NASOGASTRIC TUBES/GASTRIC DECOMPRESSION

The prophylactic placement of a polyvinyl chloride or polyurethane catheter, a nasogastric (NG)

tube, or another type of gastric tube after abdominal surgery has become, in many hospitals,
routine. After abdominal surgery bowel motility is often compromised and/or slowed, and this
can cause serious clinical complications. The NG tube is placed with the objectives of:

 Reducing abdominal distention.

 Speeding up the return of bowel function.
 Preventing aspiration.
 Decreasing nausea and vomiting.
 Decreasing the risk of aspiration.
 Decreasing the chance of wound dehiscence and hernia.
 Decreasing the chance of wound separation and infection

ENTERAL NUTRITION

Malnutrition and a poor clinical outcome are associated.12 Some patients cannot meet their
nutritional needs through oral feedings and at that point the clinician may decide on one of
several different tubes for enteral nutrition. They may be critically ill, they may have had head or
neck surgery, there may be a permanent neurological impairment that prevents safe and complete
use of the gastrointestinal tract, they may be malnourished or have increased metabolic demands
or they may be, for a variety of reasons (e.g., old age, dementia) they are unable to feed
themselves. The patient may also be considered a high risk for aspiration when eating by mouth
or there could be other medical conditions (e.g., gastroparesis, gastroesophageal reflux disease)
that require nutritional support. In these situations, the technique of enteral feeding can be used.
Enteral feeding can play a role in both short-term rehabilitation and long-term nutritional
management. The extent of its use ranges from supportive therapy, in which the tube supplies a
portion of the needed nutrients, to primary therapy, in which the enteral feeding tube delivers all
the necessary nutrients. Mechanical obstruction is the only absolute contraindication to enteral
feeding.

Enteral feeding is accomplished by gaining access to the GI tract by using a variety of tubes.
Once access has been gained, feeds can be administered as a bolus intermittently or as a
continuous infusion. Short-term feeding (less than 6 weeks) can be accomplished by placing a
nasoenteral tube into various parts of the GI tract; if the patient requires nutritional support
beyond 6 weeks, it is advisable to gain more comfortable and/or more direct access to the GI
tract through the skin.13 Enteral feeding can be accomplished using a nasogastric tube,
nasojejunal tube, a gastrostomy tube, a jejunostomy tube, or gastrojejunostomy tube.

Tube Position Visual Identification of the Tube

Nose to fundus of A catheter tip syringe or suction
NG tube
stomach. tube attaches.
 Nose to 3rd portion
of the duodenum or
A leur-lock syringe or IV tubing
NJ tube the Ligament of
attaches.
Treitz in the
jejunum.
Has an extra port for a balloon to
Gastrostomy Abdominal wall to be filled with water or saline
tube the stomach. which limits the movement of the
tube.
Jejunostomy Abdominal wall to Only has one port & may be
tube the jejunum. sutured to the skin.
Has 3 ports, 1 for the balloon, 1
Abdominal wall to
for the gastric fluids to be
the stomach and the
GJ tube removed, and 1 for nutrition and
tube is advanced into
medicines to be administered
the jejunum.
directly into the jejunum.

TYPES

Nasogastric Feeding Tubes

The large bore NG tubes that are placed for gastric decompression are seldom used for enteral
feeding. These tubes are too large for comfort and there is the risk of nasal tissue damage and
necrosis from the pressure of the tube if they are left in for a long period of time.

More commonly, a 5-10 French polyurethane NJ tube is used for short-term NG tube feedings.
The NJ tube is commonly packaged with a pre-inserted stainless steel stylet or guidewire. This
tube must be flushed with saline or water to activate the lubricant and allow for ease in removal
or manipulation of the stylet. The NJ tube is very pliable and most frequently it is advanced with
the use of the stylet to prevent buckling. Prior to tube feedings, the stylet should be removed and
the tube flushed to assure it is functioning. The disadvantage to the small diameter feeding tube
is its tendency to clog if not properly flushed post use. This tube can be inserted in the nose and
advanced to the stomach using the techniques described for the bedside placement of NG tubes.
Once placed, the position can be confirmed by an abdominal film. These tubes can also be placed
with an endoscope, using fluoroscopy or ultrasound guidance. Patients with sustained head
trauma, maxillofacial injury, or anterior fossa skull fracture should have NG, OG, and NJ tubes
placed under the guidance of fluoroscopy. Inserting these tubes blindly has the potential of
passing the tube through the criboform plate, thus causing intracranial penetration of the brain
and potentially serious injury.
Nasojejunal Feeding Tubes

Some clinicians believe that enteral nutrition delivered to the small bowel is a better choice than
feedings delivered to the stomach, and will place a NJ feeding tube. This type of feeding tube is more
difficult to place than a NG tube18, but its proponent’s say that it decreases the risk of aspiration, may
provide more calories, and the feeding schedule will be subject to fewer interruptions. However, both
the jejunum and the stomach can be safely used to deliver calories, the differences between the two
types of tubes are minimal, both can be effective, and the decision as to which one to use depends on
the skill of the practitioner and the potential tolerance of the patient.19, 20 The NJ tube can be placed
using an endoscope21 or by using fluoroscopy22 (one study indicated that these techniques were equally
effective23). When choosing fluoroscopy the practitioner must weigh the exposure to radiation, the need
for transport to the radiology department, patient safety, and cost. Some practitioners have reported
success by placing the NJ tube in the stomach and allowing it to spontaneously move into the small
bowel24 and magnetically guided tubes have also been used as well.

