Gastrostomy Feeding
Gastrostomy feeding - Advice for adults who are having or who are thinking about having a gastrostomy tube
This information has been written for those who are having or who are thinking about having a gastrostomy tube inserted.
What is a gastrostomy tube?
A gastrostomy tube is a medium to long term method of delivering nutrition, hydration and medications for those who cannot meet these needs orally (via mouth).
The procedure involves a small tube being inserted into your stomach through a small stoma (hole) made in your abdominal wall. The tube is then used to deliver specially prepared liquid feed, hydration and medication as recommended by your dietitian/healthcare team.
Why might I need a feeding tube?
There are a number of reasons why you might be offered a gastrostomy tube:
- If you have problems swallowing food, fluid and/or medications safely
- If you're having difficulty eating and/or drinking enough to meet your needs
- If you have an illness, or are receiving medical treatment, which may reduce how much you can normally eat and drink.
How will a gastrostomy tube be placed?
You may hear the term gastrostomy referred to as PEG (see picture 1) or RIG (see picture 2) - these terms are simply names for the ways in which a gastrostomy tube is fitted. Whichever method is used, the result is the same, although there are some slight differences in the design of the tube placed. If suitable for a gastrostomy tube, the specialist nutrition team (who are based at Aintree University Hospital) will then decide which of the following procedures is most suitable for you.
'PEG' is an abbreviation for percutaneous (through the skin), endoscopic (an endoscope is a camera used to perform the procedure via the food pipe into the stomach), gastrostomy. This is the most common way to have a gastrostomy placed.
1. Internal bumper: holds the PEG tube in place inside the stomach and prevents the tube from falling out.
2. External fixation plate: keeps the PEG tube in position next to the skin. Together with the bumper, this prevents the PEG tube from dislodging.
3. Clamp: prevents feeds and stomach content from coming back up the PEG tube.
4. End connector: fits into a syringe/feeding administration set through which feed, water or medications can be given.
'RIG' is an abbreviation for radiologically inserted (inserted under X-ray guidance) gastrostomy.
1. Internal balloon: the inflated balloon within the stomach will keep the tube in position. The balloon should always be inflated with sterile or cooled boiled water to ensure this.
2. External fixation plate: keeps the RIG tube in position next to the skin. Together with the inflated internal balloon this prevents the RIG tube from falling out.
3. Balloon port: used for inflating and deflating the internal balloon
4. End connector: fits into a syringe/feeding administration set by which feed, water or medications can be given.
The PEG procedure involves light sedation and lying flat for approximately 30 minutes. It may be that you will be referred for a RIG tube if these requirements are not suitable for you as this can be performed without sedation and sitting in a more upright position.
Placement of both types of gastrostomy tubes are day case procedures.
You may need to stay overnight on the ward the evening after tube is placed. The tube needs to be used on the ward before going home.
What are the benefits of having a gastrostomy tube placed?
This can be different for each person, however in general having a gastrostomy tube can:
- Allow you to have liquid feed, water and medications if you cannot take these orally.
- Support you to meet your nutritional requirements.
- Reduce the time and stress caused if mealtimes are taking longer.
- By providing an alternative route for nutrition and hydration/medication, a gastrostomy tube can reduce the risk of choking and reduce the risk of food and fluids entering the lungs, which could cause life threatening chest infections.
- Sit discretely under clothing and are less limiting on lifestyle.
What are the risks of having a gastrostomy tube placed?
Having a gastrostomy tube inserted is a relatively safe and routine procedure with a low risk of complications. As with any treatment the risks have to be weighed against the benefits and every effort will be made to reduce the risk of complications.
It is important you are aware and understand the risks before you agree to have a gastrostomy tube placed. The specialist nutrition team will also discuss these with you further on assessment.
Possible major complications of the procedure are:
- Aspiration - this is where saliva or stomach contents (which may return back up your food pipe) may enter the lungs and may cause a chest infection.
- Haemorrhage and bowel perforation - While inserting the feeding tube there is a small risk of internal bleeding (haemorrhage) or puncturing of the bowel (perforation). However, you will be monitored closely during and after the procedure.
- Peritonitis - this is inflammation of the thin layer of tissue (peritoneum) that lines the inside of the stomach covering the organs within this area. This is usually caused by a bacterial or fungal infection.
Following the procedure there may be a small risk of minor complications such as abdominal discomfort, leakage and/or local infection around the gastrostomy stoma site, tube dislodgement and granulation (scar) tissue.
If you agree with your healthcare team that a gastrostomy tube may be right for you, they will refer you to the specialist nutrition team who will then come to the ward to assess your suitability for the gastrostomy procedure.
What are the alternatives to having a gastrostomy tube?
A nasogastric (NG) tube is a small tube which can be used for feeding, hydration and/or medication which is inserted through your nose directly into your stomach. They are designed for short-term feeding over approximately four weeks.
The benefit of an NG tube is that it can be placed at the bedside (without the need for a surgical procedure) and are therefore easily removed when no longer required.
There are several disadvantages to having an NG tube however. These include:
- The tube is very visible and you may feel this coming out of your nose.
- NG tubes are narrower than gastrostomy tubes and in turn may block with feed and medications more easily.
- The correct position of an NG tube needs to be confirmed at each use to confirm the tube hasn't moved and is still safe to use. This is done by drawing up (aspirating) stomach contents with a syringe and testing its acidity using pH strips. This is alongside noting the length of the tube from the nasal passage to be able to assess if any movement of this has occurred.
