Nasojejunal tube

Nasojejunal tubes are listed among the items in "Nasogastric tubes (NG, NJ, PEG and PEJ)" from Section 2.1.19 in the second edition of the CICM Syllabus for the Second Part Examination. One may expect that the examiners will eventually rename this section into "enteral feeding and drainage tubes", because this broadens the content to tubes inserted orally nasally and percutaneously without a list of acronyms. 

There is no one specific paper to recommend here, as najojejunal tube lore is widely dispersed across the literature. Articles like Silk & Quinn (2015) are probably going to suit most readers; in describing the design of a novel device, the authors found themselves reviewing the design of other devices.

Description of nasojejunal tube equipment

It appears as if every medical equipment manufacturer has at one stage or another produced one of these, and they come with a variety of gimmicks and bonus features, not all of which are entirely useful, and some of which are possibly even harmful. Several phenotypes exist in the wild:

Plain long polyurethane tubes like this Freka Endolumina
	Just a stupid tube Simple and unpretentious Its main superpower is being 270cm long and thin enough to fit through the instrument channel of an endoscope (2.8mm) Upon insertion, it is cut to size and fitted with the screw-on adaptor that allows it to connect to the feed delivery system
Y-port NJ tubes (eg. this nameless NJ tube from Meditech)
	On a fundamental level, this is still just a simple tube. The Y-port is an access point for giving medications and flushing while maintaining a closed system.  The maintenance of a closed system is mostly to protect the appearance of the bedsheets from the potential spray of disconnected feeds, and has little effect on the tube's function or safety.
Dobbhoff tipped tubes ("Kangaroo" from CardinalHealth is a representative example)
	The Dobbhoff tip should really be called the DobbHoff tip, as it is named after Dobbie and Hoffmeister who developed this thing in the mid-1970s. In this risk-averse age, the tip is usually weighted with a steel rod, whereas "initially, the specially designed feeding tube was handmade by affixing a heat-sealed PVC mercury-filled capsule to the distal end of a standard No. 8 French feeding tube."  This weight promotes gastric peristalsis of the tip distally. Con: there is usually little peristalsis in the people for whom postpyloric feeding is indicated.
Self-advancing tubes (eg. the Cook "Tiger" tube, which appears to be discontinued)
	Otherwise referred to as a "frictional" nasjosjunal tube, this thing creeps in the aboral direction along the small bowel, because the small alternating flaps along its length gain purchase along the gut wall and allow the bowel to "grip" the tube much better. Again, this depends on peristalsis, and is perhaps unpleasant for friable or inflamed bowel.
Composite NG/NJ tubes (eg. the Freka Trelumina)
	This is a double lumen tube that does heed to the fact that many patients qualifying for jejunal feeding often have gastroparesis or something similar, that necessitates the occasional gastric decompression. The tube has two lumens, one a gastric aspiration port, and the other a jejunal feeding port.

Safety features of nasojejunal tubes

One could hardly describe the cruel barbs of the Tiger tube as a "safety feature" with a straight face, but they could be mentioned in the context of improved retention (the tube is less likely to migrate from its position, one might argue). Other common safety mechanisms include:

• Radioopaque lines
• Radioopaque weighted tips
• Depth markers to record insertion depth
• Removable stylets to improve placement accuracy
• Hydrophilic coating to improve slipperiness and reduce mucosal trauma
• Minimised diameter to improve tolerance
• Soft polyurethane or silicone material to improve tolerance and reduce pressure injury

Why polyurethane, and not PVC like endotracheal tubes? Apparently, exposure to enteric juices tends to degrade PVC by a terrifying mechanism. PVC, typically an opaque and brittle plastic, is rendered soft and transparent by the addition of various plasticisers, and nice soft tubing may be up to 40% plasticiser by weight. Digestive fluids (especially gastric acid) result in the extraction of this plasticiser, gradually rendering the tube increasingly more stiff and fragile. This degradation is therefore probably the least concerning implication of the process, because the plasticisers are usually not benign. Their range includes molecules like DEHP (diethylhexylphthalate), held responsible for various reproductive and developmental problems. One study by Subotic et al (2007) baked PVC tubes in gastric juice for one week, and found 1mg of DEHP had migrated into the solution from each 5cm length of tubing.

Indications for nasojejunal tubes

It is hard to overlabour the simple fact that the only indication for nasojejunal tubes is postpyloric feeding.

