A nasojejunal (NJ) tube is a feeding tube used to deliver nutrition directly into the small intestine. This method of enteral feeding involves a flexible tube inserted through the nose, passing down the throat, through the stomach, and ultimately resting its tip in the jejunum, the middle section of the small bowel. The NJ tube provides sustenance when a patient cannot safely eat or when the upper digestive tract cannot tolerate food or formula. It serves as a bridge for short-term nutritional support, typically for a few weeks, until the patient can transition to a less invasive feeding method or oral intake.
Defining the Nasojejunal Tube and Its Clinical Need
The primary purpose of an NJ tube is to bypass the stomach completely, a major functional difference from a standard nasogastric tube. This anatomical placement reduces the risk of pulmonary aspiration, which occurs when stomach contents are inhaled into the lungs. By delivering formula past the pyloric sphincter and into the jejunum, the gastric reservoir is taken out of the feeding equation.
This trans-pyloric feeding is indicated for patients with compromised gastric function, such as those with gastroparesis, where the stomach empties food slowly. It is used for patients recovering from surgeries or those experiencing severe, persistent vomiting or high-output gastric drainage. Conditions like acute pancreatitis, where resting the stomach is beneficial, or a high risk of aspiration due to severe reflux make the NJ tube the preferred route for nutrition.
The Insertion Process and Tube Confirmation
Inserting a nasojejunal tube is a non-surgical procedure, though it is more complex than placing a nasogastric tube. The tube is first advanced through the nasal passage, down the esophagus, and into the stomach. Specialized techniques are required to ensure the tip successfully navigates the pylorus, the muscular valve separating the stomach from the small intestine.
Placement usually requires guidance using fluoroscopy (real-time X-ray imaging) or endoscopy to visualize the tube’s path into the duodenum and then the jejunum. Blind insertion is avoided due to a high failure rate and the risk of misplacement. A chest and abdominal X-ray is mandatory to confirm the tip is fully past the pylorus and safely resting in the small bowel before any feeding can commence.
Daily Management and Feeding Protocols
Tube Security and Position Checks
Daily management begins with securing the tube and routinely checking its position to ensure it has not migrated. A small mark is placed on the tube at the nostril during insertion, and this measurement must be checked before administering any feed or medication. Maintaining skin integrity is also important; the tape securing the tube to the cheek should be changed regularly to prevent irritation or breakdown of the nasal and facial skin.
Feeding Administration
Due to the jejunum’s lack of storage capacity, formula is almost always administered via continuous infusion using a feeding pump, often over 10 to 24 hours. Bolus feeding is generally contraindicated as it can overwhelm the small intestine and cause complications like cramping or diarrhea. The giving set and formula bag must be changed every 24 hours to reduce the risk of bacterial contamination.
Flushing and Medication
To maintain tube patency and prevent clogging, regular flushing with sterile or cooled boiled water is necessary. Flushing should occur before and after formula or medication administration, and routinely every four to six hours. For medication, liquid forms are preferred, and any solid medication must be finely crushed and mixed with water, avoiding enteric-coated or time-release pills.
Patient Positioning
During feeding, the patient should be positioned with their head elevated to at least a 45-degree angle. This semi-upright position should be maintained for at least 30 minutes after the feeding is complete. This postural measure helps to minimize the risk of reflux and optimize comfort during the infusion process.
Recognizing and Addressing Potential Complications
The most common complication is displacement or migration, where the tube shifts out of the jejunum and back into the stomach. This must be detected quickly by checking the external mark on the tube. If the tube moves back into the stomach, the benefit of bypassing the stomach is lost, raising the risk of aspiration.
Other frequent issues include tube occlusion (clogging) and skin irritation at the insertion site, sometimes leading to mild nosebleeds. If a clog occurs, gentle flushing with warm water is the first step, but forceful pressure should be avoided to prevent tube rupture. Feeding-related complications like diarrhea, abdominal cramping, and hyperglycemia can also occur, requiring adjustments to the formula or feeding rate by a healthcare provider.
A rare but serious mechanical complication is perforation of the digestive tract, which requires immediate medical attention. If the tube falls out, or if the patient experiences severe coughing, difficulty breathing, or persistent vomiting, feeding must be stopped immediately, and a doctor should be contacted. NJ tubes must only be reinserted or replaced in a hospital setting with confirmation of placement.