GJ-tubes are placed in the stomach just like G-tubes, but a thin, long tube is threaded into the jejunal (J) portion of the small intestine. GJ-tubes can be a great aid for individuals with dysmotility, those who aspirate, and those who are losing a great deal of calories due to vomiting, but are not good candidates for a fundoplication. Rather than feeding into the stomach like G-tubes, GJ-tubes can be used to bypass the stomach and feed directly into the second portion of the small intestine. The gastric port can be used to give medications, vent air, drain fluids, and give feeds if appropriate and safe for the individual.
The vast majority of children who get GJ feeding tubes begin with G-tubes; it is rare for a GJ-tube to be placed initially. Most GJ-tubes have separate ports to access both the stomach (G-port) and the small intestine (J-port), though some tubes, often called Transjejunal (TJ) tubes, only allow access to the small intestine. GJ-tubes are available both as buttons or long tubes.
Switching from a G-tube to a GJ-tube is a relatively simple procedure. If there is already a G-tube in place, the GJ-tube can be placed into the same stoma, so no additional surgery is required. The switch is done in the Interventional Radiology department. A special kind of continuous X-ray called fluoroscopy is used to correctly place the GJ. Some hospitals allow parents to be in the room and others do not.
Also, sedation is used by some facilities, but others do not use any type of sedation. While the procedure is not usually very painful, it can be uncomfortable, and some children have trouble staying still or experience anxiety during the procedure. Initial placement can be more difficult than subsequent GJ-tube changes. In subsequent replacements, a guide wire can be threaded through the tube that is already in place so that the new tube can easily be put into the correct position.
Switching from a G-tube to a GJ-tube may not necessarily stop a child from refluxing or vomiting. What it can do is prevent the loss of calories from vomiting by allowing the formula to bypass the stomach so that it cannot be vomited up.
One of the challenges of a GJ-tube is that the J portion holds the pylorus partially open, and that means that bile from the small intestine can potentially seep into the stomach. This can be problematic for an individual with chronic vomiting, severe reflux, or aspiration of reflux. Having a GJ-tube is a godsend for a child who has any of these problems because the stomach can be vented without interrupting feeds. If bile reflux is a problem, the stomach can be vented continuously to prevent the bile from being vomited or refluxed and aspirated. Some doctors prefer for the bile to be re-fed through the J-port, but others prefer to replace it with an equal volume of Pedialyte. It may depend on the amount of drainage, the patient’s condition and tolerance. Other times, IV fluids are the best option for rehydration and replacement of lost electrolytes.
Parent Tip: For those with a MicKey GJ-tube, use different brand, size, or color extension sets for the G- and J-ports so you can tell them apart in the dark when you are administering medication.
Does GJ Placement Hurt?
For most children, GJ placement or replacement is mildly uncomfortable. There may be tugging at the site when the old tube is removed, and there may be a feeling of fullness or mild discomfort when the new tube is being put in place. More common than pain is a feeling of anxiety.
Is a GJ Permanent?
The GJ-tube is not necessarily permanent. Many kids who need to have a GJ do not need to stay on it forever. Some of the conditions that make the GJ necessary improve with time, and transitioning back to gastric feeds is possible. And if it doesn’t work out, it can easily be switched back to a G-tube.
GJ tubes may be a good option for individuals with poor stomach function or motility, chronic vomiting, and respiratory problems from reflux. Feeding into the intestine (through the J-port) may alleviate these problems.
Individuals who feed into the Jejunal (J) port must be fed continuously.
Part of the benefit of GJ feeds comes from getting the formula slowly. If your child has never tried continuous feeds through the G-tube, you should try this before converting to a GJ.
For some, the GJ-tube can be an alternative to a Nissen fundoplication.
Start J feeding slowly, and gradually increase the rate over hours or days. If you increase rates too quickly with J feeds, you may see retching, discomfort, or diarrhea. Often, J feeds are started with a pediatric electrolyte solution before formula is added in. It may take 24 hours or more to get to the goal rate. It is not uncommon for continuous feeds to run for 20 hours a day or more with GJ-tubes, especially in the beginning.
GJ-tubes can allow for continuous feeding through the J-port, and frequent or continuous venting and drainage from the G-port, if necessary.
Like other balloon buttons, button GJs need to be changed about every 3 months. They are more likely to clog than G-tubes and must be flushed well after feeds and medications are administered.
Life at Home with a GJ-Tube
Click on the toggles below to find information about common issues or concerns.
You will most likely still need to vent the G portion of the GJ-tube. In the beginning, you may need to vent every 3 to 4 hours. One of the challenges of a GJ-tube is that the J tubing holds the pylorus (entry to the intestines) partially open, and that may allow bile from the small intestine to seep into the stomach. If bile reflux occurs, the stomach can be vented to prevent the bile from being vomited or refluxed. In rare cases, the stomach needs to be continuously drained. What is drained out can be replaced with a hydration solution as directed by your physician, or re-fed into the intestines via the J-port. Talk to your child’s medical team if there is a problem with bile in the stomach.
Because a GJ tube cannot be replaced at home, it is critical to keep a spare G-tube button or Foley catheter on hand in case the tube ever comes out. The stoma will need to be kept open until the GJ-tube can be replaced.
