GASTROSTOMY

Effective Gastrostomy Tube Care

A gastrostomy is the placement of a feeding tube in the upper abdomen, through which food, water and medicine are fed directly into the stomach.

It is the recommended method to prevent and treat repeated inhalations.

Generally

Understanding Effective Gastrostomy Tube Care is crucial for managing feeding and nutritional needs, especially when compared to Levin nasogastric tube feeding. Gastrostomy better protects against food reflux, making it vital for patients with neurological conditions like Parkinson’s, Alzheimer’s, or stroke. These conditions can impair the epiglottis’ function in sealing the airway during swallowing, raising the risk of aspiration where food enters the lungs instead of the stomach. This can lead to bronchopulmonary complications and severe respiratory issues if not properly managed with gastrostomy. In contrast, Levin feeding often serves as a partial solution, as it may keep the esophagus open, causing food regurgitation and discomfort for the patient. Therefore, prioritizing Effective Gastrostomy Tube Care is key to ensuring patient safety and health.

Suctions

Aspiration of food often occurs due to neurological issues (like Parkinson’s, Alzheimer’s, stroke), when the epiglottis fails to properly seal the airway during swallowing. This malfunction allows food to enter the lungs, typically directed to the right lung. This leads to bronchopulmonary foci, or inflammations. Initially, these consequences might be mild and unnoticed, or mistaken as progression of the underlying disease. Over time, secretions in the bronchi increase, prompting relatives to seek medical help for aspiration of these secretions.

This condition gradually reduces the oxygen in the patient’s blood (low hemoglobin oxygen saturation), eventually leading to fever as a sign of formal aspiration pneumonia.

Without timely gastrostomy intervention, the patient’s condition can deteriorate, resulting in respiratory failure. Levine feeding, a common method, offers only a partial solution. It keeps the esophagus open, leading to food regurgitation and significant discomfort for the patient.

Levine or gastrostomy?

Levine and gastrostomy are the two alternatives when the patient presents with repeated aspiration. Although much more widespread than the gastrostomy, the levine has significant disadvantages, the main one being the extreme discomfort of the patient. Patients are condemned to spend the rest of their lives with a foreign body in their nose and throat. They often remove it themselves and for this reason unfortunately in too many cases their hands are tied to the bed.

Gastrostomy: Will the patient tolerate it?

People often ask about the duration of a gastrostomy procedure, especially for patients with conditions like motor neuron disease, those who are debilitated, or have recently recovered from an infection and lost weight. The shorter the gastrostomy procedure, the better the patient can tolerate it. On average, a gastrostomy takes about five minutes in our practice. Some procedures are even quicker, while others might take slightly longer. We measure this time from the moment we start passing the gastroscope into the patient’s mouth to when we complete the gastrostomy.

For such a brief procedure, anesthesiologists only need to use a very small dose of sedative. This ensures the patient remains comfortable and undisturbed by the gastroscope’s passage.

How is it performed?

Gastrostomy used to be done with open surgery. Today the percutaneous endoscopic gastrostomy has completely replaced the old method and so now the open gastrostomy is no longer considered an acceptable method.

Gastrostomy is now performed with a minimally invasive method with the help of the gastroscope. The gastroscope, after proper preparation of the patient, is inserted through the esophagus into the stomach, where it offers a direct view of the inside of the organ. With the help of a fine needle, the gastrostomy tube is passed through the abdominal wall in the most atraumatic way, providing the possibility of administering food, fluids and medicines without the risk of aspiration.

How does it stabilized?

Once the gastrostomy tube is passed through the abdominal wall, the doctor places a round fitting that secures the tube against the skin, preventing it from moving inward. The gastrostomy tube is then cut, and the fitting, to which the syringe or feeding device is attached, is placed on the cut end.

What care is needed

Many people wonder about the proper care for a gastrostomy site. They often ask if they should use sterile gloves, gauze, saline, oxygen, betadine, or another antiseptic. The answer is straightforward: treat a gastrostomy like any other body orifice. A gastrostomy is a body opening through which the stomach communicates with the skin, similar to the mouth. We wash our mouth with water, without sterilization. We should wash the gastrostomy site in the same way – with water, without the need for sterile gloves and gauze.

This approach also applies to other body openings like the anus, which is a small opening where the intestine communicates with the skin. We wash it with water, without antiseptics. Just as we handle the ears, nose, mouth, anus, urethra, or vagina, we should treat the gastrostomy. There’s no difference.

The gauze recommended under the gastrostomy tube’s tray, which contacts the skin, acts like underwear. We wear clean, dry underwear and change it daily or as needed. Similarly, we should change the gastrostomy gauze to keep the area around the stoma clean and dry.

Replacement of the gastrostomy tube

The gastrostomy tube does not need regular replacement, except when it wears out. The first placed can even last a year. The first tube that is placed is replaced when needed either by traction to the outside, or with a gastroscope from the inside.

Subsequent tubes have a second lumen through which an internal fixation balloon (like Folley catheters) is inflated. So subsequent replacements of the gastrostomy tube are very simple.

It is possible to replace the gastrostomy tube with one identical to the one that was placed the first time. The advantages are:

• The length of the tube is long and easier to handle.
• It does not need frequent replacements. 
• There is no way that it will leave its position on its own, as it does not have a balloon inside (which can break), but an internal retaining disc. 

Reinsertion of the same tube as the original one requires a gastroscopy. 