There may, to be sure, exist a whole variety of different reasons for why one might require postpyloric feeding. But to elaborate on these would make this page into a forum on the merits of postpyloric feeding. And one could never know how granular those reasons could become, eg. one could theoretically list every kind of obstructive tumour that might be in the way of gastric emptying. Without this becoming silly,

• Post-operative gastric rest (eg. letting an anastomosis heal)
• Bypassing a gastric outlet obstruction
• Bypassing a functionally useless stomach (eg. in gastroparesis)
• Bypassing the portion of the upper GI tract that is likely to be sending counterproductive neurohormal signals to the pancreas. This is valuable if you are a believer in the idea that this worsens pancreatitis; though De Lucia et al (2023) reviewed the data and concluded that it probably doesn't 
• Preventing reflux through incompetent gastric sphincters
• Where the patient simply cannot afford even a small amount of reflux and aspiration (eg. they are extremely marginal from a respiratory perspective)
• Where the patient is unable to have oral intake because of some kind of gastric distension associated nausea, and TPN is not an option for whatever reason.

Sheikh et al (2015) also list "psychiatric disorders" as an indication, which may horrify the imaginative reader (what kind of refractory bulemia ends up with this sort of countermeasure?)  

Relative/absolute contraindications for nasojejunal tubes

It is a difficult and very silly task, to come up with a list of absolute contraindications for the placement of such a tube. One finds oneself contemplating such insane scenes as the absence of a nose, or the absence of a jejunum. To unfocus from this madness-inducing exercise, the reader is invited to consider that all facio-enteric tubes are fundamentally the same when it comes to the course they traverse through the patient, and their placement will be limited by a common list of anatomical barriers. Thus:

• Absolute contraindications to the (blind) placement of a nasojejunal tube:
  • Base of skull fracture
  • Tracheo-oesophageal fistula
  • A discontinuity in the aerodigestive tract anywhere along the way towards the jejunum
  • A risk that the insertion may perforate a fragile section of this tract, eg. following caustic ingestion
  • Recent nasal, pharyngeal, oesophageal, gastric, duodenal or jejunal surgery
  • Fragile oesophageal varices (even if you safely place this thing under some kind of guidance, the constant rubbing and poking will eventually dislodge a clot or band).
• Relative contraindications to the placement of a nasojejunal tube:
  • Coagulopathy
  • Dependence on NIV (broken seal)
  • Epistaxis
  • Oesophageal pouches or strictures
  • The possibility that another tube (eg. NGT) could be enough
  • Ileus (no peristalsis means the weighted or barbed NJ tube will not advance)

Alternatives to nasojejunal tube placement

So, you have decided that you do want post-pyloric feeding, but not like that.  What are your options? The other methods are largely worse:

• Percutaneous jejunostomy
• Gastrojejunostomy

Or perhaps what you want is not postpyloric feeding per se, but merely access to nutrution, or less gastric distension, or better feed absorption, or improved GI motility overall, in which case, all of those have their own solutions. TPN, prokinetics, PEG, all could be reasonable alternatives.

Complications and consent for nasojejunal tube placement

It would be fair to say that the risks related to the tube itself are few, and that most of the potential harm comes from the technique of its insertion. The presence of any level of guidance (ultrasound, guidewire, fluoroscopic or direct vision with endoscopy) tends to reduce these greatly, but carries a separate set of problems (perforation, radiation, transport, anaesthesia or sedation). The most commonly experienced and complained-about problems with these are  pain of insertion, posterior pharyngeal irritation, nasal pressure areas, and nausea/gagging (so, same as normal NG tubes).

The greatest and most common complication is dislodgement. Other possible complications include:

• Blockage
• Perforation of structures
• pressure injuries on the nares
• impaired lower oesophageal sphincter patency
• failure to progress into the jejunum (i.e. malposition)

And, rarely

• Knotting

But in general this is not a procedure likely to result in death or disfigurement.

Advantages and disadvantages 

Compared to what? One must ask this whenever answering this question. Given that the main alternatives to jejunal feeding, for those who truly need it, are either a surgically placed jejunostomy or TPN, the advantages must be:

• Relatively noninvasive
• Not difficult to reverse
• Minimal risk of infection even with long term use
• Does not require central access and could easily be domiciliary
• Little maintenance
• Low cost

Whereas the disadvantages are

• Narrow, and so feed rate is limited
• Most of these cannot be aspirated
• More challenging to position and reposition than a CVC
• Usually inserted with the patient awake, which they tend to find uncomfortable
• Pearce & Duncan (2002)  report that aspiration still happens, at a rate of around 2-3%

Positioning, anatomy, site selection, and technique

Positioning and anatomy for NJ tube insertion is not different for NG tube insertion, with the exception of the caveat that it may be taking place in endoscopy or fluoroscopy. At the bedside, just as with NG tube insertion, a flexed neck and a cooperative patient sitting upright are essential elements.

