PEG Feeding Tubes – Indications and Management

PEG feeding tubes are now increasingly used for enteral nutrition for both children and adults. PEG may be used with a jejunal extension. PEG feeding is used where patients cannot maintain adequate nutrition with oral intake.

Indications

Adults

Indications include difficulties with oral intake often where obstruction to the upper airway or gastrointestinal tract makes passing a nasogastric tube difficult:

Neurologically unsafe swallowing: Acute ischaemic or haemorrhagic stroke: in patients with acute stroke, gastrostomy feeding should be considered at 14 days post-stroke.

Chronic progressive neuromuscular disease.

Failure of feeding:

Dementia; PEG insertion does not improve survival in end-stage dementia and should be avoided except in circumstances where it can be justified as a palliative intervention, genuinely in the patient’s best interest.

Cystic fibrosis: PEG feeding is safe, efficacious and acceptable in children and adults with nutritional failure due to cystic fibrosis.

Peritoneal dialysis: PEG insertion can improve nutritional status but increases the risk of fungal peritonitis and failure of dialysis. Dialysis should be stopped for three days and prophylactic antifungal therapy given.

Oro-pharyngeal and oesophageal malignancy: enteral tube placement into the stomach may hinder surgical techniques in oesophageal cancer and should be avoided if curative resection is planned.

PEG tubes may also be indicated in other clinical situations such as head injury, AIDS, Crhon’s disease, cancer of oral cavity , fistulae,and HIV encephalopathy and severe burns.

Children

The use of PEG may be indicated for children with:

Neurological disorders with inability to swallow or dysphagia.

Craniofacial abnormalities.

Oncology problems with malnutrition.

Other clinical conditions that lead to wasting and malnutrition – eg, chronic kidney disease, cystic fibrosis, metabolic problems, chronic infection such as HIV, cardiac disorders, short bowel syndrome and Crohn’s disease.

Contra-indications to PEG

Absolute contra-indications for use of PEG in adults:

Active coagulopathies and thrombocytopenia (platelet count less than 50 x 109/L) must be corrected before tube insertion.

Anything that precludes endoscopy (such as haemodynamic compromise, sepsis or a perforated viscus).

Absolute contra-indications for using PEG in children are bleeding disorders, severe ascites, peritonitis, pharyngeal or oesophageal obstruction and during periods of acute severe illness. Relative contra-indications for use of PEG in adults include acute severe illness, anorexia, previous gastric surgery, peritonitis, ascites, and gastric outlet obstruction.

Cautions

Infection: active systemic infection increases the risk of early mortality and morbidity post-PEG placement. Elevation of serum CRP is the most accurate prognostic indicator of poor outcome. Other comorbidity: poorer outcome, with increased PEG site and systemic infection have been reported in patients with diabetes mellitus, chronic obstructive pulmonary disease and low albumin levels.

Ventriculo-peritoneal shunts: placement of PEG tubes increases the risk of shunt infection but this risk decreases with increased time between shunt insertion and PEG insertion. Prophylactic antibiotics may further reduce the infection risk.

Anatomical considerations: in patients with severe kyphoscoliosis, the stomach is often intrathoracic. This particularly applies to patients with cerebral palsy. Radiological and endoscopic approaches may be impossible. A combined laparoscopic and endoscopic approach can be tried but this requires a general anaesthetic, which also represents a considerable risk for the patient.

PEG insertion method

In the majority of patients in whom there is an indication for percutaneous enteral tube feeding, an endoscopic gastrostomy is the procedure of choice.

PEG tube placement should be carried out under full aseptic technique. Antibiotic prophylaxis is indicated to prevent skin site infection.

In areas of high meticillin-resistant Staphylococcus aureus (MRSA) prevalence, oro-pharyngeal colonisation should be identified and managed prior to PEG tube placement.

Children:

In children, PEG tube insertion is performed under general anaesthesia. A single dose of intravenous antibiotic is given.

After insertion of the gastroscope into the stomach and a gentle insufflation of air, the most transluminant point of indentation on the anterior abdominal wall is marked.

After sterilising the skin of the anterior abdominal wall and infiltration of this point with local anaesthesia, a skin incision is made and a trocar with a needle is pushed through into the stomach under complete endoscopic visualisation.

A thread or a guide wire is inserted through the trocar after removing the needle and this thread is then snared. The endoscope is then withdrawn with the snare holding the thread.

A suitably sized PEG tube is then connected to the thread and the thread is pulled from the skin incision pulling the tube into the patient’s mouth through the oesophagus, to be retained in the stomach by the internal bolster. An external bolster is placed loosely on the skin.

The position of the inner opening of the tube should be checked by endoscopy.

Benefits of PEG feeding

It is well tolerated (better than nasogastric tubes).

Nutritional status is improved.

Ease of usage over other methods (nasogastric or oral feeding) reported by carers. Satisfactory use by home carers.

Low incidence of complications.

Reduction in aspiration pnuemonia associated with swallowing disorders.

Cost-effective relative to alternative methods, particularly when reasonably long survival is expected.

Management after insertion

Education of carers and patients is essential to reduce tube problems and complications.

Care of PEG tube

This routine care can be performed by the patient and/or the carers with suitable training. After about 10 days following insertion asepsis is not required.

Examine the skin for infection/irritation around the site.

Note the measuring guide number at the end of the external fixation device. Remove the tube from the fixation device and ease away from the abdomen. Clean the stoma site with sterile saline.

Dry the area with gauze.

Rotate the gastrostomy tube to prevent adherence to sides of the track. Re-attach the external fixation device to the abdomen.

Attach the gastrostomy tube gently to the fixation device and position as before according to the mark/number on the tube.

Avoid use of bulky dressings.

Complications

Immediate (within 72 hours):

Endoscopy-related:

Haemorrhage or perforation.

Aspiration.

Over sedation.

Procedure-related:

Ileus.

Pneumoperitoneum.

Wound infection.

Wound bleeding.

Injury to the liver, bowel, or spleen.

Delayed:

Gastric outlet obstruction.

Buried bumper syndrome (migration of the internal bumper of the PEG tube into the gastric or abdominal wall).

Dislodged PEG tube. Peritonitis.

Peristomal leakage or infection. Skin or gastric ulceration. Blocked PEG tube.

Tube degradation.

Gastric fistula after removal of the PEG tube. Granulation around site of insertion of the PEG tube.