Percutaneous gastrojejunostomy tube

The gastrointestinal tract is a long connection that extends from the mouth to the anus. Food travels from the mouth, to the esophagus, to the stomach, to the small intestine, to the large intestine, and finally out through the anus. The small intestine is broken down into three parts: the duodenum, jejunum, and ileum

Gastrojejunostomy Tube (GJ Tube)

A gastrojejunostomy tube is a two part tube placed into your stomach and in your small intestine. The G portion of the tube is in your stomach and the J portion is in the small intestine. The tube is held inside by a balloon in the stomach as well as a skin disc on the skin surface. These are placed if you have severe reflux or slow movement of stomach contents (Gastroparesis) and have had aspiration events where gastric contents go into the lungs. If that is happening or is a risk for you your doctor may want you to have a Gastrojejunostomy GJ Tube to “vent’ the stomach and give nutrition past the stomach into the jejunum.

They can be placed surgically in the operating room and percutaneously by an interventional radiologist. There is also a similar tube called a PEG J tube that is placed endoscopically by GI. A “PEG” tube with a Jejunal extension through the center of the G tube.

Ports of the GJ Tube (See Figures 2a and 2b that show the one tube with one port that exits in the stomach and the other that extends into the jejunum).

Gastric port - Sits in the stomach and is used to vent air, drain fluids, give medicines, and sometimes to give feedings.

Jejunal port - Sits in the small intestine and is used for feeding.

Balloon port - Connects to the balloon which sits inside the stomach and holds the tube in place.

Figure 2a. GJ tube.

Figure 2b. Image of a GJ tube showing the retention balloon inside the stomach and the two different access ports labeled Gastric and Jejunal.

Other Types of Gj Tubes

Low profile GJ tubes are available but are used less often (Figure 3).

Wash your hands with soap and water before and after care.
Remove old dressing if a dressing is being used. Check for redness, swelling, any drainage or excess skin growing around the tube. A small amount of clear-tan drainage can be normal.
Wash skin around the tube with soap and warm water. Clean around the G tube to remove any drainage and/or crusting. Rinse soap off with clear water and dry thoroughly. Keep this site clean and dry.
A dressing may be used around the G tube site. If a dressing is used it can only be placed above the external bumper. If the gauze dressing is placed under the external bumper/ retention disc it will cause the disc to slide up and the site will leak. If this happens remove the gauze and gently slide the disc down against the skin.
If your skin is irritated around the tube you can use a barrier cream. If your provider has provided one you can use that or you can purchase something over the counter such as something like “Butt Paste” or “Desitin” that are used for diaper rash.
After the first 5-7 days you can shower and get the site wet and pat the sire dry gently after. Do not submerge your tube in a bath, pool or hot tub.
It is OK to be physically active although you should not lift anything greater than 10 lbs for the first 2-4 weeks after placement.
During activities, keep the tube secured below clothing.

Flushing the GJ Tube

Flush the G port and J port with at least 30 ml of water:
- Every 6 hours even if feedings running through a pump.
- Before and after any bolus or syringe feeding.
- Before, between and after any medications.
- The J portion of the GJ tube is very narrow and can clog easily so it needs to be cared for carefully.
Since the Jejunal (J) limb of the tube is longer you may even need to flush that port with 45-60 ml water to keep it from clogging.

Administering Medications

Try to get your medications in liquid form to try to keep your tube from clogging.
For pills, check with your doctor or pharmacist before crushing any medications. If you are on a medication that is extended release then it should not be crushed.
If your pills are in tablet form then crush the tablet well and mix with warm water to give the liquid mixture through your tube.
Always give one medication at a time and give water in between each medication to prevent clogging.
For capsules, check with your doctor or pharmacist before opening the capsule. Open and dissolve powder with enough water to make a liquid.
Medications such as Flomax and Prilosec have little hard round pellets inside the capsule and these will clog your tube. Contact your doctor to change these medications to an alternative.
If the tube is sluggish stop and put papaya enzyme into the tube to improve the flow BEFORE putting medications.

Gravity Feedings

Hang the feeding container 2 feet above and to the side of the feeding tube.
Remove the cover from the end of the feeding set.
Prime the feeding set by letting the formula flow until it comes out the end of the tube.
Sit straight up on a chair.
Flush the G port with at least 30 ml of water.
Insert the tip of the feeding set into the G port.
Slowly open the clamp on the feeding set.
Set the flow to your feeding plan. Use the clamp to control the flow until you get your desired rate.
When the feeding is done, close the clamp on the feeding set and then disconnect it from the G port.
Flush the G port with at least 30 ml water afterwards.

Syringe Feedings Drip Method

Sit straight up on a chair.
Flush the GJ tube with the prescribed amount of water.
Remove the plunger from the syringe.
Place the syringe tip into the GJ tube and hold the syringe above the stomach.
Pour the amount of formula into the syringe.
Allow the formula to flow into the feeding tube via gravity until it is gone.
Flush the GJ tube with the prescribed amount of water.

