Introduction to, and care of, a balloon gastrostomy tube placed by:

• radiology (x-ray) procedure performed in the radiology department
• gastropexy procedure performed via gastroscopy in the endoscopy department.

What is a balloon gastrostomy tube?

A balloon gastrostomy tube (BGT) is a flexible feeding tube, usually made from silicone. On the outside of your body, the tube is visible with two ports at the end. One port is for feeding and this is where your feeding equipment will be connected. The other port is the balloon inflation valve and is used to deflate and re- inflate the balloon which secures the tube inside your stomach.

Why may I need a BGT?

A BGT is used to feed a person straight into their stomach if they have a problem feeding by mouth, cannot maintain their weight or are unable to digest food. It can be used either to meet all of their nutritional needs or to supplement oral diet.

What does it mean to have a BGT placed by either radiological or gastropexy procedure?

Gastropexy procedure

Following information and consent this procedure is undertaken in the endoscopy department. You will have a gastroscopy, where the stomach is secured to the abdominal wall using three small clips. These clips are known as T-clips. Once the stomach is secure, the doctor inserts a BGT through a small incision and inflates the balloon with water to prevent the tube from falling out.

Radiological procedure

Following information and consent this procedure is undertaken in the radiology department. In much the same way as the gastropexy procedure the stomach is secured to the abdominal wall. These clips are known as T-clips. Once the stomach is secure, the doctor inserts a BGT through a small incision and inflates the balloon with water to prevent the tube from falling out.

If you experience pain on feeding or external leakage of stomach contents or fresh bleeding is noted within 72 hours of insertion of your tube, stop feeding and urgently contact and attend your nearest A&E department.

What can you expect after your procedure?

You will be able to see the three T- clips sitting on your skin over your stomach. Sometimes these clips are dissolvable and fall out on their own. If they don’t fall out after two weeks, or they are not dissolvable, it will be necessary to contact your community nurse, enteral feed company nurse or GP surgery to get them removed.

Daily care

Each day you will need to provide the following care for your feeding tube.

Checking position

The tube has centimetre (cm) markings on it, check every day that the cm marking at the level of your skin is the same. It is really important that the tube does not move. If the cm marking changes this may be an indicator the tube has moved. If the cm marking at skin level has changed, please contact your enteral feed company nurse or community nurse for advice before commencing feeding.

Cleaning your BGT

• Wash your hands according to your hand hygiene
• Gently remove any dressing the day after tube
• Every day carefully clean daily around the gastrostomy site (also known as stoma), under the external fixation plate and around the tube and clips with water and a disposable cloth or gauze and
• When the site is better established after 10 to 14 days it may be cleaned with a mild soap and water, and then dried.
  • You may have a shower; be careful not to direct the flow of water directly at the stoma site. Cap off the end of the tube prior to If you can only have a bath, it is important to avoid soaking the stoma. Please ensure that the water level lies below the stoma site.
  • You may have a deep bath or go swimming after the site has healed, generally after about two to three weeks. Make sure the tube is secured and capped.
  • Do not use creams or talcum powder near or around the stoma site - to reduce the risk of irritation and breakdown of the tube.
• If the site is dry then no dressing is needed. If there is any discharge around the stoma please ask your community nurse for advice.

If you experience any of the following symptoms it could indicate that the site is infected. Please contact your GP, enteral feed company nurse or community nurse for advice if you notice:

• oozing or odor coming from the stoma site
• redness
• soreness
• raised area
• you have a temperature or feel

After two weeks and the T–clips have fallen off or been removed by a healthcare professional please follow the advice below.

Rotating and advancing your tube

Rotating and advancing your tube is important to help healing and reduces the risk of the tube sticking to the stoma tract and embedding in the stomach wall. This is called buried bumper syndrome and could result in a hospital admission.

1.    Rotation: Each day you should rotate the tube through a full circle (360°) (or if your doctor has asked you to do something different make sure you have specific instructions in a care plan).

2.    Advancing: Do not move the external fixation plate for the first 14 days to allow the stoma tract to heal. Then the external fixation plate can be moved away from the body and the tube advanced 2cm into the stoma. Return external fixation plate to its original position 0.5 to 1cm away from the skin. This needs to be done at least once a week, unless you are advised to do something different by a health care professional and have a care plan to support this.

What if I can’t advance or rotate my tube?

