This is a guide for replacing a balloon gastrostomy tube (BGT). Please read the list of equipment and instructions before proceeding. The procedure should have been demonstrated and taught by an individual who has completed their competency training.

If you do not feel confident in changing the balloon gastrostomy tube, please contact the Home Enteral Nutrition (HEN) Team for advice and support. 

Equipment

You will need:

• balloon gastrostomy tube (of correct type and size)
• two appropriately sized luer slip syringes
• sterile water or cooled boiled water for balloon
• lubricating jelly (water soluble) or water
• water to clean stoma
• pH test strips
• water for flushing
• two 60ml syringes for aspiration and flushing
• appropriate personal protective equipment
• non-sterile gloves.

Preparation

Make sure you check the following before completing the procedure:

1. Stop the feed two to three hours before changing the BGT.
2. Do not give acid reducing medications on the day of the procedure.
3. Explain the procedure, give reassurance and gain consent to continue.
4. Collect the equipment listed above.
5. Check the size and expiry date of the new BGT. If the BGT has expired, then a new BGT needs to be ordered before changing the tube.
6. Wash your hands and apply suitable personal protective equipment.
7. Check the stoma for contraindications to a tube change. This could be signs of infection, over-granulation of the stoma site or if there is any sign of trauma. You may need to delay the tube change or seek further advice from your feed company nurse, community nurse, GP or HEN Team before proceeding.

Procedure

The procedure will involve checking the balloon in the new gastrostomy tube is functioning before placing the tube safely, making sure it is in the correct position for use.

1. Position the person comfortably, ideally lying flat with their head slightly raised to aid insertion of the BGT. If you do not usually change the BGT, please check with the patient and the person who usually changes the BGT for the most comfortable position.
2. Check the length of the gastrostomy tube at skin level using tube cm markings.
3. Attach one of the 60ml syringes to the gastrostomy feeding port and withdraw some fluid from the tube. This is stomach contents. Check and note the pH before the change takes place. If the pH is above 5.5, wait for 30 minutes and check again. If it remains 5.5 or above, check the person had stopped antacids and has not been fed in the past two hours. Delay the procedure if the pH remains above 5.5. Contact a healthcare professional if in any doubt about how or when to proceed.
4. Clean stoma and remove gloves.
5. Apply a fresh pair of gloves.
6. Prepare the equipment.
7. Draw up correct volume of sterile water or cooled boiled water for the BGT in an appropriate size syringe (use manufacturer’s instructions).
8. Test the new BGT by inflating the balloon using the water in this syringe to make sure the balloon is equal and intact, move the external fixator to check it moves freely. Remove the water from the balloon with the same syringe for use later.
9. Place the BGT onto a piece of gauze and lubricate the end.
10. Clean around the site.
11. Remove the water from the balloon port of the old BGT, apply light pressure to the abdomen and pull the old BGT out. If there is excessive resistance, stop and contact your feed company nurse, community nurse or HEN Team for advice.
12. Insert the new BGT using a corkscrew action, if necessary, into the stoma, beyond the cm marking which normally sits at the skin level and re-inflate the balloon with the water in the syringe. Do not force the tube into the person if there is resistance.
13. Pull back on the BGT until resistance is felt.
14. Check the cm marking is the same as before removal.
15. Test the pH by attaching a 60ml syringe to the end of the balloon gastrostomy tube and withdrawing a small amount of stomach contents and apply to a pH testing strip.
    1. If pH is above 5.5, wait for 30 minutes and check again. If it remains 5.5 or above, do not feed or flush. Please contact the enteral feed company nurse, community nurse or HEN Team which will be able to advise you on the next steps to take.
16. If the pH is between 0 to 5.5, you may continue to flush the tube with 60ml of water, observing the person for any signs of pain or discomfort.
17. If there are no concerns, the tube can be used.

Aftercare

When the BGT has been placed, a new tube needs to be ordered and equipment disposed of correctly.

1. Dispose of equipment in household or clinical waste.
2. Check BGT stock levels. If you do not have a spare tube, contact the HEN Team who can order a spare tube for you. You will need to give the size of the tube just placed.

Troubleshooting

Please contact your enteral feed company nurse, community nurse, HEN Team or attend A&E as soon as possible if you encounter any of the following issues:

• Old BGT cannot be removed.
• New BGT cannot be fitted into the stoma or falls out.
• After inserting the BGT, pH levels are above 5.5.
• Bleeding around the stoma site.
• Pain on feeding, flushing or medication administration.
• Any other concerns.