Radiology - Radiologically Inserted Gastrostomy (RIG)

Introduction

This leaflet tells you about having a radiologically inserted gastrostomy tube (RIG). It explains what is involved and the possible risks. It is not meant to replace informed discussion between you and your doctor but can act as a starting point for any discussion. If you have any questions about the procedure, please ask the doctor who has referred you for the RIG or the nurses and doctor in the x-ray department that will perform the RIG procedure.

What is a gastrostomy?

A gastrostomy is a technique in which a narrow plastic tube is placed through your skin and into your stomach. The tube can then be used to give you liquid food directly into your stomach to provide nutrition. RIGs are placed by specially trained doctors called interventional radiologists.

Why do you need a gastrostomy?

You may be unable to eat or drink sufficient amounts to satisfy your nutritional needs or you may have a problem with swallowing, which makes it unsafe to eat and drink. Having a gastrostomy will help to ensure that you get enough nutrition and fluids.

Are there any risks?

RIG is a safe procedure but, as with all medical procedures, there are some risks and complications that can arise:

• Infection: You may have an infection of the skin at the tube site. You will have antibiotics prior to the procedure to help prevent infection and if necessary, will also have antibiotics after the procedure if the site becomes infected
• Leakage: In around 6% of procedures there is a leak around the tube, which can lead to the skin around the tube becoming red, sore and painful (localised peritonitis). This is less likely to happen if the stomach is attached to the muscles beneath the skin as part of the procedure. If a leak occurs, it may become necessary to remove the tube and allow healing to occur, or an operation may be needed to sew up the hole in your stomach
• Bleeding: To reduce the risk of bleeding during the procedure, we will check your blood clotting before the procedure starts. Very rarely (in less than 1% of cases) a blood vessel can be punctured accidently when passing the needle into the stomach, which can result in bleeding. This bleeding may stop by itself but if it doesn’t, you may need to have a blood transfusion. It may be necessary to have another procedure to block the bleeding artery
• Perforation (a hole) of the bowel: This is very rare (less than 1% of cases) and may be because the needle which is passed into your stomach, or the gastrostomy tube itself, punctures the bowel. A surgical operation may be required to remove the tube and repair the bowel
• Tube dislodgement: Occasionally the feeding tube may become dislodged or fall out and must be replaced
• Failure to place the RIG: Occasionally, it is not possible to position the tube in your stomach whilst in radiology and you may need to have a surgical operation
• Allergic reaction: You may have an allergic reaction to the sedation, the local anaesthetic or the antibiotics

Please be assured that we take great care to reduce the chances of these complications occurring

Who has made the decision?

The consultant in charge of your care and the interventional radiologist performing the procedure have discussed your case and feel that it is the best option. However, you will also have the opportunity for your opinion to be considered and if, after discussion with your doctors, you don’t want the procedure you can decide against it. If you decide to have the procedure you will be asked to sign a consent form to say that you understand what the procedure involves and that you agree to it.

Are you required to make any special preparations?

A RIG is usually carried out under local anaesthetic. You will be asked not to eat for six hours before the procedure, although you may drink clear fluids such as water if you are able. You will be given antibiotics through a cannula (small plastic tube) in your arm before the procedure. If you have any allergies or have previously had a reaction to the x-ray dye (contrast agent) you must tell the radiology staff before the procedure.

Who will I see and where will the RIG procedure take place?

You will meet a specially trained team of nurses, radiographers and radiologists (doctors) within the angiography room in the x- ray department. This room is like an operating theatre in which specialised x-ray equipment has been installed.

What happens during the procedure?

The ward staff will insert a nasogastric tube the night before the procedure. They will give you some x-ray dye down through the tube before the procedure, so that the radiologist can see an outline of your bowel. You will also have a cannula placed in the vein in your arm and you will be asked to change into a hospital gown.

You will be lying on your back in the Interventional x-ray room, and you will have monitoring devices attached to you to measure your blood pressure and heart rate. You will receive some oxygen through a tube placed in your nostrils (nasal cannula) during the procedure. You may receive some sedation and analgesia through the cannula in your arm to help you to relax and feel comfortable if required/suitable.

The RIG procedure is sterile and so the radiologist will wear a sterile gown and gloves. The skin below your ribs will be cleaned with antiseptic and you will then be covered with sterile drapes. The radiologist will use x-ray and ultrasound to decide the best place for the RIG.

The nasogastric tube will be used to inflate and distend your stomach with air before making a cut (incision) over your stomach. The doctor will inject local anaesthetic into the skin on your stomach to numb the skin where the tube will be placed.
This will sting for a short whilst it is being injected.

The doctor will make 3 small cuts in your skin to place sutures (stitches) called gastropexies, directly into your stomach. These sutures help to keep the stomach near the skin until everything heals. These sutures will eventually dissolve in 3 to 6 weeks causing the small button used to secure them to fall off. A fourth cut will be made in your skin to insert the RIG (gastrostomy/ feeding) tube. The doctor will then insert the gastrostomy tube through this cut and will be able to check that it is in the right position.

