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Indications / Contraindications
Indications
- Aspiration risk from gastric feeding: Documented aspiration on gastric feeds; neurologic patients with impaired gag/swallow
- Gastroparesis: Feeds pool in stomach, poor gastric emptying → GJ allows post-pyloric delivery bypassing stomach
- Gastric outlet obstruction distal to GJ access site
- Recurrent aspiration pneumonia in patients with existing G-tube
- G-tube conversion to GJ: Patient with existing G-tube requiring post-pyloric access
- Gastric decompression with simultaneous post-pyloric feeding: G-port drains stomach; J-port infuses feeds
Dual-port function:
GJ tubes have a G-port (drains stomach → vented to bag) AND a J-port (infuses feeds → through pylorus into jejunum). Nurses must understand this distinction — education is critical.
Contraindications
- Prior gastric surgery disrupting anatomy: Billroth II, Roux-en-Y — J-port placement may not be feasible via standard approach; consult surgery for altered anatomy planning
- Inability to traverse pylorus: Tight pyloric outlet obstruction, large duodenal mass blocking wire passage
- Small bowel obstruction (J-limb would not be deliverable into obstructed bowel)
- Coagulopathy (low risk procedure — Cat 1-2, but correct if possible before proceeding)
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Pre-Procedure Checklist
Existing G-tube required. GJ placement is typically performed through a mature gastrostomy tract (>4–6 weeks old). Primary GJ placement (through new tract) is possible but technically harder. Confirm tract age before scheduling.
CT or fluoroscopic anatomy review. Assess gastric anatomy, pylorus location, and proximal small bowel. Confirm no duodenal/jejunal obstruction that would prevent J-limb advancement.
Tube sizing. Typically 18–24 Fr GJ tube system. Confirm what will fit through the existing gastrostomy tract. Measure external tube length at skin.
Local anesthesia + moderate sedation. Access is through existing G-tube site. No new abdominal puncture needed in most cases.
Labs. Routine CBC and coagulation for SIR Cat 1-2. No antibiotics required routinely (existing mature tract).
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Relevant Anatomy
Duodenal Course
- Pylorus: Muscular ring, can be tight. Wire must cross here to reach duodenum.
- D1 (duodenal bulb): Short, first segment past pylorus
- D2 (descending duodenum): C-loop, runs alongside pancreatic head, turns inferiorly
- D3 (horizontal duodenum): Crosses midline. Often the most technically challenging segment to advance wire/catheter through.
- D4 → Ligament of Treitz (LOT): Duodenojejunal junction. J-limb must be past this point for true post-pyloric placement.
Fluoroscopic Landmarks
- Pylorus: Feel/see wire "give" as it crosses. Catheter tip should follow immediately.
- Ligament of Treitz (LOT): Key target. On fluoroscopy: wire crosses midline to the left side, then wraps back leftward into the jejunum = past LOT. J-limb must reach at least 20–30 cm past LOT for reliable post-pyloric position.
- Gastric retention balloon: Inflate only AFTER confirming gastric position — never in the duodenum.
- G-port sideholes: Must lie in gastric lumen. J-port sideholes must lie in jejunum. Confirm both on final fluoroscopy.
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Technique
Fluoroscopic GJ conversion through existing gastrostomy + community cards
Supplies
Fluoroscopy
Dilute Omnipaque contrast
5 Fr × 65 cm Kumpe catheter
10 Fr short sheath
0.035" × 145 cm stiff Glidewire
18–24 Fr GJ tube system (Halyard/Kimberly-Clark or equivalent)
Large syringe (contrast injection)
Dilators (if upsizing)
External fixator
Steps
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Access through G-tube
Inject tube to confirm position. Remove existing G-tube over Amplatz wire.
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Establish safety wire
Place 10 Fr sheath over the Amplatz wire. Place Glidewire through sheath into stomach. Remove sheath and replace over the Glidewire. Amplatz is now your safety wire.
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Gastric catheterization + opacification
Advance 5 Fr catheter over Glidewire into gastric lumen. Probe the pylorus and inject as needed to delineate anatomy.
