From the Guidelines
PEG placement is associated with a higher risk of complications in cirrhotic patients due to ascites or varices, and should be avoided if possible. The use of Polyethylene Glycol (PEG) in patients with cirrhosis is risky due to several factors, including the potential for fluid and electrolyte imbalances, which can be particularly dangerous for cirrhotic patients who already have compromised fluid homeostasis and are prone to electrolyte abnormalities 1. Cirrhotic patients often have impaired renal function, making them more susceptible to dehydration and electrolyte disturbances from the osmotic effects of PEG. Additionally, the large fluid volumes required with PEG preparations may exacerbate ascites or edema in these patients. According to the EASL clinical practice guidelines on nutrition in chronic liver disease, PEG insertion should be avoided in cirrhotic patients due to the risk of bleeding 1.
The guidelines recommend considering nutritional status and presence of sarcopenia in all critically ill cirrhotic patients and providing nutritional support while treating other manifestations of severe decompensation 1. Enteral nutrition is preferred over parenteral nutrition, and naso-gastroenteric tubes are not contraindicated in patients with non-bleeding esophageal varices 1. The daily energy intake in critically ill cirrhotic patients should not be lower than the recommended 35–40 kcal/kg.BW/d or 1.3 times measured resting energy expenditure, and daily protein intake should not be lower than 1.2–1.3 g/kg.BW/d 1.
In patients with hepatic encephalopathy, BCAA-enriched solutions may be considered to improve its resolution 1. However, standard nutrition regimens are recommended since no advantage has been shown for specialized regimens in terms of morbidity or mortality 1. The ESPEN practical guideline on clinical nutrition in liver disease also recommends avoiding PEG placement in cirrhotic patients due to the risk of complications 1.
Overall, the use of PEG in cirrhotic patients should be approached with caution, and alternative methods of nutritional support should be considered to minimize the risk of complications. The risk of bleeding and other complications associated with PEG placement makes it a less desirable option for cirrhotic patients, and other methods of nutritional support, such as enteral nutrition, should be prioritized 1.
From the Research
Risks of PEG for Cirrhotic Patients
- PEG tube placement can be risky for patients with cirrhosis, particularly those with ascites, due to the high mortality rate associated with the procedure 2.
- A study found that the 30-day mortality rate for cirrhotic patients who underwent PEG tube placement was 38.5%, and the 90-day mortality rate was 42.3% 2.
- The presence of ascites at the time of PEG tube placement was a significant factor in the high mortality rate, with 9 out of 10 patients who died in the first 30 days having ascites 2.
Complications and Mortality
- Complications from PEG procedure in cirrhosis with ascites vs non-ascites included bleeding, surgical site infection, and urinary tract infection, but there was no significant difference in the incidence of these complications between the two groups 3.
- The total inpatient mortality was higher in the ascites group (11.8%) compared to the non-ascites group (17.8%), but the difference was not statistically significant 3.
- Factors such as ascites, postsurgical bleeding, and surgical site infection did not have a significant influence on the inpatient mortality 3.
Use of PEG in Cirrhotic Patients
- Despite the risks, PEG tube placement may be beneficial for cirrhotic patients who require nutritional support, and the benefits should be weighed against the risks 2.
- The use of PEG along with lactulose has been shown to be effective in the treatment of hepatic encephalopathy in patients with cirrhosis, and may result in more rapid discharge from hospital 4.
- A study found that the use of 2-liter PEG plus ascorbic acid was a safe choice for colonoscopy in patients with liver cirrhosis, with no significant change in clinical factors or laboratory findings 5.
- PEG has also been shown to be safe and effective in the treatment of overt hepatic encephalopathy, with a significant decrease in the time needed for resolution of HE and length of hospital stay compared to lactulose 6.