Indications for Gastrostomy Tube Placement
Gastrostomy tubes should be placed when enteral feeding is anticipated for more than 4-6 weeks in patients at high risk of malnutrition who are unlikely to recover oral feeding ability in the short term, provided they have adequate gastrointestinal function to absorb nutrients. 1
Primary Clinical Indications
The most common and well-established indications for gastrostomy placement fall into four major categories 1:
1. Neurological Disorders of Swallowing
- Cerebrovascular accident (stroke) - particularly with persistent dysphagia
- Motor neurone disease/Amyotrophic lateral sclerosis - should be placed early when vital capacity >50% predicted (or ≥1L with PCO2 <45 mmHg in experienced hands) 2
- Multiple sclerosis
- Parkinson's disease
- Cerebral palsy
2. Cognitive Impairment and Depressed Consciousness
- Head injury with prolonged inability to maintain oral intake
- Note: Dementia is now considered a controversial and generally inappropriate indication, as published evidence shows PEG does not improve functional status, prevent aspiration, reduce pressure sores, or achieve stated aims in advanced dementia 2, 3
3. Mechanical Obstruction to Swallowing
- Oropharyngeal or esophageal cancer - this has become the most common indication in recent audits, replacing stroke 3
- Head and neck malignancies 4
- Radiation enteropathy
4. Long-term Partial Intestinal Failure Requiring Supplementation
- Short bowel syndrome
- Enterocutaneous fistulae
- Cystic fibrosis - improves nutritional status and stabilizes lung function; should be placed early when pulmonary function is good 2
- Crohn's disease - contrary to earlier fears, PEG is safe with no higher complication rates and is highly effective for malnourished patients 2
Critical Patient Selection Criteria
Before proceeding with gastrostomy placement, confirm ALL of the following 1:
- High risk of malnutrition with current or anticipated inadequate oral intake
- Feeding duration expected >4-6 weeks (though earlier placement at 14 days post-stroke has been suggested in some trials)
- Adequate gastrointestinal function to absorb and tolerate enteral feeding
- Patient/family acceptance of the procedure and its implications
- Appropriate prognosis - avoid in patients with clearly limited life expectancy
- Specialist assessment of swallowing prognosis by speech/swallow specialist
Absolute Contraindications
Do not place a gastrostomy tube if any of the following are present 1, 2:
- Distal small bowel obstruction (unless for decompression purposes)
- Serious coagulation disorders (INR >1.5, Quick <50%, platelets <50,000/mm³, PTT >450s)
- Interposed organs (liver, colon) at puncture site
- Marked peritoneal carcinomatosis
- Severe ascites (drain first and consider T-tacks)
- Active peritonitis
- Anorexia nervosa
- Severe psychosis
- Hemodynamic or respiratory instability
Relative Contraindications (Proceed with Caution)
These conditions increase procedural difficulty or complication risk but are not absolute contraindications 1, 5:
- Gastro-esophageal reflux (consider jejunal feeding instead)
- Previous gastric surgery
- Extensive gastric ulceration
- Neoplastic/infiltrative disease of stomach
- Gastric outlet obstruction
- Small bowel motility problems or malabsorption
- Peritoneal dialysis (convert to hemodialysis temporarily)
- Ventriculoperitoneal shunts (place concurrently or before shunt, not within 15 days after)
- Hepatomegaly
- Gastric varices
- Coagulopathy (correct first)
- Late pregnancy
- Morbid obesity
- Large hiatal hernias
- Abdominal wall hernias
Common Pitfalls to Avoid
The most critical error is inappropriate patient selection. 1 Many PEGs are placed inappropriately, and the high mortality within weeks of placement is usually due to the underlying condition and poor patient selection (e.g., severe stroke with poor prognosis, advanced dementia). The invasive and potentially dangerous nature of the procedure makes careful ethical consideration mandatory.
Always obtain specialist confirmation from an experienced gastroenterologist or nutrition support team member before proceeding 1. The prognosis of any swallowing difficulty must be assessed by a specialist to avoid placing tubes in patients likely to recover oral feeding quickly.
Recent trends show appropriate restriction: Modern practice has moved away from placing gastrostomies in dementia patients, with dementia no longer appearing as an indication in recent audits 3. The mean age of patients receiving gastrostomies has decreased from 71 years (2004) to 63 years (2022), reflecting more judicious patient selection 3.
Timing Considerations
- Standard approach: Consider placement when feeding needs are likely to persist >4-6 weeks 1
- For stroke patients: Some evidence suggests placement at 14 days post-acute dysphagic stroke, though this remains under investigation 1
- For ALS/MND: Place early before respiratory function deteriorates significantly 2
- For cystic fibrosis: Place early when pulmonary function is still good 2