“Pull-Through” Radiologically inserted gastrostomy (RIG) feeding tube

A RIG feeding tube is a small soft tube that is placed through the skin into your stomach. It allows liquid food, water, and medicines to go straight into your stomach. This can be helpful if you cannot eat or drink enough by mouth for more than a few weeks. The tube stays hidden under your clothes.

If swallowing becomes difficult, you might not get enough food or fluid. This can make you feel tired, weak, and unwell. A RIG feeding tube can help by:

• Giving your body food and water directly.
• Helping you take medicine more easily.
• Reducing the risk of choking, coughing or having chest infections.
• Making mealtimes less stressful.
• Helping manage symptoms such as constipation, diarrhoea, and dehydration.

If you do not have a RIG or another feeding tube, you may not get enough food, drink or medication. This can lead to weight loss, poor nutrition, dehydration and feeling fatigued.

The amount of medication in your body may decline and not work as well. Your doctor, nurse or dietitian can talk to you about other ways to help you eat, drink or take medication.

Like any medical procedure, having a RIG fitted has some risks. These include:

• A reaction to the contrast dye used during the procedure (tell your doctor if you have any allergies, you are allergic to or have had a reaction to contrast). The contrast solution used can be associated with mild diarrhoea, nausea, and/or vomiting.
• Minor bleeding or bruising. Rarely, a blood transfusion may be required to replace blood lost due to bleeding. In a very small number of cases, internal bleeding may occur which may require a further procedure or surgery to fix.
• A small chance of infection at the site where the tube goes in. This can usually be treated with antibiotics.
• In rare cases, a serious infection called peritonitis if stomach contents leak into the abdomen.
• Very rarely, damage to other organs like the bowel or liver.

Your healthcare team will explain these risks to you before the procedure.

Yes, these include a nasogastric tube (NGT) and percutaneous endoscopic gastrostomy (PEG) tubes.

• An NGT tube is inserted through the nose directly into the stomach. This is usually used for short-term feeding (up to 6 weeks) in hospital setting mainly. Being discharged home with NGT may not always be possible, as this tube feeding method may not be supported by local community teams.
  • The benefits of an NGT include quick insertion and removal process and that an operation is not required.
  • The main risk associated with an NGT is aspiration pneumonia, due to feed accidentally being fed into the lungs. This can happen if the end of the NGT feeding tube sits in the lungs, instead of the stomach.
  • If you have an NGT placed for feeding, you will receive training on how to check the NGT is in the correct position, the stomach, prior to commencing feeding.
• A PEG tube is inserted into the stomach via the mouth using an endoscope. This procedure may not be possible if you have limited mouth opening, breathing difficulties or a constriction or mass in your throat or oesophagus.

Your medical team or dietitian can discuss what might work best for you.

You will need to stay in hospital for few days when your RIG tube is inserted. Please bring comfortable clothing and any personal items you may need (medications, mobile phone, glasses, hearing aid, etc.). If applicable, you may wish to shave your stomach area to prevent hairs pulling when a dressing is applied post RIG procedure.

Once admitted, you will have pre-procedure tests and a review of your current medications. You may be asked to stop eating and drinking from midnight before the procedure. You will have a small needle put into your arm for intravenous fluids and medication through a drip.

On average, the stay can be about 4-5 days. This is necessary to ensure:

• The medical team can review your medications and perform necessary blood tests
• The respiratory team can assess your breathing and any use of NIV
• You have a CT scan of your abdomen before RIG placement
• The RIG site is healing well, infection-free and comfortable
• You are tolerating the liquid feed via the RIG tube
• You and your family or carers are familiar with all RIG after-care procedures
• Any medications, such as blood thinners, can be paused safely prior to insertion

Before the procedure, the doctor will explain what will happen, including the risks and benefits. If you are happy to go ahead, you will be asked to sign a consent form. If you cannot give consent, your care team will make the best decision for you with your family or carers.

The day before, a small naso – gastric tube (NGT) will be placed in your nose and into your stomach. This is used to put the contrast dye and air into your stomach. The dye helps the doctor see your stomach clearly on the X-ray.

The doctor will use a local anaesthetic and possibly a mild sedative to help you relax.

