What is PEG?

PEG stands for Percutaneous Endoscopic Gastrostomy. This is a procedure in which a feeding tube is placed directly into your stomach through the abdominal wall. It allows nutrition, fluids and medications to be put directly into the stomach.

Why do I need it?

PEG is needed when people cannot take adequate food and drinks by mouth either because of difficulty in swallowing or for other reasons. PEG feeding is the best way to provide liquid nourishment and medications directly into your stomach without taking food through your mouth.

How is a PEG put in?

The procedure will take place in the endoscopy unit. You will need to fast (nothing to eat or drink) for 8 hours before the procedure. In the procedure room the nurse will attach monitors for recording your pulse and blood pressure. You will be given some oxygen to breath through your nose. Your throat may or may not be sprayed with local anaesthetic before you are given a sedative through a needle in your arm or hand. You may be given some antibiotics to reduce the risk of infection. A mouth guard will be placed between your teeth so that you do not accidentally bite the endoscope.
With you lying comfortably, the endoscope (flexible tube with a light and camera at the end) is passed via the mouth into the stomach. The correct place to put the tube is located and the skin is injected with a local anaesthetic. A small cut is made in the skin and the PEG tube is then positioned through the cut in the skin.
Insertion of a PEG tube usually takes 30 minutes to complete.

What happens next?

PEG tube is mostly put in while you are an inpatient in the hospital. After the procedure you will return to your ward area. Rarely you may be allowed home, but that will depend upon why the PEG is being inserted and how sick you are.
You may have sore throat for a day or so after the procedure. You may feel bloated because of the air put in your stomach during the procedure. This settles quickly. You may have minor soreness in your abdomen where the PEG tube was inserted. This will feel like a pulled muscle. This settles in a couple of days and can be managed with simple painkillers. There may be some drainage around the PEG tube for the first 24-48 hours. A sterile gauze dressing will be placed around the cut.
Feeds using the tube usually start with clear fluids between 4 and 24 hours after the procedure. Your dietician will help choose the best feeds for your needs.

Is there any complication from PEG placement?

Yes. PEG procedure is generally safe but complications can occur. The likelihood of complications is more if you are very unwell.
The most common complication is wound infection. This can be treated with simple antibiotics. Other complications include nausea and vomiting for a few days or bleeding from the wound.
Other complications occur rarely but are more serious and may even be life threatening. These include a severe infection of the abdominal wall or damage to the oesophagus (food pipe), stomach or bowel at the time of examination. These complications usually require urgent treatment and even an operation.
There may be problems with the PEG tube like blockage, accidental removal or aspiration (inhalation) of the food into the lungs. These problems with the tube may occur over weeks or months.

How long would I need it?

PEG tube may be temporary or permanent. This will depend on why the PEG is being inserted.
PEG tube usually has a long life (months to years) but can be replaced when necessary. An endoscopy is usually required when replacing the tube. Usually the new tube can be put in through the same ‘hole’ (stoma) as your current tube.

Frequently asked questions.

How should I care for the PEG tube?

Most people can manage PEG tube with very little help. You and your carers will be advised on how to care for your tube. You will be given contact numbers if you need advice. It takes about 2 weeks for the ‘stoma’ or channel to form around the tube. So after 2 weeks you can bath and even go swimming.

How are feedings given?

Liquid feeds are given through the PEG tube using a large syringe, a drip using a tube connected to a hanging plastic bag or a mechanical pump. The special liquid feed contains all the essential nutrients that you would normally get from a healthy balanced diet.

Can I still eat and drink?

A PEG does not prevent a patient from eating or drinking. So if you can swallow safely without choking, there is no reason why food cannot be taken by mouth in addition to the liquid supplement through PEG tube.

What if the tube is pulled out?

It is very important not to pull out the tube in the first week after PEG tube placement. Serious complications could occur. But once the wound heals in a couple of weeks, there is not much risk in removal of the tube.
NB- it can’t answer all of your questions, since a lot depends on the individual patient and the doctor’s professional judgement. Please ask your doctor about anything you don’t understand.

• BBS occurs due to the overgrowth of gastric mucosa over the inner bumper of the gastrostomy tube.
• Overzealous tightening of the external bumper leads to ischaemic necrosis and subsequent ulceration of the gastric mucosa sandwiched between the inner and outer bumper. Subsequent healing causes mucosal overgrowth and burying of the inner bumper.
• The reported incidence of BBS ranges between 1.6 and 6.1%.
• BBS may present as increased leakage around the PEG tube or resistance to infusion or abdominal pain with infusion of feed.
• Diagnosis is obvious at endoscopy

Discuss the management of BBS?

