG tube is not available, insert largest available Foley catheter, or wash and dry old PEG tube if not contaminated (ensuring internal retention device [ie balloon] is not inflated), and tape into position (arrange for replacement gastrostomy tube within 24 hours). The Foley catheter or dislodged PEG tube should not be inserted against resistance and should not be used for feeding until the patient has been reviewed by an experienced practitioner. If doubt about the location of the PEG exists, use a PEG-o-gram to confirm location before feeding
blocked tube
Possible cause: poorly crushed medication [NB2]
preventive strategies	use liquid formulations of medications when possible flush tube with at least 30 mL of room-temperature water before and after administering medication and feeds review medication regularly to minimise polypharmacy check with pharmacist before administering newly prescribed medications—some medications cannot be crushed or are inappropriate for use with a PEG (eg bulk-forming laxatives, colestyramine) [NB2].
management	warm water is most effective for resolving blockage; gently but firmly push and pull plunger of a syringe containing 30 to 50 mL water back and forth (do not use force). If tube remains blocked, instil lukewarm water into tube and clamp; wait up to 30 minutes, then attempt flushing avoid using soft drinks or other liquid to unblock tubes if a build-up of feed in the tube is suspected, pancreatic enzymes plus sodium bicarbonate may be useful replace tube [NB1]
Possible cause: use of blended tube feeds
preventive strategies	recommend administration via a larger feeding tube (greater than 14 fr) ensure appropriate viscosity with the addition of water bolus feeding rather than continuous feeding to minimise tube blockages
management	warm water is most effective for resolving blockage; gently but firmly push and pull plunger of a syringe containing 30 to 50 mL water back and forth (do not use force). If tube remains blocked, instil lukewarm water into tube and clamp; wait up to 30 minutes, then attempt flushing avoid using soft drinks or other liquid to unblock tubes if a build-up of feed in the tube is suspected, pancreatic enzymes plus sodium bicarbonate may be useful replace tube [NB1]
Possible cause: inadequate flushing before and after feeds
preventive strategies	flush tube with at least 30 mL of room-temperature water before and after feeding. Ideally, flush at least every 4 to 6 hours
management	warm water is most effective for resolving blockage; gently but firmly push and pull plunger of a syringe containing 30 to 50 mL water back and forth (do not use force). If tube remains blocked, instil lukewarm water into tube and clamp; wait up to 30 minutes, then attempt flushing avoid using soft drinks or other liquid to unblock tubes if a build-up of feed in the tube is suspected, pancreatic enzymes plus sodium bicarbonate may be useful replace tube [NB1]
Possible cause: displacement of tube into anterior abdominal wall
preventive strategies	N/A
management	imaging required replace tube [NB1]
Note: PEG = percutaneous endoscopic gastrostomy; fr = French units; N/A = not applicable NB1: This should be performed by trained personnel only. NB2: For detailed information about drug administration in patients with an enteral feeding tube, see the Australian Don’t Rush to Crush Handbook. The Australian Don’t Rush to Crush Handbook is available for purchase from The Society of Hospital Pharmacists of Australia website or through eMIMs.