Twisting tubes: Gastrostomy tube issues

Case presentation

A 7-month-old male with a history of prematurity (27 weeks’ gestation) presents with a gastrostomy button that fell out approximately 3 hours prior to arrival. The child has had the gastrostomy button for 3 months. The mother tells you that the button “slipped out” during the child’s feeding. She attempted to replace the button but was unsuccessful. The child was seen at an outside facility, who attempted to replace the button through the existing stoma. This was done with great difficulty and there was a small amount of bleeding noted postinsertion. There are no other symptoms or concerns.

The child’s physical examination is unremarkable and his vital signs are appropriate for his age. There is a stoma noted, which has some minimal granulation tissue but no erythema, edema, discharge, or bleeding. There is no abdominal distention or apparent tenderness.

Imaging considerations

Imaging may be used to confirm the position of a gastrostomy button that has been replaced in the emergent or urgent setting. Improper placement of a gastrostomy tube (G-tube) can result in gastric perforation, false tract formation, and peritonitis. However, complication rates following gastrostomy tube replacement in the emergency department are low and are often associated with replacing the tube through an immature tract or changing from one tube type to another. According to the literature, a confirmatory contrast study of a replaced gastrostomy button may not be routinely indicated; however, at the author’s institution, we do routinely perform such a test, using water-soluble contrast injection and plain radiography, according to institution protocol. If the button was difficult to place or there is any concern about button position following placement, then confirmatory radiography should be obtained. Higher confirmatory imaging rates are found in patients undergoing gastrostomy replacement who had significantly higher rates of immature tracts, difficult G-tube replacement, and stomal stenosis. Clinical signs of proper placement include aspiration of gastric contents through the G-tube (although this is not always considered reliable). ^{, ,}