If you are unable to advance or rotate your tube you need to seek advice from your enteral feed company nurse, as the tube may have become stuck to the stomach lining. If this happens you may require medical intervention, this is called Buried Bumper Syndrome.

Checking balloon inflation

Unless you have been advised, whilst the clips are in place please do not deflate or re-inflate the balloon, as the clips may puncture the balloon and it may displace as a result.

The balloon in your BGT is holding your tube in place. It is essential after the t-clips have fallen off, or have been removed, to check the water in your BGT every week. This is to make sure that the balloon has water in it and is not leaking or perishing.

Cloudy fluid, a significant reduction in water volume in the balloon, or a very loose tube may indicate that the balloon has burst or is leaking. If this is the case you may require a replacement tube.

You should have been shown how check and replace balloon water by your enteral feed company nurse, but please find the steps below to help you. If you are finding this difficult or need further support please contact your feed company nurse.

You will need:

• Cooled boiled water
• 2 Luer slip syringes (5 to 10 ml)
• Gloves and apron if you are a

1. Following the hand hygiene advise wash and dry your
2. Check your cm marking is normal and then using a the Luer slip syringe draw up new cooled boiled water to be inserted into the balloon.
3. Holding the gastrostomy tube firmly in place throughout. Insert an empty Luer slip syringe into the balloon valve.
4. Draw back with the syringe and completely remove all the water from the You may need to do this twice to ensure all the water is removed. Note the volume and appearance of water that has been removed. Disconnect and discard the syringe.

NB: Cloudy fluid, may indicate that the balloon has burst or is leaking and will need further assessment by a health care professional. Tape the tube down and seek advice from your enteral feed company nurse or HEN Team.

5. Attach the syringe of clean water to the valve, push the plunger, and re-inflate the balloon gently. Detach and discard the syringe.
6. Gently pull the tube to check for resistance and check the cm marking at skin level hasn’t changed. Both of these checks will help confirm the tube is secure. If not please contact your enteral feed company nurse for advice.

Never fill the balloon with air.

Flushing your tube

If you are not using your gastrostomy tube for feeding please ensure you flush the tube at least once a day with fresh tap water to prevent the tube from blocking. Your dietitian can advise you on a suitable amount.

Method

• Wash your hands as per your hand hygiene
• Place all the equipment you require on a clean surface, i.e. 60ml syringe, measured water in a jug or cup.
• Ensure that the position of the feeding tube has not moved by checking the skin level centimetre

Either

1. Remove the cap from the end of your tube.
2. Remove the plunger from the syringe and attach it to your feeding tube.
3. Use your syringe as a funnel to slowly pour the correct amount of water into your feeding tube, keeping the syringe higher than the stoma site.
4. Remove the syringe and recap your tube.

or

1. Draw up the required amount of water into your syringe.
2. Remove the cap from the end of your tube. Attach the syringe to your tube and slowly press down the plunger in the syringe to flush water into the tube.
3. Remove the syringe and recap your tube.

• When flushing your tube, try to avoid emptying the tube completely by closing the clamp before all the water has gone through. Otherwise air can then enter your stomach and make you feel uncomfortable and bloated.
• Try to remain upright for at least 30 minutes after a feed or flush to help prevent reflux and
• The syringe can be disposed of in your normal household

When will my tube be replaced?

This tube will routinely be changed every four to six months. Usually this can be done at home but, may need to be done in hospital for the first tube change or if there have been any complications.

Please make sure you know when and where your tube is to be replaced. If you are unsure please contact the HEN Team or your enteral feed company nurse who will be able to help you.

It is important for you to carry a spare balloon gastrostomy tube with you at all times, should your tube fall out.

If your tube falls out within the first eight weeks of insertion, replacing the tube correctly can sometimes be more difficult. If you have not been given special instructions by your doctor to attempt tube replacement, cover the stoma tract (contact the HEN Team in working hours) and make your way to your nearest A&E department with your spare tube in-hand.

If your tube has been in longer than eight weeks please see your leaflet: What to do if your gastrostomy tube comes out or view online at www.kentcht.nhs.uk/leaflet/what-do-to-if-your-gastrostomy-feeding-tube-comes-out/

Please act swiftly as your stoma can close quickly, which if not acted on could result in hospital admission.

Further assistance

If you feel that you have exhausted all advice in this leaflet and you are still concerned please contact your nurse or HEN Team.

Information for carers

Remember to document your observations and care given.