Everything You Ever Wanted to Know About G-tubes But Were Afraid to Ask - Betsy Gerrein - APP Conference 2026

Good morning, everybody. Thank you all for being here. It's a pleasure to be here with you today. Um, my name is Betsy Garin. I'm a pediatric nurse practitioner. I've been here at Cincinnati Children's for 42 years. In the last 18 years, I've been, um, practicing clinically in general surgery. So, uh, we're gonna talk today about everything you ever wanted to know about G tubes, but maybe didn't know who to ask or were afraid to ask. Um, just for the people in the room, could I get a quick show of hands of how many of you take care of patients who have G tubes? It's just about everybody, which is what I expected. Um, so kids with G tubes really are everywhere. Um, I'm gonna say a short, a quick disclaimer, which is that a lot of the, what you're gonna see today is what's considered expert opinion. There's not a lot of evidence-based practice around gastrostomy care. Uh, if you search the literature, you know, you'll find, you'll find, you'll find some literature, but not so much about the kinds of things we're gonna talk about today. That's mostly expert opinion. So I don't have any disclosures, and this is a short talk, so I'm going to move as quickly as I can. So, my objectives today are, I hope that you'll be able to identify the various kinds of feeding tubes, that you can recognize common complications, that you'll be able to apply new knowledge to troubleshoot issues, and that you can evaluate the stoma for problems and develop a plan for managing the G tube issues. So, just a few quick facts. So, uh, in what some of the research that I did for this talk, I learned that, and this data was several years old, but I learned that about 160,000 to 200,000 G tube procedures are performed annually in the US and about 15,000 of those are children. And sometimes I think they're all here. movie. Um, so I'm gonna start off with the basics, really just talking about the kinds of gastrostomy tubes that you're going to encounter. So, the buttons are the ones that you probably see most of the time. So, uh, these are, these are very popular, and this is the goal is for most of our patients to have a button. So, um, in most cases, these are placed laparoscopically in the operating room. They do what's called a stem gastrostomy, and that's just the surgical name of the procedure. And by that, what I mean is that they are going to take, the surgeon's going to take the stomach and suture it up to the abdominal wall. And the reason for that is to make sure that the stomach is adherent to the abdominal wall and that tube is going directly into the stomach and not leaking into the peritoneum. Oh, let me go back just a second. So this, this particular tube is the AMT Mini one button. This one is a newer version of this button, but it's, uh, it's gained a lot of popularity over the last few years. Um, it's a low profile button, meaning that all you see is just, you know, that top part, um, you know, above the balloon there is what shows, um. One key thing that you should know about this button is that it's not provided by all home care companies. Lynncare does not, uh, carry this product, um, and occasionally I come across, um, an option care where they're saying that they don't have that, but most of, most of the others do. So this is, this is the Avano's Mick key button. And so, this was the original low profile button that was developed and I remember very clearly in my PACU days, the first time I saw one of these, um, they are usually also laparoscopically placed using the STEM gastrostomy procedure. And as far as I'm aware. These are provided by all home care companies. These two buttons work very similarly. They each have a balloon. They each have a port on the side where you inflate the, uh, inflate the balloon with water, and on the top is where the extension tube goes so that you can administer a feeding. So, you may not come across these very often, but just in case you do, I wanted to talk about this. So, I use a, a fair number of these AMT non-balloon buttons. And so you can see the picture in the middle there is what the button itself looks like. Um, this is made by AMT, so it's also got that glow green top. Uh, I use these for kids who either tend to pull their tubes out frequently, you know, sometimes if you, if you had, have kids who just sort of constantly pick at the tube or pull at things, um, or for kids who have high abdominal pressure. I've taken care of patients who every time they coughed or sneezed, they'll pop, pop the button out, um, and for those kinds of patients, this tube actually works pretty well, um. The image on the left with a little pink stylette in there, that is what it looks like when you take it out of the box. And it's got at the bottom of the tube there, you can see it's got a little, it's, it the tube, the tube itself, that little mushroom part is pre-stretched, and it's wrapped with, uh, in the bottom there, it's wrapped with, um, uh, a gelatin almost. Like a capsule, a pill capsule, and so you insert that into the abdomen, into the stomach, and then you pull that little, the little part at the top. I call that the rip cord that you pull the little rip cord and then it will pop open, uh, that, uh, little mushroom shape at the bottom, and then the gelatin just dissolves, um, and then you can take out the oburator. The scary looking device on the right hand side is the, is the device that you use to remove the tube. So you can see this is not a tube that just everybody's going to want to use. So it really requires some special training. I have to confess