Looking after your radiologically inserted gastrostomy tube (RIG)

Introduction

This information leaflet is for patients considering a Radiologically inserted Gastrostomy Tube. This may take place as a day case procedure or may require a short hospital admission. Your healthcare team will explain what is involved and answer any questions you may have.

Why do I need a gastrostomy tube?

Due to your medical condition, you may be unable to take enough food and/or drinks by mouth to meet your nutritional requirements. This may be due to:

• Difficulty swallowing (dysphagia) that arises from changes to the function of muscles involved in swallowing. These changes can increase the risk of food and/ or drinks to your lungs, which can result in a chest infection called aspiration pneumonia.
• Changes to your appetite and/or ability to take food orally due to reduced physical function.

A gastrostomy tube can help as it bypasses the need to swallow, meaning nutrition and/or medications can be delivered directly into your stomach.

Can I still eat and drink?

Many individuals choose to continue eating and/or drinking alongside their gastrostomy tube. If you are experiencing dysphagia, your speech and language therapist will assess your swallowing and help you to be able to do this.

What is a gastrostomy tube?

It is a tube which is placed directly into the stomach.

What is a RIG?

A RIG is a type of feeding tube placed through your skin into your stomach and is held in place by a balloon filled with sterile water. The term ‘RIG’ describes the way it is placed:

• Radiologically – using x-ray guidance.
• Inserted
• Gastrostomy – opening into the stomach.

Your feeding tube will look like this:

There are three small discs (SAF-T-PEXY) around the tube which are each held in place with a stitch. These are required to keep the stomach in a fixed position while the stoma tract matures (heal) and should not be removed before 3 weeks. After 3 – 4 weeks the sutures will dissolve, and the stitch locks (discs) will start to fall away. Please contact your Nutrition Nurse or Dietitian to arrange removal if they are still in place after 4 weeks.

What happens after your RIG placement?

The nutrition nurses will teach you and/or your family how to look after the feeding tube if you have not had pre-insertion training.

If you are discharged within 72 hours of having your PEG placed and you notice any of the following symptoms. DO NOT PUT anything through the PEG. Contact your GP (in working hours), Call 111 for advice or go to your nearest Accident and Emergency urgently.

• Leakage of fluid around the PEG tube
• Pain on feeding or flushing with water (stop the feed).
• Prolonged or severe pain with possible abdominal bloating.
• New bleeding from the PEG site

How to look after a RIG (gastrostomy) tube?

It is important not to move or release the outside bumper (triangle or disc) for the first 7 days. Keeping it in place helps the site to heal.

1. For the first week: Day 1 – Day 7 after the PEG insertion.
2. Remove the gauze dressing the day after your tube is inserted. If it feels stuck, moisten slightly with warm water to help removal.
3. Apply a small amount of Octenisan antimicrobial wash neat (do not dilute in water) to a cleaning pad or gauze.
4. Carefully clean around the PEG site starting at the area closest to where the tube exits the skin then move outward in a circular motion.
5. Repeat this action (step 3) as above, applying Octenisan wash if required.
6. Clean the top and underside of the bumper (triangle or disc) as well
7. This should be left for 1 minute before rinsing the skin around the PEG tube and the external bumper using a clean pad moistened with warm water.
8. Dry the skin around the tube and bumper (including the underside)
9. Apply a pea size amount of the Mupirocin (alternative Naseptin) antimicrobial ointment in the area around where the tube exits the skin. You may need to apply this to cotton bud to apply to the stoma site.
10. Secure the PEG tube tubing to your abdomen with tape to prevent it being pulled or dislodged. This also prevents traction on stoma.

Can I have a bath?

• For the first two days after your tube is placed do not have a bath or shower. Instead wash using a flannel with the Octenisan antimicrobial wash.
• After Day 2 you may have a brief shower or bath. Do not soak or immerse the PEG tube and exit site in water if having a bath.
• From day 8 onward if the skin around your site is clean and dry, you may return to your normal bathing routine.

If you have any concerns, please contact either your feeding company nurse or the nutrition nurse specialists.

