Small Animal Small Animal Gastroenterology The Compendium March 1997

PERSPECTIVES IN VETERINARY MEDICINE V

Practice Guidelines for

Gastrostomy Tubes
Kathryn E. Michel, DVM
Department of Clinical Studies
School of Veterinary Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
Advantages and
Disadvantages
Gastrostomy tubes have sev-
eral advantages over smaller-
bore nasogastric tubes. Blender-
ized pet food can be fed more
easily, and patients are purport-
ed to better tolerate and be
more comfortable with gastros-
tomy tubes. The principal dis-
the patient. To minimize this
risk, practices that use gastros-
tomy tubes should have clearly
established guidelines for the
indications, placement tech-
niques, and management of
these devices.
Indications
Use of gastrostomy tubes
may be required for adequate
adhesions to form in these ani-
mals than in healthy animals.
Therefore, it makes little sense
to place a gastrostomy tube in a
patient that is expected to re-
sume voluntary food intake in
less than 2 weeks.
The other major indication
for the use of gastrostomy tubes

T
he use of tube gastros-
tomy for the nutritional
support of dogs and
cats is not a new idea. Tech-
niques for surgical, endoscopic
percutaneous, and blind (nonen-
doscopic) percutaneous place-
ment have been described in
the veterinary literature for
more than a decade; however,
use of these techniques has be-
advantage of gastrostomy
tubes in comparison with naso-
gastric tubes is their relative
complexity and invasiveness of
insertion. The ability to place
tubes percutaneously, by either
endoscopic or blind techniques,
has largely mitigated these dis-
advantages because tubes can
be placed rapidly and without
the need for a laparotomy.
should be reserved for patients is in animals in which nasogas-
that will need relatively long- tric (or pharyngostomy and
term tube feeding. Neither sur- esophagostomy) tubes are con-
gically nor percutaneously traindicated, such as those with
placed tubes should be re- facial bone fractures or esoph-
moved until secure adhesions ageal disease. It is important to
have formed between the gas- bear in mind, however, that
■ Gastrostomy tubes can be used with conve-
nience and relative safety for the provision of
nutritional support for dogs and cats.
KEY POINTS

come more widespread only re-
cently.1–3
More practitioners are now
using gastrostomy tubes for a
number of reasons. The impor-
tant role that nutritional support
plays in the survival and recov-
ery of veterinary patients is be-
coming increasingly recog-
nized. Many reports in the
literature demonstrate that gas-
trostomy tubes are convenient
and relatively safe when used
for the purpose of nutritional
support.3–7 In addition, the ad-
vent of veterinary formulas
specifically developed for tube
feeding is making nutritional
support much simpler and
more convenient for veterinari-
ans and clients alike.
Because of their advantages,
gastrostomy tubes have recent-
ly become an increasingly pop-
ular means of nutritional sup-
port for dogs and cats. This
increase in popularity, however,
has been associated with an
increase in the number of com-
plications. Most reported com-
plications are minor—tubes be-
come obstructed or localized
edema or infection develops.3–9
Some complications, such as
splenic laceration or inadvertent
tube removal, however, can be
very serious and can result in
death.5–8,10 These unfortunate
occurrences are reminders that
gastrostomy tube placement is
an invasive procedure that car-
ries with it an inherent risk for
■ Gastrostomy tubes should be used for patients
that need relatively long-term tube feeding and
for those in which nasogastric tubes are con-
traindicated.
■ Percutaneous techniques for gastrostomy tube
placement allow for rapid and relatively nonin-
vasive insertion of these tubes.
tric and body walls. For percu- gastrostomy tube feeding
taneously placed tubes, it has places patients with neuromus-
been recommended that the cular abnormalities, such as
tube be left in place for a mini- megaesophagus or abnormal
mum of 7 to 10 days.7 If re- mentation, at risk of pulmonary
moval is to be by traction (as aspiration of food if gastric re-
opposed to cutting the tube and flux occurs.
allowing the tip to pass in the
feces), a 14-day waiting period Gastrostomy Tube
has been advised. 8 Wound Placement
healing in animals that are Gastrostomy tubes can be
severely nutritionally depleted is placed either surgically or per-
often impaired, and more time cutaneously (Figure 1). Either
The Compendium March 1997 Small Animal