The tube is passed through your mouth and out through a small opening made in your stomach. A small “bumper” holds the tube in place inside and an external rotation disc on the outside. The whole procedure usually takes about 30 minutes.

You may have some pain, which can be eased with painkillers. You will not eat or drink for at least 12 hours and will receive fluids via a drip. After this, nurses will flush a small amount of water through the RIG tube. If this is well tolerated, tube feeding and medicines can begin, and you may resume eating and drinking by mouth if it is safe.

The RIG tube is held in place by a small bumper inside and an external fixator. During the first few days, you usually do not need a dressing, just keep the area clean and dry. Some people prefer to use a dressing at first to help hold the tube in place. After a few days, you can leave the site open to the air.

Picture 1. RIG tube post insertion

When looking after you RIG tube you should:

• Clean the RIG skin area daily with cooled boiled water and mild soap.
• Always keep the RIG skin area dry.
• Flush the tube with 50 ml of freshly tap water before and after feeds or medicine or at least with 100 ml of water for RIG tube maintenance daily if you are not using the RIG for feeding or medications.
• For the first 2 weeks avoid full baths. It is okay to have a shower but avoid water gushing onto the RIG site. You may use waterproof dressing when showering to protect the area if you prefer.
• You may be able to swim 4–6 weeks post RIG placement.
• Always check for redness, swelling, pain or leaking around the RIG tube. Contact your local district or enteral feeding nurse or GP if you are worried. You may also contact the UCLH Enteral feeding nursing team directly if needed via email uclh.gienteralservice@nhs.net

Before you go home, you and/or your family/carers will be fully trained on RIG tube use, after care and feeding at home. Your dietitian will advise you on your RIG feeding regime.

Part of maintaining the RIG tube involves weekly advancing and rotating the tube. The first advance and rotate takes place after about two weeks from the date of RIG insertion. If you are discharged home before this time, your community nutrition nurse will perform this for the first time and advise you or your carer on how to do this subsequently. This helps to prevent the RIG bumper from becoming stuck to the inside of your stomach and causing problems. You will be shown how to do this.

You can feed in two main ways:

• Pump feeding: our ready-to-hang liquid feed container is hung on the drip stand, to which a giving set is connected. The feeding pump is then clamped to the stand and the giving set attached to the pump, delivering your feed continuously or intermittently over a set period.

Picture 2. RIG feeding via a pump.

• Bous feeding: liquid feed is given in small amounts throughout the day using an enteral syringe.

Feeds via RIG can be flexible, they should be safe, well tolerated and suit your daily routine. Your dietitian` will help you decide on the best RIG feeding method, whether by pump or bolus.

Pictures 3 and 4. Feed being drawn up using an enteral syringe.

Picture 5. RIG bolus feeding using an enteral syringe.

When feeding, always sit upright or keep your head raised to prevent the risk of the liquid feed coming back up into your throat. Never lie flat on your back when being fed through your RIG tube.

You can continue your usual activities with a RIG feeding tube and with a little forward planning and the right supplies, you can travel and/or fly with your RIG tube. Simply, ask your dietitian or medical team for a “fit to fly” letter and take your feed and feeding equipment in your hand luggage to keep your nutrition and/or hydration on track wherever you go.

For pump feeding you will require:

• A feeding pump and a drip stand, which will be delivered to your home or supplied from hospital.
• Giving sets which are disposable tubing kits used to deliver your liquid feed from the feed bag, bottle or pump, into your RIG feeding tube. Ensure you change giving sets every 24 hours.
• Multiple use Syringes for giving water, liquid feed, and/or medicine.
• A backpack (if needed).

For bolus feeding you will only require multiple use syringes for giving water, liquid feed, and/or medicine.

For pump feeding you will require:

• A feeding pump and a drip stand, which will be delivered to your home or supplied from hospital.
• Giving sets which are disposable tubing kits used to deliver your liquid feed from the feed bag, bottle or pump, into your RIG feeding tube. Ensure you change giving sets every 24 hours.
• Multiple use Syringes for giving water, liquid feed, and/or medicine.
• A backpack (if needed).

For bolus feeding you will only require multiple use syringes for giving water, liquid feed, and/or medicine.