A variety of techniques for the management of this complication have been described. Unfortunately almost all of these methods have the potential for significant complications like bleeding, wound infection and fistula tract formation. There is no standardised clinical protocol for managing BBS. The options are:

• Endoscopic removal (like needle knife technique)
• Surgical removal
• Laparoscopic removal
• Prolonged application of external traction for externally removable PEG

Leaving the buried bumper in situ and inserting a new PEG tube (if needed) may be considered as an option in some patients who are deemed not fit for a more aggressive approach.

Ref

1. Kejariwal D et al. Buried Bumper Syndrome- Cut and Leave it alone! Nutr Clin Pract. 2008 Jun-Jul;23(3):322-24

PEG tube displacement

• Stop feeding immediately. If the tube becomes displaced before the stoma is fully established there is the possibility of feed or gastric contents leaking into the peritoneal cavity.
• Insert a Foleys catheter into the stoma
• Inflate the Foleys catheter and ensures it rotates with ease and can be moved in and out of the stomach easily
• Do not use Foleys catheter- refer to Nutrition specialist nurse or gastroenterologist
• Keep the patient hydrated with SC/IV fluids

Reference:

http://www.grs.scot.nhs.uk

Contraindications
INR>1.5, Platelets <50,000
Severe erosive gastritis or ulcer should be healed before PEG insertion

No longer considered as contraindications

• Lack of diaphanoscopy (transillumination of the endoscopic light through the abdominal wall) at the puncture area is no longer a contraindication;
• a negative needle aspiration test (using a syringe containing 5ml saline solution, puncture under continuous aspiration towards the air-filled stomach without prior air aspiration) is safer than an adequate diaphanoscopy
• Mild- Moderate ascites- Moderate ascites should be drained dry prior to PEG placement. Repeated paracentesis should be performed to keep the peritoneal cavity dry until the PEG tract has healed (usually in 2 weeks). Consider using antibiotics during this period to prevent seeding of the ascitic fluid
• Ventriculoperitoneal shunt
• Peritoneal dialysis
• Crohn’s disease
• Previous GI surgery (Billroth I or II resection or total gastrectomy)
• Concomitant administration of immunosuppressant’s.

Discuss PEG insertion?

• Radiological evidence of pneumoperitoneum may occur in more than 50% of cases; nevertheless, a pneumoperitoneum is not regarded as a complication. Even in cases of pneumoperitoneum and abdominal pain the patients first should be treated conservatively since severe cases are definitely rare and many unnecessary exploratory investigations have been described.
• It is not necessary to give a single, prophylactic dose of an antibiotic if the patient is already receiving antibiotic therapy.
• As a general rule it is advisable to use PEG tubes with a large lumen (at least 15 Charrie`re)—even in children—as smaller diameter tubes are associated with higher rates of clogging.
• Delivery of nutrients via the tube can commence within 1-2h after PEG placement.

Discuss PEG buttons?

• Indications for PEG buttons:
• Cosmetic- aesthetically pleasing especially for the ambulatory patient. It lies flat against the stomach, and an external extension set is attached to the tube when administering formula or fluids.
• Mentally challenged or neurologically impaired patients- button design makes it intrinsically difficult for them to remove it inadvertently
• The switch from a PEG tube to a button can be made once the original PEG tube has been in place for a minimum of four weeks. Gastrostomy buttons are generally are made of polyurethane or silicone, and have a balloon, mushroom tip or disk to secure them internally.
• The one-step button (OSB) gastrostomy has been a useful modification of the PEG technique that allows for the initial placement of the button. Use of OSB has not been widespread possibly due to a lack of familiarity with the device and/or a high rate of previously reported complications (especially button migration, leakage and peritonitis). However, since button systems are much more expensive and have to be routinely exchanged approximately every 6 months because of material fatigue, these systems are usually only indicated for cosmetic reasons in socially fully integrated younger patients
• Currently available OSB
  • Freka Pexact

  http://www.fresenius-kabi.co.uk/internet/kabi/gb/fkintpub.nsf/Content/Product+Features+Freka+Pexact

  • AMT PEG Assist™ Initial Placement Gastrostomy Kit

  http://www.appliedmedical.net/amtipkit.htm

Discuss PEG tube removal?