that I had to teach myself how to use these. Um, AMT does have some good videos, but, um, parents don't change this one. So if I send them home with this kind of a button. Um, I send them with a regular balloon button, and that's what they're going to use in case it does get pulled out at home, which they still can get pulled out. Um, but a lot of kids will get 6 months out of this button. Um, AMT does have some videos if you're interested. And the, the way you can tell if somebody's, just remember, you know, you're only going to see the top part of the button. Um, the way you can tell that it's a non-balloon button is because there's no balloon port on the side. So, this is a, this is a long gastrostomy tube. And you don't see, you don't see these used as often as we used to. Um, it used to be that patients would get this tube first, and then in 6 weeks, we would swap it out for a button. Now, most of our surgeons will actually put the button in primarily in the operating room. Again, usually placed laparoscopically. One of the benefits of this kind of a tube is that that little disc part there and the, that you see in the middle, that part is adjustable. So if you have a patient, say, who has a lot of abdominal distention or bloating for some reason, and we see this a lot, um, you can adjust the fit of that by sliding that little disk up and down. Uh, so, uh, occasionally we use those, um, but not nearly as much as we once did. Now I'm gonna talk about a peg tube, and I want to make it clear that this tube. And this tube are different. So a lot of people will call anything that's a a long tube, they'll call it a peg tube. A PEG tube is a different kind of tube, and it's placed differently. So, PEEG actually stands for percutaneous endoscopic gastrostomy. So, in our organization, this is typically placed, uh, with a, a surgeon, a general surgeon, and a GI doctor who's doing the endoscopic part, um. These tubes have to stay in place for 12 weeks. And the, the reason is because with these tubes, they've not done that stem gastrostomy part. So they've not sutured the stomach up to the abdominal wall. The only thing that's really holding, holding that in place, let me see if I can get the pointer to work. The only thing that's holding it in place is this little bolster on the bottom there. That's what's inside the stomach. That's got, there are a couple of different brands of this, but this one has a little sponge and air is filled in that part. And then this is a little clamp you would see on the outside part, and that's all that's holding the stomach up. And so, if this gets pulled out in the 1st 6 to 12 weeks, it really is, um, kind of a medical emergency because that stomach can then fall away from the inside of the abdomen. And you can have, you know, formula or medications going into the peritoneum. So, that's a key difference with this kind of a tube. Um, the goal is never to leave one of these in place. They're usually in place for 12 weeks. And then typically we would send patients to the operating room to have these swapped out, um, under endoscopy. We used to pull these out in the clinic, and it was not very much fun for anybody, including the person doing the pulling. This is, I'm not going to spend too much time on this because in the interest of time, but this is a nice sort of infographic of, you know, how the PEG tube is placed. You can see that the, um, the endoscope is in there. The surgeon uses a little introducer to poke through, and then the tube is actually pulled down, uh, like through the esophagus and out through the hole. And, you know, then the little bolster part is, you see where that's kind of pulling it up against the abdomen. I don't have time to show the video here today, but if you want, if you're interested to see how those are done, there's lots of YouTube videos. So this is a GJ tube or button. This picture is actually a button, um, but they also come in a long tube version. So, these are used for patients who may need to have some sort of post pyloric feedings, uh, for a variety of reasons. They might have really slow motility, which is very common. The kids may be having reflux, um. These can be placed primarily in the operating room, and we do see some of that. Um, other times, the patient may start out with a regular G tube, uh, or G tube button, and then they determine that a GJ feeding is going to be better for this patient, and then they will swap that out. Um, understand that these have to be placed under fluoroscopy, and you can see that, that the, on that tube, it's, it's this part that looks dark is radio opaque, um. So, whether they're putting it in in the operating room or whether they're putting it in postoperatively, um, it has to be done in fluoroscopy, um, or in interventional radiology. I used to believe these were all done in IR and I have come to learn that actually most of them are swapped out in fluoroscopy. And these tubes have two fenestrations. That's a little, it means a little window or the opening. There's an opening right here underneath of that balloon that opens into the stomach, sometimes used for medications, sometimes used for, um, gravity drainage of excess stomach contents. And then here at the distal end, there's a little fenestration. And that little wire you see there, that's what's used when it's placed. That's what's used to kind of, you know, guide it down into the jejunum. So, I'm going to put in a little disclaimer here for using the correct tubing. So, in the past, the AMT and the Mickey tubes were supposed to be interchangeable. And in fact, on the, on the AMT packaging, it actually says, uh, it actually