- If tube position cannot be confirmed by testing the pH of the stomach contents then it may be that you will need an x-ray to confirm the position of the NG tube.
- Sometimes tube position can take time to confirm and could impact on the delivery of required feed volume, hydration and medication as a result.
- NG tubes can displace much more easily than gastrostomy tubes.
- Placement of NG tubes can be uncomfortable and will require replacing at regular intervals according to manufacturer's guidelines (typically every 90 days).
- Having an NG tube in place long term can cause irritation and damage to the integrity of the skin surrounding the nasal cavity and lining of cells within this. This can in turn cause discomfort and will require close monitoring.
Alternatively, you may decide you do not want an NG/gastrostomy tube after weighing up the benefits and risks of these. This is something that the medical team can discuss with you further.
Can I still eat and drink with a gastrostomy tube?
You can still eat and drink with a gastrostomy tube in place unless you have been advised not to do so by your healthcare team.
Your healthcare team will be able to discuss with you whether it is safe to eat and drink or not and the reasons why. This advice and the textures of diet and fluids recommended may vary between individuals.
If you have been recommended a gastrostomy tube due to swallowing issues, it may be that you require ongoing input from the speech and language therapy team; however requirements for this can vary between individuals and your speech and language therapy team will be able to discuss this with you further.
Often a common misconception is that having a gastrostomy tube placed will be a reason for the speech and language therapy team to stop assessing your swallowing function, however you are still able to have this reviewed with a gastrostomy tube in place.
How do I use a gastrostomy tube to feed and receive hydration and medication?
The end of the feeding tube can be connected to a feeding pump or syringe (This will depend on your preferred feeding regimen. Your dietitian can discuss these options with you and provide additional information to help you make that decision). Liquid feed can then be delivered into your stomach via your gastrostomy tube.
Cooled boiled water can be delivered via a pump or syringe. Medication can be altered to liquid preparations where possible to make them easier to administer via syringe into your tube. Alternatively, some medications can be crushed and mixed with cooled boiled water to give via a syringe where appropriate. Your doctor or pharmacist will be able to advise on suitable preparations.
Do I still have to brush my teeth if I am not having diet orally?
Even when you are not eating and drinking, oral hygiene remains very important to maintain your health. Your dentist and healthcare team will be able to advise you on the best way of maintaining your oral health.
What should I expect after my gastrostomy tube procedure?
- For the first few days after the placement of your gastrostomy tube there may be a small amount of leakage. This is perfectly normal and nothing to worry about.
- A dressing will be used for the first 48 hours after the gastrostomy tube has been placed and then only if needed.
- You may experience minor irritation/soreness for a day or two which is quite normal.
- Feeding will need to be established on the ward before going home.
Can I have a shower, bath or swim with a gastrostomy tube?
It is perfectly safe to have a bath, shower or swim with a gastrostomy tube. However, we would suggest initially that you only take a shower for the first two weeks following the procedure with the stoma site covered and do not submerge this in water during this time. It is also important to remember to close the cap of your gastrostomy tube when this is not in use and especially before having a shower, bath or going swimming.
Who will care for the tube?
It may be that you are able to use and care for the tube yourself following training on the ward from a specialist nurse who will show you how to administer feed, water and medications via your tube as required. This will be in addition to showing you how to care for the tube appropriately and how to use a feeding pump if required.
If you aren't able to care for the gastrostomy tube yourself, relatives and/or carers are also able to be trained on the use of this in order to provide the care required.
Following gastrostomy tube placement you will have your nutritional care plan reviewed on a regular basis by your dietitian. Additionally, you will have access to ongoing support from a specialist nurse with regards to the maintenance of your tube and any issues with this should they occur.
How often does my gastrostomy tube need to be replaced?
If you have had a PEG tube inserted this can remain in place for a number of years providing the correct aftercare has been followed. However, a RIG tube will need to be replaced every 3-6 months depending on local policy in order to maintain the integrity of the internal balloon. This will be done in the hospital for the first time, the tube can then be changed in the community.
How long will I need a feeding tube for?
This will depend on the reason as to why you had your gastrostomy placed. It may be suitable for the feeding tube to be removed, if for example, any problems with swallowing have resolved, or that you are able to eat and drink enough to maintain your nutritional and hydration status.
Removal
If you no longer require the use of your gastrostomy tube to maintain your nutritional and hydration status and you are able to take your medications orally then you may be suitable for removal of this.
Where local policies may differ, it is considered best practice that you can demonstrate that you can maintain your nutritional and hydration status and be able to take your medications orally without the use of your gastrostomy tube for four to six weeks.
You will then be referred to the specialist nutrition team if it is felt your gastrostomy tube is no longer required, who will then assess you for appropriate removal of this. It may be that a small procedure is required depending on the type of gastrostomy tube you have in place.
Organisations for additional advice
For those considering a gastrostomy tube, the following organisation's websites may be useful in order to gain further information:
- PENG (The Parenteral and Enteral Nutrition Group - A Specialist Group of the British Dietetic Association) - www.peng.org.uk
- BAPEN (British Association of Parenteral and Enteral Nutrition) - www.bapen.org.uk
- PINNT (Patients on Intravenous and Naso-Gastric Nutrition Treatment) - www.pinnt.com
Further information and support
Visit: thebraincharity.org.uk or call 0151 298 2999 for advice and information for people with neurological conditions and their carers
Department of Nutrition and Dietetics, Lower Lane, Liverpool L9 7AL, Tel: 0151-556-3865