Syringe Feedings Push Method

Sit straight up on a chair.
Flush the GJ tube with the prescribed amount of water.
Draw the amount of formula into the syringe by pulling back on the plunger.
Place the syringe tip into the GJ tube and hold the syringe above the stomach.
Slowly inject the formula into the feeding tube using the plunger
Flush the GJ tube with the prescribed amount of water.

Pump Feedings (If you had a GJ tube placed it was likely so that you can get feedings past the stomach into the Jejunum also called post pyloric feedings.

If you are getting your feedings through the jejunal portion of your GJ tube this can not be done by gravity or with the syringe. The Jejunum is a smaller reservoir than the stomach so you can not get a large volume of feeds at once or you will have bloating, abdominal pain and intolerance of your feeds. Jejunal feeding is generally done via a feeding pump so give the feeding more slowly over time.
If you are going to get your feeding through a pump the pump should have been arranged with home health and the home health nurse can give you instructions on how to use the pump.
Flush your G or J port being used for feedings with at least 30 ml water before feeds, every 6 hrs while they are running and any time the feeds are held to prevent your tube from clogging.

Venting the G portion means letting fluid or gas out your stomach. This can be used to prevent fullness and bloating and treat nausea. The G portion is meant for venting and not the J port. The Jport will not effectively vent. Even if the gastric port of the GJ tube is only being used for venting it should still be flushed at least twice a day with 30 ml water.

Using a syringe to vent

Pull the plunger out of the syringe
Open the end of the G portion
Attach the syringe without the plunger to the end of the G tube
Position the tube and syringe above the stomach, allowing air to rise.
If needed, unclamp the tube.
After venting, remove the syringe and flush the G portion with water to clear the tube and clamp the tube.

Manually venting a feeding tube

Open the end of the G portion
Attach the syringe to the of the G portion
If needed, unclamp the tube
Slowly pull back on the syringe to remove air from the stomach
After venting, remove the syringe and flush the G portion with water to clear the tube
If needed, clamp the tube

Attaching a drainage bag for venting of your tube.

Open the end of the G port and attach it to a drainage bag.
If you have an “en fit” style tube there is a specially en fit drainage bag that screws on to the end of the G port with a special leuer lock device.
If you have an older “legacy” style tube you can attach a drainage bag generally used for a foley catheter to drain fluid and gas
Empty the drainage bag as needed.

Uncontrollable nausea and/ or vomiting:

Open the G port to vent the tube if you have not already done so.

Dislodgement

Try to replace the tube into the opening about 1-2 inches and tape the tube to your abdomen. Then call your care team. DO NOT USE THE TUBE.

Leaking

A small amount of leaking around the G tube is normal. You can apply a dressing at the Gastrostomy tube site if there is drainage.
Most times when the G tube site is leaking it is from the external bumper/ retention disc having loosened. This happens from the gauze being placed under the disc and slides the disc up. You may notice your home health nurse place the gauze under the disc since nurses used to be taught to do that, however, it is no longer recommended. Check the disc daily and if it has slid up away from the skin gently slide the disc back down until it is against the skin. This usually will fix the leakage.
Other times, the tube site can leak if the tube got pulled on forcefully accidentally and the site gets stretched out. With good skin care keeping the skin as dry as possible and with good nutrition the site will heal.
You may hear someone mention “upsizing” the tube or making it larger if the site is leaking. This will actually make the problem worse and is not recommended.

Skin or excess tissue growing where the tube enters skin

This is called granulation tissue, which is the body’s natural response to the tube. It is normal for this tissue to bleed a little when bumped or irritated. Call your care team to discuss treatment. This is not an emergency but should be addressed in a timely manner. Your provider can use silver nitrate sticks at the site to treat this.

G or J port is sluggish

If you notice you are having to push a bit harder to flush your tube this is when you should intervene. Do NOT wait until it is completely clogged or you may need to go back to the provider that placed the tube to have it exchanged.
You can use papaya enzyme from your local vitamin store to help the flow through your tube. Take two tabs and crush them and mix them in warm water. Instill this mixture into the tube and leave it in the tube for 1-2 hours and flush with warm water after.

G or J Port of your GJ tube is completely clogged

Once the tube is completely clogged your options may be limited so it is important to intervene before it completely clogs.
If it is clogged you can try to slowly push /pull warm water in and out of the tube to try to break up a clog. Do not push hard forward or you may rupture the clogged tube. Never put any object into the tube to unclog it. If you are unable to unclog the tube, call your provider to arrange to have the tube exchanged.

Call your doctor and seek immediate medical care if you notice the following signs and symptoms:

Signs of infection
- Increase pain, swelling, warmth, redness around drain site
- Pus draining from the insertion site
- Fever
Sudden change in color and smell of your drainage.
Tube is coming loose out of your insertion site.
The site is leaking excessively and you have already checked the disc and slid it down if needed.
Your tube is clogged and you are unable to unclog it.
Your tube is broken.

Percutaneous gastrojejunostomy tube