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Traverse pylorus
Advance hydrophilic Glidewire through pylorus under fluoroscopy. Feel for the "give" as wire crosses into the duodenal bulb (D1). Advance catheter over wire through pylorus into D1/D2. Confirm duodenal position with small contrast injection — should see duodenal folds.
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Advance to jejunum
Continue advancing catheter + wire through D2 → D3 horizontal (crosses midline) → D4 → past ligament of Treitz into proximal jejunum. Confirm LOT passage: wire/catheter crosses midline and wraps back to left abdomen. This step is often the most technically challenging — patience and catheter torque required.
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Exchange for stiff wire
Remove sheath and exchange Glidewire for Amplatz stiff wire through the indwelling catheter. Stiff wire provides purchase/column strength for GJ tube advancement. Withdraw catheter over wire while holding wire position.
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Advance GJ tube
Advance GJ tube system over stiff wire. The gastric limb (G-port sideholes) should sit in the stomach body/antrum. The jejunal limb (J-port sideholes) extends through pylorus and into proximal jejunum. Advance until J-limb is well past LOT (≥20–30 cm if possible).
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Confirm on fluoroscopy
Inject contrast through J-port → confirms jejunal position, contrast flows distally without reflux. Inject contrast through G-port → confirms gastric position, no retrograde flow into jejunum. Both ports confirmed in correct position before inflating balloon.
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Inflate retention balloon & secure
Inflate gastric retention balloon with 10–15 mL sterile water in the stomach. Gently withdraw to seat balloon against gastric wall. Secure external portion to skin. Label G-port and J-port clearly — nursing confusion between ports is a common error.
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Troubleshooting
Problem
Cannot traverse pylorus
Likely cause: Pyloric spasm, tight pyloric stenosis, or poor catheter angle.
Next step: Use a different wire angle (more perpendicular approach to pylorus). Try Glidewire angled-tip manipulation with torque. Wait 5 minutes and retry. Rarely the pylorus is anatomically obstructed → clinical discussion about alternative access (direct jejunostomy).
Problem
Wire won't advance past duodenal C-loop (D3)
Likely cause: D3 (horizontal duodenum) is a tight turn that is the most technically challenging segment.
Next step: Use hydrophilic angled-tip Glidewire + Cobra catheter. Torque and rotate wire to redirect tip through D3. Use short pushes and torque rather than sustained forward force. Repositioning the catheter back in D2, reshaping wire tip angle, then reattempting is often effective. Patience is key here.
Problem
Jejunal limb migrates back into stomach
Likely cause: Most common problem — J-limb not advanced far enough past LOT, or tube too short for patient anatomy.
Next step: Ensure J-limb is advanced ≥20–30 cm past LOT. Use a GJ tube with a longer J-limb if available. Confirm position on KUB at 24h and 1 week — this is why follow-up KUB is mandatory. If J-limb migrates: reposition in IR fluoroscopically (same technique, shorter since tract is established).
Problem
Tube kinked at pylorus
Likely cause: J-limb too short in the jejunum, causing buckling at the pyloric angle.
Next step: Advance the entire tube further so the J-limb is longer in the jejunum. This reduces the kink by distributing tension across a longer intraluminal segment. If tube length is limiting: consider GJ tube with longer J-limb on exchange.
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Complications
GJ-Specific Complications
- Jejunal limb migration (most common) — J-limb retreats back into stomach; patient inadvertently receives gastric instead of post-pyloric feeds; KUB confirms; requires IR repositioning
- J-port clogging — small lumen clogs easily; flush 30 mL water before/after every medication; crush all meds finely
- Gastric balloon inflation in duodenum (misposition) — confirm gastric position by contrast before inflating; inflation in duodenum causes obstruction and pain
General Enteral Tube Complications
- Pyloric injury (rare — from wire/catheter manipulation)
- Peritonitis (rare — catheter misplacement outside gastric lumen)
- Tube dislodgement — same protocol as G-tube; within 4 weeks of original gastrostomy = emergency
- Peristomal infection at gastrostomy site
- Duodenal perforation (very rare — aggressive wire manipulation)
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Post-Procedure Care
Immediate (0–48h)
- KUB at 24h: Mandatory. Confirm J-limb position in jejunum, not kinked back into stomach. This step catches the most common complication before it causes clinical harm.