says on the box, um, Mickey feed set compatible. Somewhere along the line in the last couple of years, something seems to have changed and they don't really seem to be compatible anymore. So, if you're using the AMT button, the AMT buttons are, um, they have this glow green top. Um, it's, it's when you're looking at it in real life, it looks, it's not, it's a little bit more subtle than that, but it's got a glow green top. And then the extension tube here is also glow green. So these actually glow in the dark. So, just remember you want to have the glow green tubing with the glow green button. And this again is the, is the McKey one. And again, you can see that the top of this tube is white and the end of the tube that goes into it is white. So, whichever tube you've got, you want to make sure you have the right one. And we have seen multiple instances where there were, um, Multiple instances where this tubing was put into the AMT button and when somebody, you know, turned it, it's broken off in there, which could be a real problem if that happens in the first few weeks. So, briefly, the routine care of the gastrostomy is to try to keep the skin clean and dry, to allow air to get to the skin because that prevents all kinds of problems. You're going to clean it 1 to 2 times daily with mild soap and water. You're going to use a, sorry, you're going to use a moisture barrier, um, to protect the skin. We'll talk more about that. And the preferred dressing, and the wound nurses will tell you the same thing. The preferred dressing is a split gauze, not Meylex, not those cloth things that a lot of parents will buy. So, we're gonna talk about some common G tube problems, leaking and drainage, granulation tissue, gastric prolapse, keyholing, yeast infections, and cellulitis, which is rare. So, leaking versus drainage, it, to me, there's a difference between, you know, people, people will say the tube is leaking. There's really a difference. So to me, leaking means stomach contents, including stomach acid is coming out around the stoma, you know, around the tube itself for some reason. Um, and, you know, that acid is rough on the skin. Drainage is usually more superficial and generally comes from granulation tissue. Um, that that drainage can be, uh, yellow or even a little bit of bloody drainage, which is not usually worrisome. Uh, and as I said, usually comes from the granulation tissue. So here's a few pictures that were taken in my clinic. Uh, the very first one is, you know, a patient who has some pretty severe breakdown there, um. You know, from gastric contents leaking, and you can see there have been some methods deployed there to try to stop it, uh, you know, that obviously hasn't been successful. The middle picture where it says, you know, typical yellow drainage, um, one of my colleagues actually took this picture a couple of weeks ago when I was preparing these slides. You can see there's a large granuloma on there with just granulation tissue growing around the tube, and you can see all the muck and crusty stuff that's, you know, leaking down around that. Um, and then this is what the gauze looks like. This is very common. Almost everybody we see in those first few weeks will have, you know, a dressing that looks just like that. It's, this, this is not an emergency, even though you may see moisture. It may look yellow, it may look green. It's very, very common and not a, not a reason for alarm. I like to tell people there's very few G tube emergencies. The only thing I really consider a G tube emergency is if that button or the tube comes out really in the 1st 6 weeks. So, this is a picture I took in one of my recent clinics. This is a patient that I saw. I can't recall if it was the 2, I think this was a 2-week post-op visit. So, the granulation tissue is very normal. It's healing tissue that the body's making to try to close up that wound. And of course, we don't want the wound to close, and it won't because the tube is in there. This tissue is typically pale, pink, and moist. It can be smooth or it can be, you know, sometimes it's even flat, or it can be sort of cobblestone looking, sort of bumpy looking. I like to tell people it looks like the inside of your cheek or the inside of your lip. It will secrete that yellow, even greenish looking exudate, and we have several ways we can treat it. So the next picture is the same patient. After I applied the silver nitrate. Um, so you can see, you know, what the silver nitrate did to, uh, you know, fulgurate where I fulgurated, which is a chemical cautery, fulgurated that granulation tissue. A little bit of bleeding is common. You can also use Kenalog, which is a steroid cream, or granuloion, which is, um, an astringent lotion. Uh, I rarely use Ciprodex drops. Those are otic drops with ciproflox uh, ciprofloxacin and, uh, dexamethasone. And if you do use it, just be aware that it's off label. So a couple pro tips for using the silver nitrate. This is a chemical fulguration. When you use it, it can sting and burn, and so the kids are usually not very happy about that. Um, sometimes if I have an autistic patient or somebody who I know we're really gonna struggle, I will sometimes use another method. Um, I can tell you from personal experience that the silver nitrate will stain everything. It will stain your skin. It'll stain the patient's skin. It will stain your fingernails. So wear gloves when you're doing this. Um, and you want to protect the patient's skin as you're applying it. I usually just use a wet piece of gauze as I'm applying it and, you know, going around, um, and a little bit of bleeding can occur. So a couple pro tips