GJ-tubes need to be flushed more often than G-tubes. The J-port is particularly likely to clog because of the longer length and smaller diameter of the tube. The J-port should be flushed every 4-6 hours, especially after medications have been given, and after feeds have ended. Water should be flushed slowly into the J-port each time. It is usually OK for parents not to wake in the middle of the night to flush the J if feeds are running continuously.
The length of the J portion can be 15cm, 22cm, 30cm, or 45cm, and the amount of water needed to effectively flush the tube will vary depending on the length of the tube. To avoid clogs, the J portion should be flushed often and with the amount of water recommended by the physician, especially after medications have been given and after feeds have ended. Make sure it is enough to clear the extension set and the J tubing.
If the J-port does clog and cannot successfully be unclogged, it will have to be replaced.
It is very important never to bolus feed the J-port of a GJ-tube. The intestine is not able to hold a large volume like the stomach can. It is not uncommon to see continuous feeds of 20 hours a day or more with GJ-tubes, especially in the beginning.
Most medications can be given in either the G- or J-port, though there are a few that must be given through the G-port. A doctor or pharmacist can determine which medications should be given through which port. Some kids are highly sensitive to volumes in either the G- or the J-port, so medications and flushes may need to be spaced apart and given slowly.
Be aware that there may be drastic changes in stools for the first few days. The body needs time to adjust to formula bypassing the stomach and going directly into the intestines. If your child is having diarrhea or constipation issues, it is important to let your doctor know so he or she can help manage stooling problems.
If you see formula when venting the stomach or if your child vomits formula, you should contact your doctor immediately. This can be a sign that the J-tube has migrated to the stomach. See GJ Out of Place for more information.
A common issue with button-style GJ-tubes is that the backflow valves wear out quickly. The intestine cannot tolerate high feed rates, so most individuals with GJ-tubes are fed very slowly for the majority of a 24 hour period. Having the extension tubes connected to the button for that much time out of every day causes the valves to wear out quickly. Many people end up needing to leave extension sets connected all the time to prevent the valves from leaking.
You CAN still do oral feeds with a GJ-tube, as long as the child is safe with swallowing and as long as the orally consumed food is still able to pass through the stomach well enough to not cause problems. You may also be able to drain orally eaten foods out of the G, if need be. The J portion of the tube does partially block the pylorus, so that can make it more difficult for food to leave the stomach, but if the child’s medical team feels that oral food trials are okay, there’s no reason why it can’t be done. Having a child eat and handle water boluses or feeds in the G-port without vomiting can be signs that that you can return to G feeds.
Venting and Draining the G-Port
Farrell bags allow for venting the stomach while feeding. Moreover, it gives food a place to go until the stomach is better able to handle it. The food enters the bag and then is gravity fed back into the stomach.
Some families, especially those with small babies, also use the Chimney Method for venting. The G-port is attached with a long extension set to an open 60ml syringe. This syringe is suspended in the air above the child so that air can bubble out as needed while the child is sleeping. Families have developed a number of methods of suspending the syringe, including using a clamp on the side of the crib or bed.
Draining the G-port
With gastroparesis and other motility disorders like Chronic Intestinal Pseudo-Obstruction is sometimes necessary drain the stomach. Farrell bags only work well if what is vented can be re-fed into the stomach on its own. However, that may be less likely to happen with motility disorders.Many parents have devised their own systems to deal with continuous draining. Here are some options.
Farrell Bags. While Farrell Bags were designed for venting, they can also be used for draining. Simply place the bag lower than the stomach and it will drain.
Diaper Method. This system is made from what you already have. It is best to test out continuous draining. Cut the tubing from a used feeding bag and wrap a diaper around the cut end. Place the diaper in a plastic bag and twist-tie it closed. Keep it lower than the stomach, or on the floor while sleeping. The diaper can be weighed to measure output.
Adapted Feeding Bag Method. Very clever parents have figured out a way to use a feeding set as an alternative to a Farrell bag. Cut out the part of the tubing that goes into the pump and use the pliable tubing to connect the bag to the rest of the tubing.
Urinary Collection Bags. A number of parents use small urinary collection bags to drain gastric contents. The tubing that comes with the collection system can be bulky, and some parents find it too short. Urine bags have valves that prevent the contents from going back out. Most have a cap to allow emptying of the bag. The bag can be used up to a week with daily (or more often) rinsing.
This image shows a homemade drainage bag, using a diaper inside a plastic bag.
This image shows how you can adapt a feeding bag to become a venting or drainage bag.
This image shows a urine bag being used for gastric drainage.
Parent Tip: If you are going to be draining overnight, put a plastic container near the crib or bed and put the bag in it, so that if it leaks it doesn’t ruin the floor. Bile will remove the polyurethane off of wood floors and will stain carpeting.
What do you do with the drainage?
Your doctor must decide what should be done with anything that drains out of the stomach. Gastric juices and bile are important for hydration and weight gain. Sometimes doctors recommend replacing gastric output with pedialyte. Blood work may be done to make sure your child’s electrolytes are within the appropriate ranges.
If the volume of output is considerable, it may be necessary to re-feed it. This sounds so much worse than it is. Bile should be collected and re-fed several times a day. Bile can be mixed with formula and run through the feeds into the J-port.
Check with your doctor on his or her recommended procedure. Some parents will re-feed in addition to the full daily formula intake. Children who are prone to dehydration may benefit from re-feeding all that is drained out.