Flat valve (button) gastrostomy

The flat gastrostomy valve is intended for patients who for some reason have gastrostomies but are otherwise healthy enough to be socially active.

E.g. someone who in the summer would like to put on their t-shirt and go outside, not wanting to see the gastrostomy tube under them. 

Gastrostomy feeding

Gastrostomy feeding is done in two ways:

• With a feeding syringe
• Through a special device with gravity.

In this video we present how feeding with a syringe is done. Aiming at the amount that the patient should take in a day, we administer small amounts at intervals of less than an hour.

In other words, we simulate feeding someone who never sits at the table, but often takes small amounts of food. This is the ideal way to feed a patient, so that the possibility of regurgitation and aspiration is greatly reduced.

Passed foods or feeding solutions?

In a patient who has a gastrostomy, what food do we give? The foods we take every day when we sit at the table have only one advantage and too many disadvantages.

The only advantage is:

• The taste

Disadvantages:

• Saturated fats
• Animal and plant hormones
• Antibiotics
• Preservatives
• Pesticides.

Taste greatly affects our quality of life, often leading us to add unhealthy elements like saturated fats, carcinogenic hydrocarbons, and more to our food. These include chicken skin, butter in pastries, or grilling over coals. Even in “healthy” cooking, avoiding hidden cholesterol, hormones, and pesticides is tough.

When feeding a patient through a tube, like with a levain or gastrostomy, the benefit of taste is lost. This leaves only the disadvantages of prepared food. For gastrostomy patients, it’s best to use special nutrient solutions. These solutions contain all essential life ingredients (proteins, fats, carbohydrates, vitamins, minerals) in the right proportions and are free from pesticides, preservatives, hormones, and antibiotics.

Many pharmaceutical companies produce these high-quality solutions, with slight differences for patient-specific needs.

To retain the joy of taste, I suggest giving patients small amounts of their favorite flavors orally. This can include snacks or even alcohol, as small quantities won’t cause harm or induce suction. Meanwhile, they receive complete nutrition through the stoma in the right quantity and quality.

Gastrostomy and suctions

We perform gastrostomies mainly to prevent aspiration, where food and liquids enter the airway instead of the stomach. However, gastrostomy doesn’t fully stop aspiration risk. After we safely introduce food into the stomach, its reaction varies. Ideally, the stomach should push contents to its outlet, but sometimes it causes reflux.

Everyone occasionally experiences reflux, like sourness in the throat. In a gastrostomy patient, the stomach might push fluids upwards, risking aspiration.

To minimize this, it’s best to feed gastrostomy patients small amounts regularly and check digestion before the next feeding. This approach greatly lowers, but doesn’t eliminate, the risk of aspiration.

For patients with dysphagia, oral feeding increases the lung aspiration risk. A Levin tube lowers this risk, but it keeps the esophagus open, allowing stomach contents to rise.

Gastrostomy reduces this risk further as there’s no foreign body keeping the esophagus open. But stomach function remains unpredictable. Reflux can happen even when upright.

Laying a patient down after eating can increase aspiration risk. An elevated position helps, but isn’t foolproof. It’s crucial to feed in small amounts and confirm stomach emptiness before the next meal.

For the most effective aspiration prevention, gastroenterostomy is the best method. It feeds directly into the intestine, bypassing the stomach and almost entirely preventing aspiration.

Gastroenterostomy

Gastroenterostomy becomes necessary when substances administered to the stomach risk moving towards the esophagus and lungs, leading to chemical and microbial pneumonia. This typically happens when the stomach does not properly direct its contents to the intestine.

To perform gastroenterostomy, a medical professional inserts a second, very thin tube through the existing gastrostomy tube. They use a special technique and endoscopy to guide this tube into the small intestine. This ensures that all administered solutions and even the stomach’s own liquids go directly to the intestine, eliminating any chance of them moving upwards towards the esophagus and lungs. This method offers absolute certainty in preventing unwanted upward movement of stomach contents.

Gastrostomy control

When a gastrostomy is present, it is very important that caregivers check the contents of the stomach before any administration. It goes without saying that the same applies in the case of feeding through a nasogastric tube (Levain). This must be done because in some cases the stomach shows reluctance to push its contents towards the intestine. In normal individuals, this prolonged gastric filling is perceived by the brain and the individual avoids further food intake. However, patients who are fed through a gastrostomy are usually unable to express their potential gastric load. If the caregivers do not realize this and administer the next meal, simply because the time has come, then the patient will experience vomiting and then regurgitation with very serious consequences.

Feeding frequency and amounts

To feed a patient with a gastrostomy effectively, you should administer small amounts of food at frequent intervals. Avoid complicated instructions like measuring food with syringes. Instead, determine a total amount of food the patient needs over a 24-hour period and distribute this quantity gradually throughout the day. Regularly check the patient’s stomach to ensure it digests the food.

This method is like someone who nibbles throughout the day instead of having full meals. Small, frequent feedings increase the likelihood of the stomach processing the food efficiently and sending it to the intestine. This approach significantly lowers the risk of reverse peristalsis and the potential for gastric contents to move up towards the esophagus, which can lead to aspiration.

If the stomach struggles with even these small amounts, adjust the feeding plan. You might consider medications with gastro-intestinal benefits or switch to the gastroenterostomy method. Gastroenterostomy involves using a thinner tube through the gastrostomy tube, extending into the small intestine. This ensures that food and fluids bypass the stomach, eliminating the risk of them backing up into the stomach, esophagus, and lungs.

Is the patient taking enough food?