• The standard method of removing percutaneous endoscopic gastrostomy (PEG) tubes is by repeat gastroscopy and retrieval of the internal PEG bumper by the oral route.
• PEG Tubes can be removed by external traction, if so designed.
• In adult patients with no risk of distal adhesions or strictures, gastrostomy tubes with rigid internal fixation devices can be removed by cutting them off close to the skin, pushing them into the stomach, and allowing them to pass spontaneously (http://www.bsg.org.uk/pdf_word_docs/enteral.pdf)

Patient can eat immediately after removal of a PEG tube

Pic 1 Corflo bumper

Ref

1. ESPEN guidelines
2. PEG insertion video

PEG feeding should be considered for any patient who is unable to meet his/her nutritional requirements via the oral route and who is likely to require artificial nutritional support for at least four weeks.

• Clinical situations in which these conditions may apply can be divided into the following broad categories:
  • Mechanical dysphagia due to obstruction to the upper aero-digestive tract (e.g. head and neck cancers).
  • Neurological dysphagia- acute strokes, reversible coma, brain injury etc where swallowing may recover.
  • Increased nutritional demands- malabsorption
• PEG may be indicated in carefully selected patients with:
  • Progressive neurological disease with no prospect of recovery like MND. In view of the uncertainty of medical prognosis, a trial of PEG feeding may be appropriate to allow time for further assessment.  This should be undertaken for a predetermined period with prearranged review.
• PEG should be avoided where there is refusal to eat because of a psychiatric disorder (e.g. depression or anorexia nervosa). Such patients are often manipulative and PEG placement is best avoided as it simply shifts the focus of attention from food to issues concerning PEG function.
• PEG and dementia
• PEG does not lead to prolongation of life or increased comfort in patients with severe dementia. So PEG is usually not indicated. A PEG may occasionally be considered
  • to achieve objectives like healing pressure sores that is worsening quality of life.
  • Where the dementia itself is not the primary cause of eating difficulty (e.g. the patient with dementia who has had a stroke).

L. John Hoffer forcefully argues that severely demented patients fail to benefit from tube feeding for two main reasons: they lack the potential for physical or neurological rehabilitation and they are not starving. In advanced dementia, a constant body weight, even if subnormal, rules out progressive starvation and eliminates any medical indication for tube feeding. These patients live in a condition of metabolic homeostasis characterised by a low metabolic rate, low energy (food) consumption and constant body weight without apparent detriment.
He further argues that the moral argument that it is wrong to deny a person ordinary nutrition sustenance does not apply to the severely demented person who merely indicates a disinclination to eat much food and whose weight remains nearly constant. However, on the contrary, a patient who shows a strong desire to eat but cannot be allowed to eat by mouth for mechanical or safety reasons is a candidate for tube feeding.
Further a patient who continues to loose weight despite optimisation of diet but whose BMI remains > 18.5 is more likely to be harmed than helped by tube feeding.

Discuss the ethical controversy in PEG tube feeding?

PEG feeding is contentious in patients who are terminally ill or have little potential for rehabilitation. Most retrospective studies showed no benefit of PEG placement in dementia. However, there are other uses (gastric venting, medication delivery and hydration) of a PEG tube besides feeding. These uses of PEG should also be considered in decision making as to whether a patient would benefit from PEG placement.

So PEG could be considered in advanced dementia or persistent vegetative state as long as the family understands the use of PEG (hydration and medication). They should understand that PEG will NOT improve outcome, prolong life or reverse the underlying disease state.
It is also reasonable not to place a PEG, if the patient or family so requests.

Does tube feeding prevent aspiration pneumonia in patients with dementia?

Aspiration pneumonia is often an imprecise diagnosis both conceptually and clinically. Some authors use it to refer to a self limited pneumonitis (tachypnea, wheezing and hypoxia).
The term is also used to describe pulmonary infection due to aspiration of oropharyngeal secretions into the airway.  Infection probably results when normally non pathogenic organisms arrive in high enough inoculum to overcome host defences. Tube feeding cannot be expected to prevent aspiration of oral secretions, and no data show that it can reduce the risk from regurgitated gastric contents.

Finucane et al (Finucane T et al. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA. 1999; 282:1365-1380.) concluded in their pivotal paper that tube feedings did not reduce the risk of oral secretion or regurgitated gastric content aspiration. They noted that in a nonrandomized, prospective study, patients with oropharyngeal dysphagia fed orally had significantly fewer aspiration events than those fed by a tube.

Ref

1. L John Hoffer. Tube feeding in advanced dementia: the metabolic perspective. BMJ 2006
2. Delegge MH. Tube Feeding in Patients With Dementia: Where Are We? Nutr Clin Pract 2009; 24; 214