Percutaneous Endoscopic Gastrostomy (PEG) Tubes



Percutaneous Endoscopic Gastrostomy (PEG) Tubes





(Am J Gastroenterol 2003;98:272-7. Endoscopy 1998;30:781-89. Gastroenterology 1995;108:1282-1301)


INDICATIONS: In general, patients should have a functional GI tract and anticipated life expectancy >30 days



  • Malnutrition/poor volitional intake (BMI <18.5, Wt.loss >10%, Starvation >7-10 days); Oropharyngeal dysphagia (i.e. throat cancer)


  • Malabsorption, Short Gut Syndrome; Need for gastric decompression; Major trauma/burns


  • Permanent neurological impairment: CVA, MS, Parkinson’s, Dementia


PRE-PEG CHECKLIST:



  • Obtain consent from the patient or healthcare power of attorney


  • Check vitals: any recent fevers, homodynamic/respiratory instability?


  • Check basic labs: CBC, PT/PTT


  • Does this patient have any contraindications (see below)


  • Adjust any anticoagulation/anti-platelet agents (see page 58)


  • NPO/stop enteral feeds after midnight


  • Antibiotic prophylaxis needed? See below and See also Endoscopy & Procedures- Infectious Endocarditis Prophylaxis (Chapter 7.10)


POST-PROCEDURE CARE:



  • Clean area with soap and water


  • Dressing: cut drain sponge placed over the external bumper to avoid unnecessary tension at the site


CONTRAINDICATIONS:

General:



  • Cannot pass endoscope (i.e. obstructing esophageal malignancy) » Consider percutaneous radiological or surgical gastrostomy


  • Inability to transluminate abdominal wall; Inability to appose the anterior gastric wall (peritoneal carcinomatosis, ascites)


  • Gastric outlet obstruction (unless PEG is for venting reasons) or Severe malabsorption


  • Others: Severe diarrhea or vomiting, SBO or severe intestinal dysmotility (Ileus/pseudo-obstruction), Peritonitis, High-output fistula

Relative:



  • Coagulopathy, Gastric varices, Morbid obesity, Prior abdominal/gastric surgery, Ascites, Peritoneal dialysis, Gastric/abdominal wall neoplasm


  • Technically difficult, but not contraindication: Pregnancy, Liver disease, Obesity, and Prior abdominal/gastric surgery


COMPLICATIONS: (TOTAL 4-23%)

Minor: 7-20%: ileus, peristomal infection, stomal leak, buried bumper, gastric ulcer, fistulous tracts, inadvertent removal

Major: 3-4%: peritoneal leak/peritonitis, hemorrhage, aspiration (higher risk as patient left decub position); these may require surgery

Death: 0-2%



  • Bleeding:



    • Check post-procedure hemoglobin and inspect site for hematoma


  • Perforation/Peritonitis:



    • Think about peritonitis if patient has abdominal pain, high WBC, ileus, fever (Transient subclinical pneumoperitoneum occurs in 56% of PEGs; It is usually of no clinical significance but may persist making use of post-procedure X-ray very limited; A better evaluation post-PEG in a patient with suspected peritonitis would be a gastrografin injection)


  • Ileus:



    • Most post-procedure related ileus are managed conservatively; If concern for acute gastric distention, uncap and decompress; Also consider if the bumper of the PEG tube could have migrated and be causing gastric outlet obstruction


  • Excessive granulation tissue (at PEG site):



    • Apply topical silver nitrate to reduce irritation and decrease drainage



  • Infections:



    • 30% of PEGs may have peristomal infections at some time but 70% are minor


    • Decrease risk: limit tension between bumpers; Pre-PEG antibiotics 30 min prior to procedure (Cefazolin 1 gm IV); small skin incision


    • Early diagnosis: po antibiotics for 5-7 days; More severe infection: may require IV antibiotics


  • Site Irritation/Leak:



    • Identify cause: Infection/ulceration at site; High gastric acid secretion (Tx: PPI); Patient cleaning excessively with hydrogen peroxide; Buried bumper; Torsion of PEG (consider clamping device to stabilize tube or replace with low-profile); No external bumper to stabilize tube


    • Prevent local skin irritation: Zinc oxide applied topically as a barrier to irritation; Use foam dressing rather than gauze (foam will help lift away drainage from skin); Topical antifungal if suspicion for local fungal infection


    • Refractory leakage/irritation: may need to relocate PEG site


  • Buried Bumper:

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Aug 24, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Percutaneous Endoscopic Gastrostomy (PEG) Tubes

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