Feeding Jejunostomy and Gastrostomy
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Direct answer
Gastrostomy feeds the stomach; jejunostomy bypasses it. A gastrostomy — PEG endoscopically, radiologically inserted, or open Stamm — suits long-term enteral feeding in patients with a functioning stomach but an unsafe or impossible swallow, such as stroke dysphagia and head-and-neck cancer. A jejunostomy — Witzel tunnelled, needle-catheter or laparoscopic — delivers feeds distal to the stomach, reducing reflux and aspiration risk after oesophageal and gastric surgery and in severe gastroparesis. Neither belongs to short-term need: anticipated access for under 2 to 3 weeks is a nasogastric or nasojejunal tube. Prophylactic antibiotics before PEG placement and respect for tract maturation (7 to 14 days) before tube removal are the two details that separate safe practice from sloppy.
What you must remember
- PEG techniques: pull (Ponsky–Gauderer, commonest), push (Sachs–Vine), introducer (Russell); radiologically inserted gastrostomy when tumour blocks the endoscope's passage.
- Open eponyms: Stamm gastrostomy (seromuscular purse-string) and Witzel jejunostomy (subserosal tunnel) — the classical exam favourites.
- Duration rule: under 2–3 weeks, nasogastric or nasojejunal; longer, gastrostomy or jejunostomy.
- PEG complications: peristomal infection (commonest, reduced by prophylactic antibiotics), buried bumper syndrome (internal bolster eroding into the gastric wall — pain and resistance to feeding), early dislodgement before tract maturity causing peritonitis, colonic injury and gastrocolocutaneous fistula.
- Jejunostomy character: feeds must run as continuous drips — boluses cause cramps, bloating and diarrhoea; tube blockage (flush after every feed) and small-bowel obstruction or volvulus around the site are real risks.
- PEG contraindications: ascites, peritoneal carcinomatosis, severe coagulopathy, interposed colon or liver, and a prognosis measured in weeks where feeding will not alter outcomes.
- Head-and-neck cancer: place enteral access before radical chemoradiotherapy, because mucositis mid-treatment makes eating impossible when it matters most.
- Indian context: preoperative malnutrition is the norm rather than the exception in oesophageal cancer, so a needle-catheter jejunostomy at index surgery is standard oncology practice in Indian units.
A worked decision: the dysphagic stroke patient
A 74-year-old with dense dysphagia three weeks after a stroke, aspirating on videofluoroscopy, alert and likely to live for years, has pulled out two nasogastric tubes. Decision: PEG. Before the pull-technique placement — prophylactic antibiotic 30 minutes prior, safe tract confirmed by finger indentation seen endoscopically, no ascites, acceptable platelets and INR. Aftercare: feeds within hours, daily flushing, and a family briefing on the one emergency — a tube falling out in the first two weeks leaks feeds into the peritoneum through an immature tract, so it is nil by mouth and urgent endoscopy or surgery, not a casual reinsertion; after maturation, prompt replacement keeps the tract open. The contrast patient is the post-oesophagectomy man with a feeding jejunostomy placed at surgery, running continuous feeds from day one, delivering nutrition past the healing anastomosis with less reflux risk than gastric feeding.
Where students slip
Choice errors are predictable: PEG in a patient with weeks to live (dying patients do not benefit from feeding tubes), nasogastric tubes kept for months (sinusitis, pressure necrosis, continued aspiration risk) and jejunostomy where the stomach is normal. Buried bumper syndrome must be recognised rather than memorised — pain on feeding and a tube that will not advance or rotate — because the MCQ describes the syndrome and asks the diagnosis. The Witzel and Stamm eponyms, the continuous-drip rule for jejunal feeds and the 7–14 day tract maturation figure are the one-liners examiners recycle.
Frequently asked questions
When is PEG preferred over a nasogastric tube?
When enteral access will be needed beyond about 2–3 weeks — stroke dysphagia, head-and-neck cancer — since NG tubes cause sinusitis, pressure injury and repeated dislodgement.
What is buried bumper syndrome?
Migration of the PEG's internal bolster into the gastric wall, causing painful, difficult feeding; treated by endoscopic removal and replacement.
Why do jejunostomy feeds run continuously rather than as boluses?
The small intestine tolerates slow drip delivery; boluses overwhelm absorptive capacity, producing cramps, diarrhoea and dumping-like symptoms.
What is the emergency if a PEG falls out in the first two weeks?
The tract is immature (maturation takes 7–14 days), so leakage causes peritonitis — nil by mouth, antibiotics, and urgent endoscopic or surgical reassessment.
Which patients should not be offered PEG insertion?
Those with ascites, peritoneal carcinomatosis, uncorrected coagulopathy, or a prognosis of weeks in which feeding will not change outcomes.