- Start feeds via J-port once position confirmed on KUB
- G-port: Vent to bag or drainage (drains gastric secretions). Do NOT cap the G-port initially — patient may vomit if G-port not draining.
- Monitor for pain, fever, signs of tube misposition
Ongoing Care
- J-port flush: 30 mL water before/after each medication and feed. Small bore = clogs easily. Do not administer medications without flushing.
- Nursing education: Dual-port tubes require specific education. Label G-port (drainage) and J-port (feeds) clearly. Common nursing error: attaching feeds to G-port.
- Exchange: Every 3–6 months (balloon retention tube). Cannot leave GJ indefinitely — jejunal limb tends to migrate with time.
- Follow-up KUB at 1 week recommended to confirm sustained J-limb position.
J-Limb Migration — The #1 GJ Problem
- If patient has vomiting or aspiration on GJ feeds → suspect J-limb has migrated back to stomach. Order KUB immediately.
- If KUB confirms gastric position: return to IR for fluoroscopic repositioning (short procedure — tract already established).
- If J-limb migration recurs 3+ times despite appropriate tube length: consider direct jejunostomy (see j-tube.html).
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Critical Pearls
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Glucagon is your friend. 1 mg IV before traversing pylorus = dramatically reduced pyloric spasm = much easier wire and catheter passage. Do this routinely — do not try to force through a spasmed pylorus without it.
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The ligament of Treitz is your target. J-limb must be past the LOT for true post-pyloric feeding. On fluoroscopy: wire/catheter crossing the midline, wrapping back toward the left upper abdomen = past LOT. Get there — don't stop at D3.
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J-limb migration is the #1 problem. A tube that works on day 1 can have the J-limb in the stomach by day 3. Use the longest J-limb available. Confirm on KUB at 24h and 1 week. Educate nursing on how to recognize this (patient vomiting on post-pyloric feeds = migration until proven otherwise).
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GJ tubes are G-tubes with a J-port extension. The gastric port still exists and still drains stomach. If patient is vomiting → first check: is the G-port vented to a bag? An uncapped G-port causes retained gastric secretions and reflux.
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If unable to get past D3 (duodenal horizontal): Consider direct percutaneous jejunostomy (j-tube.html) as the next step. Two failed GJ attempts with D3 traversal issues = reassess anatomy with CT and plan accordingly.
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G vs. GJ vs. J-Tube Comparison
| Feature | G-Tube | GJ-Tube | J-Tube (Direct) |
|---|---|---|---|
| Feeding location | Stomach | Jejunum (via J-port) | Jejunum (direct) |
| Aspiration risk | Standard | Lower (post-pyloric) | Lowest |
| Gastric venting | Via G-tube | Via G-port | Not possible (separate G-tube needed) |
| Complexity | Low | Moderate | Higher |
| J-limb migration | N/A | Common (most frequent complication) | N/A (direct placement) |
| Requires existing gastrostomy | No | Usually yes (mature tract preferred) | No (new abdominal access) |
| Best for | Standard enteral nutrition | Gastroparesis, aspiration risk, G-tube conversion | Post-gastrectomy, refractory GJ migration, complete gastric bypass |
Decision Algorithm
- Standard gastric access OK → G-tube (retrograde push, gastrostomy.html)
- Aspiration risk / gastroparesis with existing G-tube → GJ tube (this page)
- GJ tube repeatedly migrates after 2+ attempts → Direct jejunostomy (j-tube.html)
- No stomach present (post-gastrectomy) → Direct jejunostomy (j-tube.html)
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- SIR Standards for GI Tube Placement
- ACR-SIR Practice Parameter for Fluoroscopic GJ Tube
Primary References
- Thornton FJ et al. Percutaneous radiological gastrojejunostomy: a retrospective comparison with Witzel surgical jejunostomy. Clin Radiol. 2002;57(5):416-421.
- Cope C. Conversion of a gastrostomy to a gastrojejunostomy: technical aspects of a simple "shortcut" procedure. J Vasc Interv Radiol. 1998;9(6):961-967.
- Rumalla A, Baron TH. Results of direct percutaneous endoscopic jejunostomy, an alternative method for providing jejunal feeding. Mayo Clin Proc. 2000;75(8):807-810.