The technique is:

• Introduce into nare
• Advance to 50-70cm
• Wait 30min
• Advance another 10cm, and repeat every 30 minutes until a depth of 100cm is achieved
• If able, confirm placement either fluoroscopically or using some kind of poor man's fluoroscopy-like technique. Here is a bedside portable Xray defines the position of the tip as jejunal by the demonstration of the characteristic appearance of the jejunum with a squirt of contrast:

• Environment, monitoring
  • At minimum, one would want to know that they have caused some kind of aspiration by having the patient monitored for oxygen saturation
• Staff, team, roles
  • Usually this is a two-person job, but a cooperative patient can play the role of the second person.

Technical procedural caveats

An et al (2025) is by far the best resource for practical guidance when it comes to inserting one of these things. Their advice:

• Right lateral position: After the tube is shoved all the way in, but you have not seen it enter the jejunum, lay the patient in right lateral decubitus  position with pelvis elevated 15–30°. This is to facilitate the migration of the tip towards the pylorus, using gravity.
• Metoclopramide or erythromycin 10–30min prior to insertion seems  to improve the chance of successful jejunal migration.
• At the depth of about 60–65cm, rotate the tube gently during advancement to prevent kinking.
• At the pylorus, once resistance is felt (75–90 cm), use the “jiggling technique” and partially withdraw guidewire to reduce gastric wall adherence
• Gradually withdraw ~20 cm of the guidewire; observe for recoil. A guidewire should withdraw smoothly, suggesting no entanglement. If resistance is felt, the tube may be looped or kinked. If that is the case, re-introduce the guidewire until resistance is felt, and then the whole tube needs to be withdrawn with the guidewire in situ, hoping that this somehow results in a less coiled tube.
• Aspirate fluid and test pH. Gastric aspirates are acidic (pH 1–5); alkaline fluid (pH >7) suggests jejunal placement
• If it won't go in beyond the stomach:
  • Leave it there. Peristalsis may take it further
  • Withdraw to 50-55cm, rotate, change the position of the patient, try again
  • If still not working, try fluoroscopy or endoscopic placement

Site selection for nasojejunal tube tip position

The selection of the correct destination for a device like this is not rocket science. Beyond the pylorus, there are really only two places it could be.  A duodenal position would not be the worst possible place, except the duodenum is short and the dislodgement by a few centimetres could bring the tip into the pylorus. Pushing it further guards against this possibility. Also, placement in the duodenum risks refluxing the feeds and medications back up into the stomach or up into the pancreatic and bile ducts if the injectate is delivered under pressure.  

Lastly, if the main reason for the placement of such a tube is to avoid the stimulation of pancreatic secretion, then a mid-distal jejunal position is best according to Kaushik et al (2005). They measured the secretion of trypsin and found that feeding the duodenum increased it, whereas feeding into the jejunum did not. The caveat, of course, was that the feeds were delivered about 60-120cm past the ligament of Treitz, which is much further than you are ever likely to get with a normal nasojejunal tube.

Safe maintenance of the nasojejunal tube

Unlike for example the ECMO circuit, improper maintenance of the NJ tube is unlikely to instantly kill the patient, and so the question "what would you do to ensure the safe continued use of this device" would confuse many people. However there are specific maintenance and process guides for using these things, which mostly aim at keeping it in the jejunal position.

• Documented insertion depth helps keep track of tip migration
• Regular flushes (4-hourly or 6-hourly) with either water or saline- remembering that the tube is somewhat longer than the usual NGT, which means a larger volume of flush is required, perhaps up to 30 ml in some designs.
• Continued, rather than intermittent, feed delivery - because not only is blockage prevented, but the patient will thank you ("dumping syndrome" is an unpleasant experience of neurohormonal activation that occurs when the abrupt arrival of a large volume of hyperosmolar feed into the jejunum, manifesting as flushing, nausea, palpitations and syncope).
• Care with administering crushed tablets and mostly limiting medications to effervescent and syrup formulae