After the first week: From Day 8 onward

It is no longer necessary to use the Octenisan antimicrobial wash and the Mupirocin Ointment, but you will need to continue cleaning the PEG site daily with warm soapy water.

You can now move the outside bumper along the tube to make cleaning the site easier. Make sure you replace the bumper approximately 2mm from the skin so that the tube does not slide in and out the stoma tract.

How to care for a Balloon Retained Gastrostomy Tube

Weekly Water Balloon Change step by step guide

The water in the balloon should be checked weekly, unless otherwise advised, to ensure there is enough water in the balloon to hold the tube securely in place

Equipment

• 5ml Luer slip syringes x 2
• Water (cooled, boiled)
• Tape

Please wash your hands with soap and water before and after using your PEG

1. Pre-fill a new 5ml syringe with the recommended amount of water* (as advised by your healthcare professional)
2. Move the external fixation device to allow access to the skin around the stoma site (check the external number close to the skin is the same as the last time)
3. Advance the tube 2-3cm into the stomach and rotate 360°
4. Hold the tube in place with tape to the skin during the procedure, so it remains in the stomach
5. Attach an empty 5ml syringe onto the balloon inflation port of the tube, making sure this is pushed in far enough to open then a quarter turn to hold in place
6. Gently draw back the plunger and withdraw fluid until no more water comes out of the internal balloon
7. Now detach the 5ml syringe from the balloon inflation device (quarter turn to release)
8. Connect the prepared syringe, reinflate the balloon with new syringe and the correct volume of fresh water
9. Remove the tape
10. Gently pull the tube back, until slight resistance is felt, then confirm the cm graduation markings remain the same as before
11. Ensure the skin and fixation device are thoroughly dried
12. Replace and close the external fixation device so it lies 2mm from the skin surface
13. Secure your PEG tubing to your abdomen with tape

Contact your Nutrition Nurse or Dietitian urgently if any of the following occurs when completing your water balloon change

1. If the cm graduation marking has changed, if there is any discomfort, or you are unable to advance or rotate the tube.

DO NOT use the tube and contact your healthcare professional immediately. Attend your local accident and emergency department with your spare tube if this occurs out of hours (overnight/weekends/bank holidays)

2. If the volume of “old” water removed is less than the correct amount (3mls or less), discoloured or any particles are present, contact your healthcare professional for advice. This could be an early indication that your tube will need to be replaced before your routine appointment.

As an additional measure apply an adhesive dressing or tape secure the bumper to your abdomen.

You can still use your PEG but stop if you experience leakage and/or pain (discomfort) with feeding or water flushes occurs and follow the advice above.

What nutrition (feed) is put through the tube?

Your Dietitian will discuss specialised liquid food (feed) that is designed to provide your body with the nutrients (carbohydrates, protein, fats, minerals and vitamins) that your body needs. They will also create a plan for you that will explain how much feed you need and when to have it. It is strongly recommended that only prescribed/approved feed, fluid and liquid medications are put through the tube to avoid damage and blockages.

When should I flush my PEG tube

It is important to flush your tube to prevent blockages.

When to Flush:

• Before and after each feed or medication.
• Between each individual medication dose.
• At least once daily if not feeding, typically every 4-6 hours.

Equipment Needed:

• 60mL enteral syringe
• Cool tap water

Step-by-Step Flushing:

Position: Maintain an upright position (at least 30-45 degrees) when using the PEG tube for administration of feed, medication or water flushed. Remain upright 30 minutes to an hour after flushing or feeding to prevent reflux.

1. Wash your hands with soap and water, dry then assemble your equipment
2. Prepare: Draw the recommended amount of water into the syringe from a clean cup.
3. Connect: Close the clamp (if available) on your PEG tube, open the cap from your PEG tube, attach the syringe, then re-open the clamp
4. Flush: Slowly press the plunger, using a "push-pause" technique, pausing briefly every 5mL to push water through until complete
5. Disconnect: Close the clamp on the tube before removing the syringe, close the cap then open the clamp (if available).
6. Secure the tube to your abdomen using tape or a fixation device

Cleanliness: Remove the plunger from the enteral syringe barrel and wash with warm soapy water, rinse and let it dry after use. Store in a clean, covered container. Enteral syringes can be used up to 1 week then will need to be changed.

