Can a percutaneous endoscopic gastrostomy (PEG) tube be flushed in a patient with ileus?

PEG Tube Flushing in Patients with Ileus

PEG tubes should not be flushed in patients with ileus due to the risk of exacerbating the condition and potentially causing complications such as worsening abdominal distension, vomiting, and aspiration. 1

Understanding Ileus and PEG Tube Management

Ileus represents a functional obstruction of the intestines characterized by decreased or absent peristalsis. When managing patients with both a PEG tube and ileus, several important considerations must be addressed:

Why Flushing is Contraindicated

• Introducing fluid into a non-functioning gastrointestinal tract can worsen distension
• The ESPEN guidelines on artificial enteral nutrition highlight that ileus is a potential complication of PEG tube management 1
• Flushing could potentially lead to regurgitation, vomiting, and aspiration in the setting of intestinal dysmotility

Assessment of Ileus Severity

Before considering any intervention with the PEG tube:

• Evaluate for abdominal distension, absence of bowel sounds, nausea/vomiting
• Assess for passage of flatus or stool
• Consider radiographic confirmation of ileus if diagnosis is uncertain

Alternative Management Approaches

Decompression Function

• In some cases, PEG tubes can actually serve as a palliative drainage device for gastric secretions in patients with chronic gastrointestinal stenosis or ileus 1
• Rather than flushing the tube, it may be more appropriate to use it for decompression until the ileus resolves

Tube Maintenance During Ileus

• Monitor the PEG site for signs of infection or complications 1
• Continue daily site care even when the tube is not being used for feeding
• Once the stoma tract has healed (typically after one week), the tube should still be rotated daily to prevent complications like buried bumper syndrome 1

Resuming PEG Tube Use After Ileus Resolution

When ileus resolves, as evidenced by:

• Return of bowel sounds
• Passage of flatus or stool
• Decreased abdominal distension

Then:

1. Begin with small water flushes (20-30 ml) to test tolerance
2. If tolerated, resume regular flushing with 40 ml of water after medication administration 1
3. Gradually reintroduce enteral nutrition as tolerated

Preventing PEG Tube Complications

Tube Occlusion Prevention

• Once feeding is resumed after ileus resolution, routine water flushing after feedings can prevent tube occlusion 1
• This is especially important for small-caliber tubes

Managing Clogged Tubes

If the tube becomes clogged after ileus resolves:

• Simple water flushing should be the first intervention 1
• Avoid using cola-containing carbonated drinks (not recommended due to sugar content increasing risk of bacterial contamination) 1
• If necessary, a guide wire or commercially available tube declogger can be used by an expert 1

Important Caveats and Pitfalls

• Never attempt to flush a PEG tube in a patient with active ileus as this may worsen the condition
• Be aware that patients with liver disease and ascites have higher risks with PEG tubes in general 1
• Improper PEG tube management can lead to serious complications including perforation and peritonitis
• PEG tubes should be removed endoscopically rather than by the cut-and-push technique due to reports of subsequent ileus 1, 2, 3

By following these guidelines, clinicians can appropriately manage PEG tubes in patients with ileus, minimizing risks while maintaining tube patency for future use once the ileus resolves.