What are the management steps for drainage from a percutaneous endoscopic gastrostomy (PEG) site?

Management of Drainage from PEG Site

For drainage from a PEG site, first identify the cause (infection, leakage, granulation tissue, or fistula), then implement appropriate treatment including site cleaning, antimicrobial therapy, barrier protection, and tube management as needed.

Assessment of PEG Site Drainage

When evaluating drainage from a PEG site, it's essential to determine the cause:

1. Inspect the drainage characteristics:

   • Purulent discharge suggests infection
   • Clear/serous drainage may be normal in first week post-placement
   • Gastric contents indicate leakage around the tube
   • Feculent drainage suggests gastrocolocutaneous fistula 1

2. Examine the PEG site for:

   • Erythema, induration, warmth (infection signs)
   • Excessive granulation tissue
   • Proper tube positioning and tension
   • Tube integrity (breakage, degradation)

Management Based on Cause

1. Infection Management

PEG site infections occur in approximately 28% of patients 2 and require prompt treatment:

• For suspected/confirmed infection:
  • Clean site daily with antimicrobial cleanser 3
  • Apply topical antimicrobial agent to entry site and surrounding tissue 3
  • If infection persists, add systemic broad-spectrum antibiotics 3
  • If infection still cannot be resolved, tube removal may be necessary 3

2. Leakage Management

For peristomal leakage of gastric contents:

• Protect surrounding skin:

  • Apply zinc oxide-based skin protectants 3
  • Use barrier film, paste or powdered absorbing agent 3
  • Use foam dressings rather than gauze (foam lifts drainage away from skin) 3

• Reduce gastric acid and improve healing:

  • Consider proton pump inhibitors to minimize gastric acid secretion 3
  • Treat underlying factors (diabetes control, nutrition optimization) 3

• Adjust tube positioning:

  • Verify proper tension between internal and external bolsters 3
  • Avoid unnecessary tube movement or excessive pressure 3
  • Correct side torsion by stabilizing tube or switching to low-profile device 3
  • For balloon devices, check balloon volume weekly 3

• For refractory cases:

  • Consider removing tube for 24-48 hours to allow slight tract closure 3
  • If all measures fail, place new gastrostomy at different location 3

3. Granulation Tissue Management

For excessive granulation tissue (common, vascular, and sometimes painful):

• Daily care:

  • Clean minimum once daily with antimicrobial cleanser 3
  • Apply barrier film/cream to protect surrounding skin 3

• Treatment options:

  • Apply topical antimicrobial agent under fixation device 3
  • Use foam or silver dressing (change weekly or when significantly soiled) 3
  • Consider cauterization with silver nitrate directly on granulation tissue 3
  • Apply topical corticosteroid cream/ointment for 7-10 days with foam dressing 3
  • For persistent cases, consider surgical removal or argon plasma coagulation 3
  • Try alternative brand/type of gastrostomy tube if above steps ineffective 3

4. Tube Issues Management

For tube-related problems:

• Replace tube if:

  • Breakage, occlusion, dislodgement or degradation occurs 3
  • Fungal colonization with material deterioration is present 3

• Proper tube maintenance:

  • After tract healing (about one week), rotate tube daily 3
  • Move tube inwards at least once weekly (2-10 cm) 3
  • Return tube to position with 0.5-1 cm free distance between skin and external bolster 3
  • For gastrojejunostomy or gastrostomy with jejunal extension, do not rotate (only push in/out weekly) 3

Prevention Strategies

• Proper site care:

  • First week: daily monitoring and aseptic wound care 3
  • Consider glycerin hydrogel dressing to reduce infection risk 3
  • After healing: clean 1-2 times weekly with soap and water 3
  • Avoid occlusive dressings (promote moisture and skin maceration) 3

• Patient education:

  • Proper wound care practices significantly reduce infection risk 2
  • Recognize warning signs requiring medical attention

Special Considerations

• For unusual drainage (especially feculent), consider rare complications like gastrocolocutaneous fistula 1
• For persistent drainage despite standard measures, consider advanced wound management techniques like vacuum-assisted closure therapy 4
• Patients with diabetes, obesity, poor nutritional status, or immunosuppression have higher infection risk 3

By systematically addressing the cause of PEG site drainage and implementing appropriate management strategies, complications can be minimized and patient comfort maintained.