Gastro-Jejunal (GJ) Tubes

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.

• 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.

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.

• Enteral Drainage Bags. Halyard has recently released ENFit closed system drainage bags for enteral drainage. See their website for complete information.
• 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 the Halyard Enteral Drainage System.

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.