Gastrostomy Feeding Tubes

if enteral feedings are needed for a period of time beyond 6 weeks, tubes inserted through the
nose are not appropriate, more direct access to the GI tract is needed, and a gastrostomy tube is
an option for providing nutritional support for patients who are not at risk for aspiration. A
gastrostomy tube is a polyurethane or silicone feeding tube that is inserted through the abdominal
wall laprascopically, by an open surgical technique, or more commonly by using an endoscope.
The surgical technique is seldom used.28

The percutaneous endoscopic gastrostomy (PEG) technique is the one most often used. In this
procedure, sedation and analgesia are administered and an NG tube is placed. The stomach is
distended with air, a medication that decreases intestinal movement (e.g., glucagon) is given, and
an endoscope is inserted.29 The position of the endoscope in the stomach can be seen through the
abdominal wall because of the very strong light at the end of the endoscope and the proper site
for insertion of the tube can thus be determined. The most common method of placing a
gastrostomy tube with the endoscope is by using the pull-through method.30
In the pull-through method, a skin incision is made through the abdominal wall. A guide wire
with a suture attached is advanced through the gastric puncture site into the stomach. The suture
is grabbed by a snare inside the endoscope and pulled up through the esophagus. The endoscope
is removed leaving the guide wire in place. The G-tube is then attached to the suture on the guide
wire. By applying tension on the guide wire, the G-tube will be pulled through the mouth,
esophagus and out through the abdominal wall. A pliable mushroom or bumper low-profile tube
is generally used. The endoscope is once again inserted to visualize the interior of the stomach
and check for bleeding. Although this is the most common method for placing a G-tube with the
endoscope, a patient’s condition could warrant a push-through method. The push through method
is frequently used on patient’s who have esophageal disease. In the push-through technique, an
incision is made through the abdominal wall into the stomach. A guide wire is placed through the
incision into the stomach. The tract is dilated and the G-tube is pushed through the abdominal
wall over a guide wire into the stomach. The tube is held in place by a saline or water inflated
balloon or by a retention flange.
Jejunostomy Feeding Tubes

A Jejunostomy tube is a time-proven method of providing nutritional support; a feeding tube is

placed directly through the abdominal wall into the jejunum. It is particularly useful in patients who are
at high risk of aspiration of feedings delivered to the stomach, patients with non-functional stomachs,
patients with esophageal carcinoma or chronic pancreatitis, and patients who have had a total
gastrectomy.37,38 The classic technique of placing a J-tube is the direct percutaneous endoscopic
method. An anti-peristaltic drug is given and an endoscope is placed into the stomach and on into the
jejunum. The powerful light at the end of the endoscope is used to ensure that the endoscope is in the
proper position and to identify the proper insertion site. Once the appropriate site has been located, a
needle is passed through the abdominal wall and into the jejunum. The needle is visualized with the
endoscope, the tip of it is grabbed with a snare, and the jejunum pulled into and held up against the
abdominal wall. A trocar is placed over the needle and advanced into the jejunum and the jejunostomy
tube is passed through the trocar.39 Although this technique has a relatively high success rate, it is not
simple or easy to do. The jejunum cannot be opacified, it is mobile and difficult to maintain in the proper
position during the procedure, and it is easily decompressible.40,41
Gastrojejunostomy Feeding Tubes

A GJ tube is a dual lumen tube that is inserted through the abdominal wall. One lumen is
open to the stomach and the other lumen is open to the jejunum. These tubes are used when patients
need nutritional support, but the stomach cannot be used and there is also a need for gastric
decompression. A single lumen GJ tube is also available when direct access to the stomach is not
required for gastric drainage or the administration of medications. GJ tubes were first introduced
approximately four years after the introduction of PEG tubes, and there is much less clinical experience
with their use.48 These tubes are appropriate for patients with severe gastroesophageal reflux disease
and oropharyngeal dysphagia, patients with gastroparesis or functional gastric dysmotility caused by
sepsis, pancreatitis, or narcotic therapy, or who are status-post pancreaticoduodenectomy.49,50 They are
commonly placed via endoscopy, but fluoroscopy can be used, as well.51 One study noted that using
fluoroscopy to place GJ tubes resulted in a higher success rate and fewer complications when compared
to the percutaneous technique.52 Although these tubes have their proponents and appear to be of some
clinical value, several authors have reported high rates of complications (e.g., more hospital days, bowel
obstruction, intussception, lack of weight gain, aspiration, mechanical tube problems) and the need for
more frequent tube replacement.53,54