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Thread: Perforation by Feeding Tube Pictures - Duodenum,Ampulla Atlas

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    Default Perforation by Feeding Tube Pictures - Duodenum,Ampulla Atlas

    Introduction
    Percutaneous endoscopic gastrostomy (PEG) and feeding jejunostomy (FJ) are well-established methods of providing access to the gastrointestinal tract to administer enteral nutrition and medication over prolonged periods of time in patients with neurological disorders.

    There is evidence to demonstrate that a FJ is a safe procedure with associated reductions of infective and metabolic complications when compared with total parenteral nutrition Although a relatively simple technical procedure it is not without risk or complication We report a rare complication secondary to insertion of a FJ.

    Case presentation
    A 17-year-old boy was admitted to the surgical ward for insertion of a FJ as his PEG tube was not functioning properly. He had been involved in a road traffic accident at the age of 12 and had suffered diffuse irreversible brain injury that had left him bed-ridden and in a vegetative state. Nutritional issues had been managed successfully for 5 years by means of a PEG tube, until the 'buried bumper' of the tube made feeding difficult. The PEG tube was removed and a FJ tube was inserted via a small laparotomy, 25 cm distal to the duodenojejunal flexure.

    Twenty-four hours later the patient was restless and appeared to be distressed. Clinical assessment was limited due to his inability to communicate. A contrast study was performed into the jejunum to rule out any tube-related complications; this was reported as normal. Water infusion was subsequently commenced through the FJ as per protocol.

    The patient became tachycardic and pyrexial over the next 24 hours and began to vomit. His white cell count was raised at 20 × 109/litre. Chest auscultation revealed right basal crepitations and a plain anterior-posterior chest X-ray showed right lower lobe consolidation. A diagnosis of aspiration pneumonia was made and he was commenced on intravenous antibiotics. The FJ was left on free drainage.

    On the third postoperative day he remained septic in spite of the treatment. Clinical examination showed abdominal distension and tenderness. An urgent computed tomography scan was performed which confirmed right basal consolidation but no leak from the FJ tube and no other bowel abnormality.

    As his condition did not improve the decision to explore the abdomen was made on clinical grounds. At laparotomy the tip of the feeding tube was found to be lying outside the jejunal lumen having eroded directly through the wall of the small bowel (Figure ​(Figure1).1). There was minimal spillage of bile in the peritoneum indicating recent perforation. The FJ was removed and replaced by a new tube positioned distally. The perforation and previous FJ site were closed. The patient was admitted to the intensive care unit postoperatively. He made a slow recovery and was discharged home 3 weeks postoperatively.

    Discussion
    FJ is associated with high complication rates ranging between 15% and 55%. The incidence of major complications is 8% to 20%, with a jejunostomy related mortality of 2% to 10% .

    Mechanical complications are difficult to assess clinically in neurologically impaired patients because of the lack of appropriate communication. This carries the risk of pathologies going undetected for longer periods of time with a subsequent increase in morbidity and mortality. The threshold for imaging and operative intervention should be low in such patients. Despite our repeated efforts to diagnose a tube-related complication we were unable to do so until surgical exploration. This case demonstrates the need for good clinical judgement and a high index of suspicion for tube-related complications, especially in situations where both clinical assessment of the patient and the appropriate investigations fail to provide adequate evidence of the problem.

    A possible explanation for such a perforation is the presence of localised pressure necrosis of the bowel wall caused by constant pressure exerted by the tip of the feeding tube on a single point of the bowel wall. Attempts to prevent this occurring are undertaken by using appropriately designed soft-tipped tubes and by fixing the bowel wall to the anterior abdominal wall to prevent any rotation.

    Choosing the Type of Feeding Tubes to Place
    Gastric tubes are available in a variety of materials, sizes and configurations. The composition of a medical device should be determined by the environment in which it is meant to reside and the properties that are required to perform its function. Materials used for neonatal feeding tubes need to be resilient across wide ranges of pH, gentle to fragile tissues, and have the tensile strength to allow for the largest possible interior lumen in a tube that will have a very small exterior size. A search of currently commercially available products reveals tubes that are labeled as neonatal that are generally made from one of three materials: polyvinylchloride (PVC), polyurethane, or silicone. A few feeding tubes are made of other polymers or mixtures of these products. Tubes found labeled neonatal use range in size from 3.5 fr to 10 fr with an equally wide range of lengths.

    Why is it important that the bedside nurse be aware of the composition of tubes? Each material has advantages and disadvantages. The materials vary in stiffness, strength, ease of placement and cost. Each nursing unit must balance the qualities and costs of tubes in identifying the correct tube for their population.

    For many years, feeding tubes were frequently made of PVC. PVC is relatively inexpensive, but stiff. Feeding tubes made of PVC become stiffer over time when exposed to the acid environment of the stomach. While these tubes are still available commercially, they have fallen out of favor in the last several years due to the stiffness of the product and concerns about exposure to the plasticizer Di (2-ethylhexyl) phthalate (DEHP).
    Perforation Feeding Tube Pictures Duodenum,Ampulla attachment.php?s=adbe708b0753452846e029e99c9955ee&attachmentid=2464&d=1442868593

    Polyurethane is slightly more expensive and has some unique features. Polyurethane becomes softer at body temperature. It is the strongest of the materials currently used; this allows polyurethane tubes to be made with a relatively thin wall that does not easily collapse when suction is applied.The use of polyurethane with its greater strength allows for the largest interior diameter with the smallest exterior diameter. Most commercially available sumped or double lumen gastric tubes are made of polyurethane for this reason.

