Emergency Presentations for Gastrostomy Complications Are Similar in Adults and Children

Abstract

Gastrostomy tube (GT) complications are often managed in the Emergency Department (ED). We aimed to characterize and compare the pattern of ED presentations of GT complications in adults and children. A retrospective chart review of patients with GT complications presenting to 3 Australian EDs in 2 years was undertaken. ED visits for GT complications occurred in 70 GT patients (36 adults, 34 children) with 122 presentations. When comparing adults to children, infections occurred in 21% versus 36%, respectively; P = 0.08, mechanical issues in 48% versus 52%; P = 0.86, vomiting in 23% versus 8%; P = 0.02, and other issues in 7% versus 5%; P = 0.7. Presentation to ED within 28 days of initial GT insertion occurred in 3 (8%) adults and 3 (9%) children, predominantly with tube dislodgement. GT complications seen in ED are predominantly infectious and mechanical in nature, with an increased frequency of vomiting in adults when compared with children.

What Is Known/What Is New

What Is Known

• Gastrostomy tubes are commonly inserted for nutritional support in adults and children.
• Gastrostomy tubes are increasingly placed and well tolerated. Complications are common but typically minor.
• The most common complications relate to tube blockage, leakage, and infections.

What Is New

• Patterns of emergency department presentations for gastrostomy tube complications are similar in both adults and children.
• A dedicated gastrostomy service may be effective in reducing the number of emergency presentations for gastrostomy complications.

Gastrostomy tubes (GT) provide nutritional support in children and adults with a wide range of medical conditions ^(1,2). GT insertions are common, with up to 7 per 10,000 in children ⁽³⁾. Major complications are classified as: aspiration pneumonia, gastric haemorrhage, peritonitis, abscess, organ damage, buried bumper, and early tube displacement requiring re-operation. Minor complications are classified as: tube displacement with uneventful re-insertion, minor wound infection, and peristomal leakage ^(4–6). Major complications in adults range from 0.4% to 21.8% ^(4,5,7–10) and 3.3% to 12.6% in children ^(2,11–15). Minor complications range from 2.7% to 64.7% in adults ^(4,5,7–10) and 16.4% to 47.7% in children ^(2,11–15).

Depending on the service model, patients with complications contact the department that placed the device or present to the emergency department (ED). Initial management is usually advised by gastrostomy services, gastroenterologists, or surgeons. There is minimal literature describing the complications presenting to ED in a combined pediatric and adult population. Our institution provides tertiary pediatric and adult gastrostomy care, with a gastrostomy outreach service that operates for 15 hours per day. Our primary objective was to characterize and compare ED presentations of GT complications in both adults and children.

METHODS

A retrospective chart review of all patients with GT complications who presented to 3 EDs encompassing the same health service in Victoria, Australia from January 2017 to December 2018 was undertaken. Patients enrolled in the gastrostomy service were matched with ED attendance records. ED notes were reviewed, and patients included if presenting with a GT-related issue. Patient records were reviewed for demographics, indications for GT and reason for presentation. Outreach records were reviewed to determine if the gastrostomy service was contacted. GT complications were defined as: Mechanical, inclusive of GT blockage or dislodgement, with dislodgement being defined as GT removal in a consolidated stoma and displacement of GT within 30 days of insertion; infectious, inclusive of cellulitis or stomal secretions causing infection; vomiting or abdominal pain inclusive of both mild and acute episodes potentially because of gastrostomy placement, and other, inclusive of bleeding or GT site pain.

Ethics approval was received from the Monash Health Human Research Ethics Committee (RES-18-0000-347Q). Data was analysed using GraphPad Prism, Version 8.3 for Mac, GraphPad Software. Descriptive statistics were presented as median (Interquartile Range (IQR)) and Fisher exact test was used to compare categorical variables between adults and children. A P value of <0.05 was considered to be statistically significant.

RESULTS

During the study period, 523 patients (278 adults, 245 children) with a GT were enrolled in the service. New gastrostomy tubes were placed in 139 patients, 88 (63.3%) adults and 51 (36.7%) children. Indications for GT insertion in adults compared with children were: neurological 125 (45%) versus 112 (46%), respectively; P = 0.93, genetic 17 (6%) versus 54 (22%); P = 0.0001, gastrointestinal 54 (19%) versus 22 (9%); P = 0.0007, oncological 72 (26%) versus 7 (3%); P = 0.0001, and others 10 (4%) versus 50 (20%); P = 0.0001.

