G/GJ tubes: Low-profile combination G/GJ tube

What is a low-profile combination G/GJ tube?

A low-profile combination G/GJ tube is a type of feeding tube that provides fluids, nutrition and medications directly into the small intestine (jejunum) through the jejunal feeding port. There is a second port that gives access to the stomach for venting and a third port for balloon inflation. The balloon keeps the low-profile combination G/GJ tube in place. It is called "low-profile" because it sits close to the skin and is very discreet. Low-profile combination G/GJ tubes are placed by an interventional radiologist using image guidance.

The low-profile combination G/GJ tube is placed through an opening in your child's abdomen called a stoma. The tunnel from the outside through the stoma is called the tract.

Low-profile combination G/GJ tube

The port labelled "Gastric" on the side of the tube, is used to access the stomach. This port is usually used for venting.

The port labelled "Jejunal", on the top of the tube, is used to access the small intestine. This port is usually used for feeding, medications and fluids.

Inside both ports is a one-way valve. This valve helps prevent stomach and jejunal content from flowing back out through the tube.

A low-profile combination G/GJ tube is not used for primary tube insertion. This means that your child will have a different type of feeding tube first, and may then transition to a low-profile combination G/GJ tube after a few months.

How is a combination G/GJ tube different from other types of tubes?

Low-profile combination G/GJ tubes are different than surgically inserted J tubes. While both tubes are inserted into the small intestine, the low-profile combination G/GJ tube enters through your child's stomach, passes through into the first part of the small intestine and ends in the jejunum. Surgical J tubes are inserted directly into the jejunum by a surgeon in an operating room.

The low-profile combination G/GJ tube is also different from a low-profile GJ tube. Both types of feeding tube provide fluids, nutrition and medication directly into the small intestine, however the combination G/GJ tube has a gastric port through which gas can be vented from the stomach, while the low-profile GJ tube does not.

The G tube team provides support related to both low-profile combination G/GJ tubes, low-profile GJ tubes and surgical J tubes after insertion.

Giving feeds, liquids and medication through the low-profile combination G/GJ tube

Your child's tube feeds are to remain the same as with previous GJ or combination G/GJ tube exchanges.

A Mic-Key low-profile combination G/GJ tube extension set needs to be attached to the jejunal feeding port to administer feeds and medications. As well, an extension set needs to be attached to the gastric port to vent the stomach. Both extension sets can be connected at the same time to allow you to vent the stomach during feeds. A slip-tip syringe can be attached directly to either port; however, this is not recommended as the one-way valve can break with frequent access by syringes.

It is important to clean the extension sets between each use and remove them from the low-profile combination G/GJ tube when they are not in use. The extension sets should be replaced as needed (i.e. broken, rigid, stained).

Using the extension, flush the jejunal port with at least 5 to 10 mL of water before and after each tube feed and medication dose, and every 4 hours during continuous feeds to help prevent the tube from becoming blocked. To ensure this flush volume is safe for your child, discuss with your child's health-care team. Some children may also require flushing into the stomach, using the gastric port. Only do this if your health-care team has told you to.

Caring for your child's low-profile combination G/GJ tube

The balloon port of your child's low-profile combination G/GJ tube helps to keep the tube from accidentally being pulled out.

Here are some things to remember when caring for your child's low-profile combination G/GJ tube:

• Do not feed your child through the balloon port
• Do not fill the balloon with saline solution or air
• Filling the balloon with more or less sterile or distilled water can affect the position of the tube

The doctor who inserts the tube may fill the balloon with less than the recommended balloon volume. If this is the case, you will need guidance from your health-care team before you increase the balloon volume.

Filling the balloon with more or less sterile or distilled water can affect the fit of the tube against the skin. Less water in the balloon makes the tube sit looser and stick out from the skin. More water in the balloon makes the tube sit tighter and closer to the skin. If the tube is so tight you can see an indent in your child’s skin, you can decrease the amount of water in the balloon. If the tube sticks out too much and is dangling from the stoma, you can increase the amount of water in the balloon. If adjusting the balloon volume does not help with the fit of your child’s tube, you may need to have the tract re-measured by your G tube specialist.

Checking the volume of water in the balloon

It is important to check the amount of water in the balloon at least once a week. Use a 5 mL slip-tip syringe to do this.

1. Insert a 5 mL syringe into the low-profile combination G/GJ tube's balloon port (marked "BAL").
2. Remove all the water from the balloon. Throw the removed water away - do not reuse it. It is normal for the removed water to be discoloured. You may re-use the syringe as long as you wash it well with hot water and soap.
3. Re-inflate the balloon with the amount of new sterile or distilled water you usually use to inflate the balloon.

It is normal to remove 0.5 mL less water from the balloon than you originally put in. This is because some of the water has evaporated.

If there is no water after attempting to withdraw, re-inflate the balloon with 5mL of water. After three to four hours, attempt to withdraw this water.

• If you get all the water back, the balloon may simply have been empty before. You can then re-inflate the balloon with the amount of water you normally put in. Check the balloon volume every two to three days to make sure there are no further problems.
• If you do not get any water back when you withdraw after three to four hours, the balloon is likely damaged and the tube will need to be replaced.

If you are concerned that the balloon is broken, there is a risk that the tube may be accidentally pulled out. Tape the tube in place until you can contact your G tube specialist to arrange an appointment for a tube change in a radiology department.

If you see excessive leakage from either the gastric or jejunal port, it means the one-way valve is likely broken and the entire tube will need to be replaced in a radiology department. This is not an emergency. You can leave the extension set in the port to prevent leakage until the tube can be changed.

Skin care

Keep the stoma and surrounding skin as dry and clean as possible. Dressings and tape are not needed with a low-profile combination G/GJ tube.

Despite your best effort to keep your child's skin around the stoma healthy, some common skin problems may occur including:

• infection
• sensitivity and irritation
• hypergranulation tissue
• leaking stoma

When to seek medical attention

Contact the G tube specialist if you notice any of the following signs and symptoms:

• Your child's stoma site appears infected. Signs of infection include redness, edema (swelling) and odorous discharge.
• There is hypergranulation tissue, which is pink to bright red, bloody, raw, moist, oozing yellow sticky discharge and/or painful.
• The stoma site is leaking intestinal or stomach contents and/or formula.
• The gastric port is leaking stomach contents.
• Your child experiences abdominal pain, distension, discomfort, vomiting and/or other signs of feeding intolerance.
• Your child has signs of respiratory distress (i.e. higher breathing rate or difficulty breathing).
• The tube appears to be damaged, broken or dislodged.

If the tube has moved into the stomach

If the low-profile combination G/GJ tube has moved out of the small intestine and into the stomach, your child may experience:

• increased vomiting
• vomiting formula
• gagging and retching
• abdominal discomfort or pain
• bloated stomach
• diarrhea
• leaking of formula from the gastric port or stoma

The position of the tip of the combination G/GJ tube will need to be confirmed by an interventional radiologist using image guidance. Do not use the tube for feeding until the tube position is confirmed.

Intussusception

Intussusception may occur around the tube. Intussusception is when one part of the small bowel slides into the next part. This can happen at the tip of the combination G/GJ tube. Large combination G/GJ tubes and/or normal movements of the bowels may cause intussusception.

A child with intussusception will experience:

• discomfort and feeding intolerance (vomiting when fed)
• vomiting bile (green fluid)
• diarrhea or blood in the stool

If you think that your child’s tube has intussuscepted, contact your G tube specialist during business hours. After hours, on weekends or on holidays, take your child to the Emergency Department.