with the granulotion. Um, you just want to need to apply a small amount of, uh, the lotion, uh, to the, to the granulation tissue 2 to 3 times a day. Um, I recommend that people only use this for 14 days because it's severely drying, and I can tell when somebody has overused it because the skin will look so sort of friable when they come to the clinic. Be aware that you cannot prescribe granulotion. You can recommend it or you can give it to families, which is what we do. But, um, if you, if you send an order to the pharmacy, the pharmacy is not going to carry it. This is actually an over the counter product. So you can order it directly from granulotion.com or you can get it from Amazon. It's kind of expensive. A little tube is about 48 bucks. So, we're going to talk about gastric prolapse. This occurs with high intraabdominal pressure for kids who have like peritoneal dialysis or they've had an organ transplant in their belly. Um, kids who have a lot of constipation are straining. They may have severe leaking because now you don't have a good, nice tight fit around that stone, around the. Around the tube, um, this tissue will bleed easily because it's stomach tissue and it's, it's very vascular. And to me, it looks more like an ostomy, like an ileostomy or a colostomy. The only way to, oops, I don't know why that, I don't know why that wouldn't come up, um. The only way to really, uh, uh, treat this is to resite the stoma by going to the operating room and closing this opening and making a new one. This should be used as a last resort because whatever is causing that high pressure is likely to cause the new stoma too, um. Uh, you know, to prolapse again. This child was on a ventilator. Uh, you can see the tubing and when I took the picture there is on, you know, trached and ventilated, which is part of the reason that they're, um, uh, that they're prolapsed. And also you can see there's a yeast infection around there because, you know, and you can see they're distended. So, um, those are the significant things that I think are shown in that picture. Keyholing, we don't see as often. I think now that we use the buttons from the beginning, we don't see it nearly as often. So, keyholing is just when that nice little round stoma gets a tear in it. It's much more likely to happen early on after the surgery. Um, this can cause mild to severe leakage and can be very difficult to heal. So, Uh, a lot of times people will send us, uh, will send us a patient and say, we want you to put in a bigger tube, and by that they mean the French size. Putting in a bigger tube just stretches it out more and doesn't help. So some of these kids will need to be admitted for post-pyloric NG feeds. Um, this patient also has a yeast rash because of all the leaking. Um, it's very common when you have moisture. The goal again is clean and dry. You want to protect the skin with a moisture barrier. I would typically treat this, uh, with a nystatin powder or cream or a Criticcaid antifungal. Um, for a patient like this, I'll usually use a nystatin powder, and then on top of that, I put a Cavallo no sting spray and then a moisture barrier. The moisture barriers won't stick to that macerated tissue. So, oh, I'm, I'm getting ahead of myself here. Um. Uh, the, my favorite is the, is the, um, Comoseptine. It's a great, it's a great oint ointment. It's not terribly expensive, and you can find it in pharmacies. Uh, it is over the counter, um. You know, Aquaphor for some patients is fine. Zinc oxide is one that a lot of families have at home, so sometimes when they're calling over the phone, we'll tell them to try that. So, I want to make sure that we talk a little bit about infection. Actual cellulitis is really, actually pretty rare, um, and it's overdiagnosed. I'm not sure about outside of our organization, but here in our hospital, it's overdiagnosed all the time. So, my recommendation is do not culture the site. We all have skin flora on our skin, and this is a tube that's going into an abdominal wound, you know, into the stomach. The GI tract where there is normal bacteria. So, the culture is not going to tell you anything useful. I do not recommend prescribing mupirocin, uh, It'll, it may help sometimes because what it'll, because it's in Vaseline and so that will protect the skin. If they really truly have cellulitis, then you need to prescribe a course of antibiotics. Um, I had trouble finding a picture. This is not one of my own, um, but I found this one on the internet, so. Um, a couple, couple interesting facts. General surgery is responsible for the tube, um, until the first change happens around 6 weeks post-op. Uh, general surgery has to do the first change. Um, please do not remove the water from the balloon prior to the first G tube change. And sometimes folks will do that. I've had somebody call me and say, we checked the water and it was a 5 day old, uh, G tube. Um, they can take a bath after the first couple of weeks, and after 6 weeks, they can swim. I usually tell folks after 2 weeks, they can have tummy time. So, we're coming here, um, in the home stretch. Uh, some kids, many kids will be able to get rid of their G tube, you know, if it was a preemie and they finally get to where they can eat, uh, they may be able to remove the tube. So, in order to be able to take the tube out, we need to have sustained weight gain over several months. They have to be taking 100% oral intake and medications. Some kids will take the food, but they won't take their meds. And the managing team, that is whoever's managing their food and their growth and nutrition, that team needs to say it's OK for us to take it out. And