You and/or your family members will receive RIG training from the nursing team before you leave hospital.

On discharge from hospital there will be few health care professionals within your local area available to support you including your home enteral feeding dietitian, nurse advisor and/or district nurse. The community support will depend however on you and/or your family’s’ ability to manage the RIG feeding at home.

If you are not able to look after the RIG tube independently, then a package of care (POC) can be organised privately or through local social services before discharge home. Please speak to your medical, nursing team to ensure eligibility for social services POC.

Designed specifically for enteral tube feeding, the liquid feed is a commercially prepared formula and is usually the first‐line choice. It is available on prescription and, unless you are exempt from prescription fees, you will be expected to pay the standard prescription charge.

Your liquid feed is prescribed by your GP and delivered alongside your feeding equipment such as giving sets and/or syringes directly to your home on monthly basis by the local enteral feeding Home Care Company.

Your dietitian will recommend the most suitable liquid feed for you, which contains all your daily calories, protein, vitamins, and minerals. You may receive part or of your daily nutrition via the RIG tube, depending on your needs or preferences.

Together with your Dietitian, you will consider what options are best for you i.e., type of feed, timings of feeds and how much fluid you require daily to best suit your lifestyle. You may also require extra fluids via your tube, the dietitian or medical team will advise you on this.

If you are considering a “blended diet” via your RIG instead of a ready-to-use formula, please discuss this with your dietitian first. Blended diets can present several challenges, and your dietitian will provide the tailored information you need to make an informed decision.

How do I store the feeds?

Unopened containers of commercially prepared liquid feed should be kept at room temperature. Once opened the feed should be used immediately or be stored in the fridge in between use. Do not use any feed that has been open for longer than 24 hours. Empty the unused contents down the sink. Avoid feeds being kept in direct sunlight or heat source e.g., radiators.

• Loose stools, constipation or sickness: Contact your local dietitian and GP.
• Cough or chest infection: See your doctor.
• Leaking or sore tube site: Contact your local dietitian and feeding company nurse. You may also contact your GP and/or district nurse.
• Blocked tube: Make sure that the feeding tube is not kinked. Try warm water with a syringe. If it stays blocked, ask for help by contacting your local dietitian and feeding company nurse.
• Tube falls out: the RIG tube is held by internal bumper and external rotation thus preventing your tube to fall out. But if your tube falls out, go to local A&E straight away and contact your local dietitian and feeding company nurse.

Important:

Occasionally, you may need to increase your RIG fluid intake for a variety of reasons, for example

• If you have diarrhoea
• If you are vomiting
• If you have a fever
• If the weather is hot

Can I still eat and drink? Yes, if it's safe for you. Your speech therapist will let you know.

Will I gain weight? Your dietitian will make sure the liquid feed meets your needs.

Do I still need to brush my teeth? Yes, keep your mouth clean even if you’re not eating.

Will it cure my illness? It won’t cure your condition, but it can help you feel stronger.

Can I swim? Yes, once your RIG site has fully healed (approx 6 weeks) and with a waterproof dressing.

Can I go on holiday? Yes, with planning. Your feed can be delivered abroad with notice.

Will it affect sex? No. Just tape the tube securely to your skin.

Can the tube be removed? Yes, if you no longer need it.

Is it my choice? Yes. If you’d like to discuss any of these points further or have another question, please speak to your UCLH dietetic team or your immediate medical care team.

If you have any further questions about your RIG, please contact your UCLH dietitian or your immediate medical care team.

• The University College London Hospitals (UCLH) Department of Nutrition and Dietetics
  Address: 3rd Floor East, 250 Euston Road, London, NW1 2PG.
  Telephone: 0203 447 9289
  Email: uclh.dietitiansdept@nhs.net
• The Queen Square Department of Nutrition and Dietetics
  Address: Box 91, The National Hospital for Neurology & Neurosurgery, Queen Square, London, WC1N 3BG
  Telephone: 020 3448 3109
  Email: uclh.NHNNdietitians@nhs.net

Switchboard: 0203 456 7890
Website: www.uclh.nhs.uk

Car parking is available at the hospital, but the parking space is very limited, please plan ahead.