Seventy (13%) patients (36 adults, 34 children) presented to ED 122 times (56 adults, 66 children) with gastrostomy-related complications. Indications for GT insertion in this cohort is outlined in Figure 1. Of these patients, 65 (92.9%) patients had initial GT inserted endoscopically whilst 5 (7.1%) were inserted radiologically. Presentation to ED within 30 days of initial GT insertion occurred in 6 (8.5%) (3 adults and 3 children), predominantly with mechanical complications. The remaining 64 (91%) presented a median of 17 (9–49.3) months following initial placement, 16 months (9--49.7) for adults versus 15.5 months (6–43.3) for children.

FIGURE 1: Underlying diagnoses for gastrostomy tube placement amongst patients presenting to emergency departments. ED = emergency department; GT = gastrostomy tube.

Reasons for GT complications are outlined in Figure 2. When comparing adults to children, complications were categorized as infections in 21% versus 36%, respectively; P = 0.08, mechanical issues in 48% versus 52%; P = 0.86, vomiting in 23% versus 8%; P = 0.02, and other issues in 7% versus 5%; P = 0.7. GT replacement occurred in 20 (37%) adults and 34 (66%) children (P = 0.1), all for minor complications. Recurrent ED presentations were significantly less common in adult patients: 9 (25%) versus children 18 (53%), P = 0.03, resulting in 25 (44.6%) adult and 47 (71.2%) paediatric ED presentations. Fourteen (77.8%) children and 7 (77.8%) adults had at least 1 subsequent visit for the same complication. The most common recurrent GT complication was mechanical, with 25 (53.2%) paediatric and 16 (64%) adult presentations. Over a 2-year period, the gastrostomy service received 7494 telephone calls, 5296 (71%) during 9.00 a.m. to 5.00 p.m. and 2198 (29%) out of hours. The service was contacted in 48 (39%) presentations representing 0.6% of overall calls made to the service during this period. Contact was made directly by patients in 21 (27%) presentations.

FIGURE 2: Gastrostomy tube complications seen in emergency departments (adults vs children). ED = emergency department; GT = gastrostomy tube.

DISCUSSION

To our knowledge, this is the first study to compare GT complications in adults and children presenting to ED. Complications of gastrostomy tubes are well described ^(7,13–15); however, there remains a paucity of literature on how complications differ between adults and children, long-term frequency, and the impact of a gastrostomy service on ED presentations. For both adults and children, complications seen in ED were predominantly infectious or mechanical, consistent with the literature ^(13,15). Vomiting was, however, significantly more common in adults. We speculate this may be related to a significantly higher proportion of feeding devices inserted in adults for gastrointestinal or oncological reasons. GT care in children often depends on parents, and children may be more likely to remove their GT. This may have resulted in the trend towards higher rates of GT infections, re-insertions, and higher rates of repeated ED visits in children versus adults. Our data also suggests that adults and children present within 1 to 2 years of insertion with GT complications. Often, they present with recurrent presentations predominantly mechanical in nature, albeit more frequently in children than adults. We speculate that generally, GT complications could be because of degradation of gastrostomy devices, as well as weight changes in growing children and alterations in gastrointestinal motility and secretions leading to leaking and skin degradation. Ongoing education may be useful to prevent recurrent complications, such as tube dislodgement.

The frequency of complications presenting to our ED was similar between the 2 groups, with an overall rate of 13%, in the entire cohort. Whilst this rate is low, it is unlikely to be a true representation as phone calls to the outreach service may have led to resolution of complications that previously would have presented to ED. Considering the large population of gastrostomy tubes, the outreach service cares for and the volume of calls received (7494 in a 2-year period), calls from ED represented a small fraction of overall call burden (0.6%). This suggests that the service was effective in reducing the number of ED presentations for minor GT complications. Rates of re-presentation within 28 days of insertion were similar between groups suggesting that early education regarding GT care provided by the gastrostomy outreach service are similar in both populations. Only 27% of patients, however, utilized the outreach service before ED presentation. We hypothesize that ED presentations for minor issues could be reduced with additional patient education on contacting outreach services.

Strengths of our study include the similar sample sizes of both adults and children cared for by the gastrostomy outreach services and presenting to ED. Limitations include its retrospective nature and small size. Additionally, the adult and paediatric cohort are heterogenous with significantly different indications for GT placement in both the overall GT population and ED cohort, potentially affecting GT complications. We did not analyze the impact of gastrostomy insertion technique on the rate of complications because of the small number of radiological insertions. Of note, there were no major GT complications presenting to ED. Four cases of buried bumpers were, however, managed directly by the outreach service without ED presentation. This is further supportive evidence of the utility of a gastrostomy outreach program in decreasing ED presentations.

CONCLUSIONS

A majority of GT complications presenting to ED are predominantly infectious or mechanical, with significantly more vomiting in adults. The calls to outreach services generated by these presentations are a small fraction of their overall workload. Rates of complications managed in ED are typically low, this may have been contributed by access to a gastrostomy outreach service but large studies comparing centres with and without such a service are needed to determine this.