then we typically don't want to do that during respiratory season when they could get congested and not eat. Um, it's really important to protect the skin after you take it out. We use a really good moisture barrier like the Comoseptine. We use gauze folded up into a little sort of a little ball, and then put Tegaderm over that. It's going to leak significantly for 2 to 3 days. I usually recommend small sips of fluid instead of guzzling a lot, and thickened foods can help as well. It's important to prepare families, uh, with the information that they need. It can take 4 to 6 weeks to close. If it's still leaking after 4 to 6 weeks, you need to refer back to general surgery for closure. And just another little pro tip, if they have gastric prolapse, it's not going to close spontaneously. It's just, you know, that gastric tissue is there and it's just not going to heal. So when the surgeon does the procedure, they're not just suturing it closed, they're taking down those layers and separating them out and closing the, um, the hole in the stomach. So, 3 quick questions, um. So, uh, PEG tubes are inserted laparoscopically, true or false. So this one's, these are pretty easy. I'm not trying to trip anybody up here. So, PEG tubes are not inserted laparoscopically. Remember, that's the percutaneous tube. So, you know, that it, that's the one of the ones that we talked about that's not percutaneous. So, um, so that statement is false. Uh, the next question is, G G tube site infections are common and should be treated with mupirocin. So you guys have got this one figured out. This is false. The actual cellulitis is not common, and, and I don't recommend the mupirocin. And so one last question, how would you treat this site? It's an A B A, B, C, or D. So you guys, you guys are doing a good job with this one as well. Um, for this patient, what I would do is, you know, put the nystatin, I'm sure that's what I prescribed for this patient, nystatin powder next to the skin, Cavallo no sting spray. What that does is it forms kind of a. It seals it in and kind of forms almost like an artificial scab. And then you can put the ointment on top of that. The ointment, as you can see in this picture, will not stick to that macerated skin. So you need some other layers of stuff, so the moisture barrier will work. I have, uh, so this is really fast. I could go on for a long time, but, uh, now you've completed the G tube 101, um. I have a few references here. Again, not a lot of evidence-based practice and a couple of GTube resources. And I know we're out of time, but I'd be happy to answer any questions. Betsy, thank you. We have a couple of questions from online. One is, um, I think it's difficult to differentiate between granulation tissue and prolapsed gastric mucosa. Is there any tip or trick to help us with distinguishing? Yes, um, to me, the, you know, again, the, even for me, I've been doing this for a very long time. I have a G tube clinic every week. Um, the the granulation tissue you typically see in the first few weeks or few, few months after the tube is put in. Again, it's usually smooth or it can be cobblestone-looking. It's usually a little bit paler, and it will secrete that yellow or even greenish-looking exudate. And so, people see that exudate, the secretions, and then they see the redness on the skin, and they assume it's infected. What you really need to do is just treat the granulation tissue, and then, um, you know, and then use a good moisture barrier. The prolapse, um, is usually a little bit redder. Sometimes it's bright red. Um, it will bleed easily. So, with the granulation tissue, I see more yellow drainage. I see more bleeding. Usually, if I see blood on the gauze, I'm looking for some sort of gastric tissue, even if it might just be on the inside of the stoma. I, I might have to look for it. Um, and just a little bit of that will, um, actually, you know, even a tiny little bit of that gastric tissue, you know, can cause some bleeding. Thank you. The other question is, um, how do you decide when to resci the tube, and what if the cause of the increased abdominal pressure is not something reversible or avoidable? So some of the causes of the, um, some of the causes of the increased abdominal pressure, some of them are. Treatable. For example, constipation. I have learned the hard way that constipation, you know, most kids who have a gastrostomy tube probably have some kind of constipation. They're, they're getting a liquid diet. There's not much fiber and. Many of these kids have other problems, so they may be straining to poop. Um, if you can treat the, if you can treat the constipation effectively, a lot of times you can, you know, solve some of that distention and bloating and gas, um. Other problems, you know, like if you've got a kid who's trached and ventilated and they're coughing and gagging and wretching all the time, you may not be able to do anything to resolve that. Um, so, uh, so, so some of those things are treatable and some are not. I usually will sort of try to, you know, see the family several times, you know, I always apologize and say there's not a lot we can do about this prolapse other than to manage it and do great skin care, um. But you know, if they've come back to my clinic 3 or 4 times and that, you know, we're still dealing with a lot of problems or you just can't get the skin clear, I usually will then, you know, consult with one of the surgeons. I did that this past week with a transplant patient, talked to the transplant surgeon, um, and that one probably will get recited, but I just usually hold on as long as I can. Thank you so much. Thank you.