What problems might I encounter after placement of a gastrostomy tube?

Pain

The site where the tube enters the stomach can be painful for a few days after the procedure. Patients are usually encouraged to use pain killers (analgesia) regularly for the first two to three days following insertion. This will be discussed this with you on the day of your procedure and painkillers prescribed if required.

Infection at the site of insertion

This can occur if the PEG site is not kept clean and dry but is rarely serious. You will be provided with a PEG treatment kit containing Octenisan antimicrobial wash and Mupirocin antimicrobial ointment to clean the PEG insertion site for the first seven days. After this period patients are usually encouraged to clean with soap and water then dry well. Dressings are not usually required.

Leakage around the gastrostomy site

Occasionally feed or gastric (stomach) fluid may leak around the tube – this commonly occurs if the retention plate or circular disc is not close to the skin allowing the tube to slide in and out of the stomach causing leakage. This can be corrected by tightening the circular disc or retention plate (external bumper) close to the skin. The surrounding skin should be cleaned and kept dry. A protective skin barrier spray maybe applied to resolve any redness/ skin irritation caused by the leakage. In exceptional circumstances, the tube may need to be repositioned at a different site.

Over granulation at the gastrostomy site

This is the appearance of light red or deep pink flesh that forms beyond the surface of the stoma opening. There are many reasons this may develop, and the treatment plans will be patient specific.

PEG tube related problems

• Blockage of the tube: This can usually occur after giving some medications or not flushing the tube at the end of a feed. Though blockages can be resolved, you are encouraged to prevent this by flushing before and immediately after feed. Additional advice will be provided if you will be giving medications down the PEG tube.
• Balloon failure (burst balloon): If the balloon that retains your gastrostomy tube bursts the tube may fall out. First to prevent the tube from falling out, apply an adhesive dressing or tape to secure the bumper to your abdomen then contact your Nutrition Nurse (Community or Hospital) for advice if this occurs Monday – Friday excluding Bank Holidays (8am –4pm) Nutrition Nurse (Community or Hospital). Out of hours (Weekends/Bank Holidays). Please attend your local accident and emergency and ensure you take your spare tube with you.
• PEG dislodgement (fallen out): If the PEG tube has fallen out you will need to attend your nearest Accident and Emergency department within an hour for a replacement to prevent the stoma (hole) from closing. If you have been provided with emergency stoma plugs (ENPLUGS) these can be used to keep the stoma open while awaiting a PEG replacement.

How long will my tube last for?

Your gastrostomy tube can last up to six (6) months, but we would usually recommend this is replaced between 4-6 months. You do not need to attend hospital as your tube can be replaced by the Nutrition Nurses in community (at home).

If you no longer need your tube, it can easily be removed by either the nutrition nurse specialists or your company nurse.

Who to contact about what?

You will be trained in all the necessary techniques to look after the feeding tube and what to do if you do have problems. However, your community nurses, GP, dietitian, and nutrition nurse will be available to help and support you. Your dietitian or nutrition team will provide regular follow up. The company delivering your feed also has a nurse helpline.

1. If you have any concerns about your feed or plastics order (including syringes and dressings) – contact your feed company:

• Nutricia Homeward: 0800 093 3672
• Abbott Hospital to Home: 0800 0183799
• Fresenius Kabi: 0808 100 1990

2. If you have any concerns about your PEG site or feeding pump – contact your feed company nurse in the first instance:

• Nutricia: 0800 093 3672
• Abbott: 0800 0183799
• Fresenius Kabi: 0808 100 1990

3. Please contact your local dietitian if you have any concerns about:

• any symptoms that suggest you are not tolerating your feed e.g. bloating, nausea
• your weight
• the amount or type of feed you take
• or if you need extra syringes or other supplies ordering
• or you want to discuss tube removal

4. Contact details for Enteral Nutrition Nurse Specialists

Monday – Friday (8am –4pm) excluding weekends and Bank Holidays

• Phone: 01223 216 037 Option 1 for Enteral Nutrition
• Mobile: 07710 365156