    The last material is silicone; it is the most expensive material of the group, but is the softest and least likely to cause trauma. The silicone tubes require thicker walls in order to maintain strength and stability of the tube, due to the softness of the material. There is at least one documented case of a feeding tube curling during insertion in the literature; the composition of this tube was not noted. There is also a case report of a Silastic™ (a silicone elastomer) tube becoming knotted inside the patient. There are no data to document the frequency with which these types of complications occur, but there is some discussion among experts that softer tubes may be more likely to coil or turn during placement.

    The available evidence suggests that there may be an important relationship between the material used to manufacture NG/OG tubes and perforation of immature tissues. Case reports in the literature demonstrate that preterm infants are at increased risk for perforation of the oropharynx, esophagus, stomach or duodenum. (See Fig. 1.). As described above, NG/OG tubes manufactured from PVC have been implicated in tissue perforation. Yong et al.[ describe three cases of esophageal perforation in preterm infants following the insertion of a 5 fr NG tube made of PVC. Esophageal perforations have also occurred with the use of silicone tubes. While the rate of tissue perforation is difficult to define, it is imperative that infants are monitored closely for signs of tissue perforation such as pneumothorax, pleural effusion, pneumoperitoneum, and sepsis. In the above mentioned case reports, tube composition cannot be isolated as the single causative agent. In 2005, Filippi et al. published a report suggesting that in a group of infants less than 750 grams the incidence of esophageal perforation might be as high as 1 in 25 when PVC tubes were used and recommended the use of softer materials.

    There has been some discussion, but little research about the use of tubes with end holes or side holes. Some manufacturers have suggested that the use of end holes rather that side holes may decrease stagnation of feeding in the tube and eliminate a space for bacterial growth. A search of the literature did not demonstrate a single study to substantiate this claim. This literature search also found no studies to guide the decision whether to place a tube with an end hole or side holes. If a tube with side holes is chosen, these holes should be in the radiopaque strip of the tube so they can be identified on x-ray and the tube needs to be placed deep enough that all of the side holes are in the stomach.Quandt et al. have demonstrated that the injection of a small amount of air into a feeding tube prior to x-ray allows the tip to be more easily visualized and improves assessment of placement.

    There is a relatively large range of sizes and lengths of feeding tubes available for use in neonates. It is important that the nurse considers the use for the tube when determining the size feeding tube to place. While some authors have attempted to create guidelines, this issue is unstudied and no standard of care exists. The size of the tube affects both the comfort for the infant and how feedings or secretions move through the tube. Poiseuille's Law of Physics notes that resistance to flow through a tube depends on the viscosity of the fluid, the length of the tube, and the internal radius of the tube to the fourth power. This means that small changes in tube size quickly change how easily feedings can flow through a tube, how completely residuals can be aspirated, and how well these tubes can decompress the stomach. Even small changes in tube size can change the functionality of a tube.

    Gastric residuals are frequently used as a measure of feeding tolerance in preterm infants. Gastric residuals are measured by aspirating stomach contents through the feeding tube. Of concern is whether the small bore feeding tubes used in these infants are restrictive and prevent the accurate measurement of gastric residuals. A study of tube feeding in adults demonstrated that when these adults had concurrently indwelling tubes of varying sizes, smaller residuals were obtained from smaller bore tubes and larger residuals were obtained from the larger bore tubes. The ability of tube size and tube composition to alter residual volumes obtained was also documented in a laboratory study using neonatal tubes and frequently used neonatal formulas. The researchers attempted to aspirate a known volume of breast milk or formula mixed with hydrochloric acid to simulate the gastric environment. Tubes with a smaller internal diameter consistently allowed less residual volume to be aspirated.

    Gastric tubes are also frequently used to provide decompression of the stomach. A study by De Boer, Smit, and Mainous examined 326 x-rays for gastric distention and correlated this with the position of the tube and the size of tube in place. They demonstrated a significant relationship between tube size and gastric air; bigger tubes did a better job of decompressing the stomach. The researchers hypothesized that the smaller sized tubes may provide too much resistance to allow excess air to readily escape.

    The features that improve feeding tube function, namely a larger size and a shorter length, are features that are frequently at odds with infant comfort and respiratory effort. As a general rule, caregivers presume smaller tubes are more comfortable and interfere less with work of breathing. The nurse must carefully consider what the tube is being used for, the composition of the tube, and the size of the infant when choosing a tube. The goal should be to choose the smallest tube that will perform the function while minimizing infant discomfort. Unfortunately, little specific data exist to guide these decisions.

    References:
    Medscape: Medscape Access
    Esophageal Perforation: Causes, Symptoms Treatments
    Jejunal perforation caused by a feeding jejunostomy tube: a case report











    Last edited by Medical Photos; 09-21-2015 at 08:51 PM.

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