A B C

D E F
Figure 1—(A and B) Percutaneous endoscopic gastrostomy tube placement. (C and D) Blind percutaneous gastrostomy tube
placement using a specially designed device. (E ) Percutaneous (endoscopic or blind) gastrostomy tube being drawn through the
body wall. (F) Mushroom-tip gastrostomy tube in place (illustrated with and without [inset] an inner flange).
Small Animal
MANUFACTURERS OF TUBES
AND TUBE PLACEMENT DEVICES
Urologic Catheters (balloon and mushroom tip)
C.R. Bard, Inc
Covington, GA
800-526-4455
Specific-Purpose Gastrostomy Tubes and
Percutaneous Endoscopic Gastrostomy (PEG) Kits
Cook Veterinary Products
Bloomington, IN
800-826-2380
CORPAK MedSystems
(Distributed by MILA)
Erlanger, KY
606-371-6452
800-323-6305
Ross Products Division
Abbott Laboratories
Columbus, OH
800-231-3330
Blind Percutaneous Gastrostomy (BPG) Devices
ELD Gastrostomy Tube Applicator
Jorgensen Laboratories
Loveland, CO
970-669-2500
approach requires general
anesthesia, although the percu-
taneous techniques can be per-
formed rapidly (in less than 10
minutes) by experienced practi-
tioners. If an endoscope is
available, the choice between
performing a surgical gastros-
tomy versus a percutaneous
gastrostomy depends primarily
on whether the patient requires
a laparotomy for reasons other
than tube placement. Other sit-
uations in which a surgical ap-
proach is indicated are when a
patient has an oropharyngeal or
esophageal obstruction or
when a patient is obese. If an
endoscope is not available, us-
ing a blind technique for percu-
taneous gastrostomy tube in-
sertion is an option.
Some of the techniques for
blind percutaneous gastrosto-
my (BPG) require special de-
vices for guiding tube insertion,
whereas others simply use a
piece of vinyl tubing.3,8,9,11 (The
purchase of a specially de-
signed instrument for BPG is
insignificant when compared
with the cost of an endoscope.)
The risks associated with
BPG are similar to those seen
with percutaneous endoscopic
gastrostomy (PEG): inadequate
tube tension resulting in inade-
quate adhesions to the gastric
and body walls, excessive tube
tension resulting in pressure
necrosis of the gastric and
body walls, and inadvertent
perforation or displacement of
abdominal organs (such as the
spleen or colon). The use of an
endoscope helps to decrease
these risks by allowing both di-
rect visualization of the process
and insufflation of the stomach
with air.
To date, the reported compli-
cation rate for BPG is similar to
that of PEG. However, a recent
study found a greater likelihood
of penetration of the visceral
surface of the stomach and the
deep leaf of the omentum when
BPG tubes were placed either
without any gastric insufflation
or when the stomach was in-
sufflated after the guide tube
had been positioned against the
lateral abdominal wall. 11 Al-
though this was a nonsurvival
study, the investigators be-
lieved that tube malpositioning
of this sort could lead to poten-
tial injury of intraabdominal or-
gans. The stomach was insuf-
flated using an orogastric tube
connected to an electric air
compressor. Gastric insuffla-
tion prior to positioning the
guide tube against the lateral
abdominal wall resulted in
more consistent and safer tube
placement.
Tube Selection
Gastrostomy tubes used in
veterinary patients (see Manu-
facturers of Tubes and Tube
Placement Devices) have tradi-
tionally been designed as uro-
logic catheters (e.g., balloon-tip
and mushroom-tip catheters).
These tubes are inexpensive
and readily available. Mush-
room-tip catheters have been
successfully adapted for use as
PEG tubes and seem to with-
The Compendium March 1997
stand the gastric environment
for weeks or even months with-
out deterioration.
The balloon-tip catheter is
generally used for surgical in-
sertion; the safety of this proce-
dure depends to some degree
on the integrity of the balloon.
Relatively inexpensive balloon-
tip catheters that have been
specifically designed as gas-
trostomy tubes are now avail-
