Friday Board Review

Board Review by Dr. Edward Guo (Edited by Dr. Parikh)

A 30 year old male with a history of cardiac arrest with ischemic encephalopathy status post tracheostomy and gastrostomy placement presents from a long-term care facility for a feeding tube problem. His nurse was bathing and performing dressing changes when the patient’s gastrostomy tube fell out. He has otherwise had no fever or vomiting, and his last bowel movement was earlier today. Vital signs are within normal limits. On exam, he appears comfortable. Patient is non-verbal and does not follow commands. There is a patent gastrostomy stoma in his left upper quadrant with no surrounding erythema or drainage. Old charts state that general surgery created the gastrostomy 6 weeks ago with a 16-french tube. Which of the following is the most appropriate initial management?

A: Consult General Surgery for gastrostomy tube replacement

B: CT abdomen and pelvis

C: insert a 14-french gastrostomy tube

D: insert a 16-french gastrostomy tube

Answer: Insert a 16-french gastrostomy tube

Artificial stomas are at risk for premature closure if the tube has been accidentally removed. Closure may begin quickly (within hours) depending on how mature the tract is. It is important for the emergency physician to be knowledgeable of the maturity of different surgical stomas and when consultation is necessary. In general, gastrostomy tracts mature after 2 to 3 weeks and then afterward can be replaced in the emergency department. Using the previous size tube is preferred to prevent leakage around the tract with a smaller diameter tube. CT of the abdomen and pelvis is unlikely to change management given the patient is asymptomatic. If the gastrostomy tract is immature or a 16-french tube is difficult to insert, then it would be indicated to consult general surgery for replacement. Do not attempt to push through resistance due to the risk of creating a false tract. In that case, attempting to insert a smaller size tube is advised to keep the original tract patent.

Type of Surgical StomaTime to Mature
Tracheostomy7 to 10 days
Gastrostomy2 to 3 weeks
Cystostomy (suprapubic)4 to 6 weeks (little evidence, varies based on provider)


Witting MD. Gastrointestinal Procedures and Devices. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.
Buscaglia  JM: Common issues in PEG tubes—what every fellow should know. Gastrointest Endosc 64: 970, 2006. [PubMed: 17140906]

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