Last reviewed: March 2026
Contents
MDM Templates
G Tube Obstruction
Patient presents with inability to administer feeds or medications through gastrostomy tube. Exam reveals tube in appropriate position without peristomal erythema, tenderness, or signs of infection. No abdominal tenderness or distension.
Tube flushed with warm water using gentle back-and-forth technique. Patency restored. No evidence of tube displacement, peritonitis, or deeper complication.
Disposition: Discharge with instructions on tube maintenance (flush with 30 mL warm water before and after feeds and medications, avoid crushing enteric-coated medications). Follow up with PCP or GI within 1 week. Return for fever, abdominal pain, or recurrent obstruction.
G Tube Displacement
Patient presents with gastrostomy tube that has become dislodged. Stoma site is open and intact. No peritoneal signs. No signs of infection at the stoma site.
If mature tract (>4 weeks old):
Tract is mature. Replacement tube inserted through existing stoma (see procedure note). Confirmation of intragastric placement obtained with Gastrografin instillation and abdominal X-ray. Tube is functioning with successful aspiration of gastric contents.
Disposition: Discharge with GI or surgery follow-up within 1 week for tube position verification.
If immature tract (<4 weeks old) or unable to replace:
Gastrostomy tube dislodged from a tract less than 4 weeks old. Immature tract at risk for peritoneal contamination and tract closure. Foley catheter placed into the stoma to maintain tract patency. Surgery/GI consulted for definitive replacement. No signs of peritonitis on exam.
Disposition: Admit for surgical consultation and formal replacement.
Peristomal Infection
Patient presents with erythema and tenderness at the gastrostomy site. No fluctuance, no purulent drainage, no crepitus. Well appearing without systemic signs of infection. No peritoneal signs suggesting deeper extension.
History and exam consistent with superficial peristomal cellulitis. No evidence of deeper space infection, necrotizing fasciitis, or peritonitis.
Plan: Oral antibiotics — cephalexin 500 mg QID for 7 days.
Disposition: Discharge with return precautions for worsening redness, fever, purulent drainage, or abdominal pain. Follow up with PCP and GI within 48 hours.
If abscess, MRSA concern, or systemic infection:
Peristomal infection with *** concerning for deeper involvement. IV antibiotics initiated. Surgery consulted. CT may be indicated if abscess or deeper extension suspected.
Disposition: Admit.
G Tube Leaking / Granulation Tissue
Patient presents with leaking around the gastrostomy tube site. Tube is in appropriate position and functional. No signs of infection. Exam reveals granulation tissue at the stoma margin. No peritoneal signs.
Plan: Granulation tissue treated with silver nitrate application at bedside. Counsel on skin barrier cream (zinc oxide) around the stoma to prevent skin breakdown from gastric contents.
Disposition: Discharge with GI follow-up for possible tube resizing. Return for fever, worsening leaking, or abdominal pain.
Procedure Notes
G Tube Replacement
Indication: Displaced gastrostomy tube with mature tract (>4 weeks old)
Time Out: Correct patient, correct procedure confirmed
Approach: Stoma site inspected — open and clean without signs of infection. Replacement *** Fr Foley catheter lubricated with water-soluble lubricant and inserted into the tract. Tube advanced to appropriate depth. Balloon inflated with *** mL normal saline. Gentle traction confirms the balloon is seated against the gastric wall.
Confirmation: Gastric contents aspirated from tube. Gastrografin 20–30 mL instilled through tube followed by upright abdominal X-ray demonstrating contrast in the stomach without extraperitoneal leak.
Post-procedure: Tube secured to skin. Dry sterile dressing applied.
Complications: None. Patient tolerated procedure well.
Clinical Education
Obstruction Management
Stepwise approach to unclogging a G tube:[1]
1. Warm water flush with 30–60 mL syringe, gentle back-and-forth technique. 2. If that fails: Coca-Cola instillation (30–60 mL, let dwell 15–30 minutes, then flush). 3. If that fails: Pancreatic enzyme mixture (Viokace or crushed pancrelipase dissolved in bicarbonate solution). 4. If that fails: Mechanical declogging with a Fogarty catheter or commercial declogging device (Clog Zapper).
Prevention is the best treatment. Counsel patients/caregivers: flush with 30 mL warm water before and after each feed and medication, don’t mix medications together in the tube, use liquid formulations when available, and avoid crushing enteric-coated or extended-release medications.
Displacement Pearls
The critical distinction is mature vs immature tract. A mature tract (typically >4 weeks after initial placement) has a well-formed fibrous tract that allows safe bedside replacement. An immature tract can close within hours and the peritoneum has not sealed — replacement carries a risk of creating a false passage or peritoneal contamination.[2]
If the tract is immature and you cannot get surgery immediately, place a Foley catheter into the stoma to maintain patency. Use the smallest Foley that will fit. Don’t inflate the balloon — just keep the tract open until the surgical team can perform definitive replacement.
Always confirm placement after reinsertion. Gastrografin instillation with X-ray is the standard. Aspiration of gastric contents alone is supportive but not definitive — a false passage into the peritoneum can also return clear fluid. Do not start feeds until confirmation imaging is obtained.
Infection Management
Superficial cellulitis is managed with oral antibiotics. Cephalexin is first-line. If MRSA is a concern (prior MRSA, nursing home resident), use clindamycin 300–450 mg PO TID or TMP-SMX 1 DS tab PO BID.[3]
The tube does not need to be removed for simple cellulitis. Tube removal is indicated only for: peritonitis, necrotizing fasciitis, infection not responding to antibiotics, or buried bumper syndrome.
Fungal infection around the stoma (candidal peristomal dermatitis) is common, especially in patients on antibiotics. Satellite lesions and erythematous plaques with a moist, macerated appearance suggest yeast. Treat with topical nystatin or clotrimazole powder.
Buried Bumper Syndrome
Buried bumper syndrome occurs when the internal bumper erodes into or through the gastric wall. Presents with inability to flush the tube, pain during feeding, peristomal leaking, or immobile tube. This is diagnosed endoscopically and requires surgical or endoscopic intervention — the tube cannot be simply replaced at bedside.[4]
Suspect it when: The tube won’t rotate, the external mark has changed position, or there’s new resistance to flushing in a patient with a long-standing tube. Do not apply traction to a tube that won’t move — this can worsen the tissue injury.
Disposition
Admit if: Immature tract displacement (need surgical replacement), peritonitis, necrotizing infection, significant peristomal abscess, inability to maintain tube patency with concern for nutritional compromise, or hemodynamic instability.
Discharge if: Obstruction cleared and tube functioning, mature tract successfully replaced with confirmed placement, superficial cellulitis without systemic signs, granulation tissue treated. Ensure caregiver education on tube maintenance.
References
- Itkin M et al. Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression. JPEN J Parenter Enteral Nutr. 2011;35(1):8-13. PubMed
- Schrag SP et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16(4):407-418. PubMed
- Blumenstein I et al. Gastroenteric tube feeding: techniques, problems and solutions. World J Gastroenterol. 2014;20(26):8505-8524. PubMed
- Cyrany J et al. Buried bumper syndrome: a complication of percutaneous endoscopic gastrostomy. World J Gastroenterol. 2016;22(2):618-627. PubMed
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