able. Because serious compli-
cations can occur if the balloon
ruptures before adhesions have
formed, practitioners should
consider using the specific-pur-
pose rather than the urologic
balloon-tip catheters for surgi-
cal insertion.
Tubes are available in a wide
range of sizes; 18 or 20 Fr for
cats and small dogs and 24 Fr
for larger dogs should usually
suffice. Using smaller tubes has
two drawbacks. First, smaller-
bore tubes negate one of the
chief advantages of the gastros-
tomy tube, that is, ease of feed-
ing blenderized pet foods. Sec-
ond, recent clinical reports
suggest that when tubes 18 Fr
or larger are used, it is not nec-
essary to use an inner flange.7,8
When PEG tube insertion was
first described for small ani-
mals, use of an inner flange
was recommended for added
security in preventing the tube
from migrating out of the stom-
ach. The disadvantage of using
an inner flange, at least in cats
and small dogs, is the risk of
gastrointestinal obstruction if
the flange is not retrieved endo-
scopically.7
Tube Management
Feeding protocols and man-
agement of tube-related com-
plications have been reviewed
extensively.12,13 Several impor-
tant issues related to tube man-
The Compendium March 1997
agement, however, are often
overlooked. The first issue con-
cerns tube labeling. Proper
identification of feeding tubes is
critical in patients that have
multiple tubes (e.g., chest tubes
or biliary stents). Very often,
these patients have extensive
body wraps, and the origin of
the tube is not readily apparent.
When inserted, the tube should
also be marked at the point
where it exits the skin. This
mark will aid in assessing
whether the tube has migrated
or been dislodged.
The second issue concerns
medical recordkeeping. Com-
plete records should include a
description of the placement
technique, the type and size of
tube, and whether an inner
flange was used. This informa-
tion is necessary to ensure that
any complications that arise are
addressed appropriately and
that, when the animal resumes
eating, tube removal is accom-
plished safely.
References
1. Crane SW: Placement and
maintenance of a temporary
feeding tube gastrostomy in the
dog and cat. Compend Contin
Educ Pract Vet 2(10):770–776,
1980.
2. Bright RM, Burrows CF: Percu-
taneous endoscopic tube gas-
trostomy in dogs. Am J Vet Res
49:629–633, 1988.
3. Fulton RB, Dennis JS: Blind
percutaneous placement of a
gastrostomy tube for nutritional
support in dogs and cats.
JAVMA 201:697–700, 1992.
4. Bright RM, Oransinski EB,
Pardo AD, et al: Percutaneous
tube gastrostomy for enteral al-
imentation in small animals.
Compend Contin Educ Pract
Vet 13(1):15–22, 1991.
5. Armstrong PJ, Hardie EM: Per-
cutaneous endoscopic gastros-
tomy—A retrospective study of
clinical cases in dogs and cats.
J Vet Intern Med 4:202–206,
1990.
6. Jacobs G, Cornelius L, Allen S,
et al: Treatment of idiopathic
hepatic lipidosis in cats: 11 cases
(1986–1987). JAVMA 195:635–
638, 1989.
7. DeBowes LJ, Coyne B, Layton
CE: Comparison of french-pez-
zar and Malecot catheters for
percutaneously placed gastros-
tomy tubes in cats. JAVMA
202:1963–1965, 1993.
8. Mauterer JV, Abood SK, Buffing-
ton CA, Smeak DD: New technique
and management guidelines for
percutaneous nonendoscopic
tube gastrostomy. JAVMA 205:
Small Animal
574–579, 1994.
9. Mark SL, Rishniw M, Henry CJ,
et al: Blind percutaneous gas-
trostomy: A new technique.
Proc 12th ACVIM Forum:981,
1994.
10. Miller MA, Allen SW: What is
your diagnosis? JAVMA 207:
1283–1284, 1995.
11. Clary EM, Hardie EM, Fischer
WD, et al: Nonendoscopic ante-
grade percutaneous gastrosto-
my: The effect of preplacement
gastric insufflation on tube po-
sition and intra-abdominal
anatomy. J Vet Intern Med
10:15–20, 1996.
12. Wheeler SL, McGuire BH: En-
teral nutritional support, in Kirk
RW (ed): Current Veterinary
Therapy. X. Philadelphia, WB
Saunders Co, 1989, pp 30–37.
13. Armstrong PJ, Hand MS, Freder-
ick GS: Enteral nutrition by tube.
Vet Clin North Am Small Anim
Pract 20:237–275, 1990.