Transcript

You’re on call in the middle of the night and one of your patients on tube feeds suddenly  vomits and may have aspirated. Thankfully, their   vitals are stable, they’re oxygenating well on room air, and a chest X-ray shows no significant consolidation. So in the immediate aftermath, things seem okay.  But what do you do next to prevent this from happening again? Well, the answer has to do with  where we’re feeding this patient, and IR might be able to help. Welcome to another episode of Behind the Lead Shield, where we demystify the world of interventional radiology so you can place that consult with confidence and clarity. Let’s talk about enteric access.  So when you’re placing an IR consult, ask yourself a few key questions.  Where in the gastrointestinal system does the problem lie?  Does the stomach work?  Is there obstruction?  Is aspiration the issue?  And what are the goals of care?  Feeding,  decompression,  or both? Ultimately, the right tube depends on the physiology.  Let’s rewind and start with our patient. She’s a seventy-six-year-old woman who was admitted a few weeks ago after a large stroke. Speech therapy confirmed  severe dysphagia.   There was no obstruction or vomiting. So the team said, “Let’s consult IR for a feeding tube.” Fair enough. But the real question is: Where should we feed her?  where we place a tube depends largely on where the problem lies.  In this patient’s initial presentation,  the stomach was functioning normally. Gastric motility was intact, no obstruction, no severe reflux, no gastroparesis.  The problem was in the esophagus.  So in this situation, we place a gastrostomy tube or G-tube directly into the stomach.  A G-tube is a short tube that passes through the skin and abdominal wall and terminates in the  stomach. While they come in many different designs, most have a retention balloon that sits just inside the stomach wall and is filled with a small amount of sterile water to prevent the tube from falling out, similar to a Foley catheter. This allows patients to receive  bolus feeds, medications, and hydration while bypassing the esophagus, which in this case wasn’t functioning well. So if the stomach works, we use it. But things can evolve.  Now we return to the night in question. It’s a few weeks later, and she begins vomiting with feeds. As part of your workup, you obtain a KUB, which shows  its significantly distended stomach. Now there’s concern for severe gastric dysmotility, and if this continues, she may be at risk for a significant aspiration event. So the question evolves, not does she need a tube, but  is the stomach still the right place to feed?  This is when we consider converting a G-tube to a gastrojejunostomy tube or GJ-tube. The access tract and skin site stay the same, but this tube has two lumens,  one that ends in the stomach and a  longer limb that extends through the duodenum and beyond the ligament of Treitz into the jejunum. Feeds can now go directly into the jejunum, which reduces the risk that these feeds will be aspirated. The gastric port can still be used for  medications or for decompression if needed. The physiologic shift here is simple. If the stomach isn’t functioning well for feeding, we bypass it and simply move the feeding downstream. Now let’s change the patient.  Imagine someone with metastatic pancreatic cancer and a high-grade gastric outlet obstruction causing persistent vomiting. Feeding into the stomach is simply not possible here.  In this case, we may place a  GJ tube up front using the jejunal limb for feeding beyond the obstruction and the gastric limb for decompression or medications.  But what if it’s unsafe or  impossible to pass a tube through the obstruction?  In that situation, we may place a primary jejunostomy tube or  J-tube directly into the jejunum for  feeding. A separate  gastrostomy tube may also be placed into the stomach for decompression. This combination is also sometimes used in patients with severe long-term gastric dysmotility or gastroparesis. Ultimately, the goal is always the same. Bypass the area that isn’t working and restore enteric access either for things to go in or for things to come out.  IR manages the downstream issues as well:  dislodgement,  clogging, balloon rupture,  leakage, and  migration of the jejunal limb of the GJ tube back into the stomach.  But there are also some early troubleshooting steps that can help. For example, if a patient with a GJ tube is feeling significant bloating and suddenly vomits their tube feeds, think migration of the jejunal limb. A simple KUB can often confirm that. If there is leakage around the tube, the retention balloon may be deflated, damaged, or not properly apposed to the stomach wall. Gently assessing the tube for excessive mobility can sometimes provide a clue. And of course, when in doubt, call IR. We’re always happy to help troubleshoot. One final point. In IR, we place these tubes percutaneously, so we typically review recent cross-sectional imaging to make sure there is a safe window into the stomach or bowel. The abdomen can be a crowded place, and sometimes there simply isn’t a safe path for a needle. In those cases, endoscopic placement of the tube may be required. So that’s a quick tour of enteric access. Remember, a feeding tube only describes part of the story. These tubes can feed, decompress, or sometimes do both. As always, like, share, and subscribe for more sharp takes from Behind the Lead Shield. See you on the next one!