The tube is held in place by a small balloon at the end of the tube which will prevent the tube from falling out.

For this examination a small amount of radiation will be used. This dose is kept as low as possible. If you think there may be a possibility of you being pregnant you must make staff aware prior to the procedure. You may be in the x-ray department for about an hour.

What happens after the procedure?

After the RIG insertion you will be taken back to the ward. Nursing staff will carry out routine observations including blood pressure and heart rate and will also check the RIG site. You will stay in bed for a couple of hours. Pain relief will be offered as standard following the procedure.

The nasogastric tube will be removed once feeding has started. At around 4 hours after the procedure the dietitians/nutrition nurses will pass some water through your gastrostomy tube before they start using it to feed you. Feed is then given at a slow rate via a pump. Your dietitian will tell you the type and amount of liquid feed to suit you. You may have your feed at intervals during the day or continuously overnight or a combination of the two depending on which is best for you.

It is normal for your stomach to feel a bit sore for a few days and you may have some discomfort and discharge at the gastrostomy tube site. The tube will stay in place until you can eat and drink safely and normally. You will have a specially trained dietitian looking after you who will show you and your carer how to look after your tube. You will be shown how to connect your feeds; clean the skin around your tube and check the position of your tube.
 
You must always wash your hands before handling the tube or feeding equipment. Where possible, your medications will be in liquid form so that you can have them through the tube.

Mouth care

When you are unable to eat it is very important to keep your mouth clean and moist. You should clean your teeth regularly and use a mouth wash. If your mouth is particularly dry due to chemotherapy or radiotherapy your dietitian will give you special instructions.

What happens when I go home?

Before leaving hospital you (and/or your carers) will be shown how to use the feeding equipment. You will be given further information on the care of your gastrostomy tube and the use of the feeding equipment. You will also be given useful contact numbers to ring if you have any problems with feeding at home.

When you are discharged, you will be given a week's supply of feed and equipment. Your feed will then be prescribed by your GP and delivered to you at home either by the company that make the feed or by your local chemist.

The community dietitian will visit you soon after your discharge from hospital and then on a regular basis to assist with changing the water in the balloon holding the tube in place, monitor the balloon and flag any concerns. The community feeding nurse will also visit you at regular intervals.

The gastropexy sutures placed during the procedure will either dissolve themselves or will be removed by the community nurse 3 weeks after the gastrostomy tube is inserted. If you notice any leaks of fluid around the gastrostomy tube, pain when feeding, or new bleeding, you must stop the feed immediately and telephone the accident and emergency department for urgent advice.

What about bathing or showering?

After 2 to 3 weeks when the gastrostomy tube site is fully healed, you can bath or shower as normal.

How long will the gastrostomy tube stay in?

The life of the gastrostomy tube varies from person to person but will need it changing every 4 to 6 months. If, however you’re swallowing and intake of food improves, and your dietitian/ speech and language therapist think you no longer need the tube, it can easily be removed.

Further information PINNT – Patients on Intravenous and Nasogastric Nutrition Therapy. This is a support group for patients receiving parental or enteral nutrition therapy.

Address: PO Box 3126, Christchurch, Dorset BH23 2XS Email: pinn@dsl.pipex.com
Website: www.pinnt.co.uk

Could you be pregnant?

If there is any chance you could be pregnant, please call 0161 206 5091 if your appointment is at Salford Royal or 0161 656 1178 if your appointment is at Royal Oldham Hospital.

Is x-ray guidance dangerous?

All x-ray machines use potentially harmful x-rays. Modern equipment is designed to keep the dose you receive as low as possible. If your doctor has asked for this test, they will have decided that the benefits from the procedure outweigh the risks from the very small dose of radiation that you receive.

What if I cannot attend my appointment?

If you have any queries about your appointment or cannot attend, then please telephone the booking office on 0161 204 2044/2404 (Salford Royal Hospital) or 0161 656 1178 (Royal Oldham Hospital) Monday to Friday 8.30am to 4.00pm.

You can also email booking.radiology@nca.nhs.uk (Salford Royal Hospital) or ir.bookingsOldham@nca.nhs.uk (Royal Oldham Hospital).

Please include name, date of birth, address and hospital number (if known) in any correspondence.

I need an ambulance. How do I arrange one?

If you need an ambulance there are contact details on your appointment letter.

Please contact us if you are arriving by ambulance, so we can time your appointment with your ambulance arrival. If we are not aware that you are coming by ambulance, you may miss your appointment and it may have to be rebooked.

If you need an interpreter

If you need an interpreter for your examination, please call the department so that we can try and arrange this.

Contact Details

We hope your questions have been answered by this leaflet.

If you require help or any other information regarding your appointment you can contact:

The Angiography Department, Salford Royal Hospital
Tel: 0161 206 2206/5091

Interventional Radiology, Royal Oldham Hospital
Tel: 0161 778 5314/5414