Why is a Gastrostomy (G-) tube not recommended over a Percutaneous Endoscopic Gastrostomy (PEG) tube for a 71-year-old patient with Herpes Simplex Virus-1 (HSV-1) Encephalitis and bacterial pneumonia?

From the Guidelines

A G-tube would not be recommended over a PEG tube for a 71-year-old patient with HSV-1 encephalitis and bacterial pneumonia due to the patient's acute conditions requiring immediate nutritional support. PEG tubes are preferred in this scenario because they can be placed endoscopically at the bedside without requiring general anesthesia, which is advantageous for an elderly patient with active infections 1. The procedure is less invasive than surgical G-tube placement, which would require an operating room and potentially expose the immunocompromised patient to additional infection risks.

Key Considerations

• The patient's bacterial pneumonia further complicates matters, as surgical G-tube placement could exacerbate respiratory distress.
• PEG tubes can be placed more quickly, allowing for faster initiation of enteral nutrition, which is crucial for the patient's recovery from both HSV-1 encephalitis and pneumonia.
• According to the ESPEN guideline on home enteral nutrition, percutaneous tubes, such as PEG tubes, should be used instead of nasal tubes for long-term needs to reduce mechanical complications 1.
• A Cochrane systematic review found that PEG feeding demonstrated a lower probability of intervention failure compared to nasogastric tube feeding, suggesting that PEG is a safer and more effective option 1.

Recommendations

• Once the patient stabilizes, a conversion to a more permanent G-tube could be considered if long-term enteral feeding is anticipated, but in the acute setting with active infections, the PEG tube represents the safer, more efficient option for nutritional support.
• Regular assessment of the patient's condition and the effectiveness of enteral nutrition is necessary to determine the best course of treatment 1.
• The ESPEN guideline on clinical nutrition and hydration in geriatrics recommends reassessing the indication and expected benefits of enteral nutrition on a regular basis 1.

From the Research

Patient Selection for Gastrostomy Tubes

• The decision to use a Gastrostomy (G-) tube or a Percutaneous Endoscopic Gastrostomy (PEG) tube depends on various factors, including the patient's medical condition, anticipated need for enteral nutrition, and potential risks associated with the procedure 2, 3.
• For a 71-year-old patient with Herpes Simplex Virus-1 (HSV-1) Encephalitis and bacterial pneumonia, the choice between a G-tube and a PEG tube should be based on the patient's overall health status, gastrointestinal function, and the presence of any contraindications for PEG tube placement 4, 5.

Contraindications for PEG Tube Placement

• Absolute contraindications for PEG tube placement include distal enteral obstruction, severe uncorrectable coagulopathy, and hemodynamic instability 3.
• Relative contraindications include recent gastrointestinal bleeding due to peptic ulcer disease with risk of rebleeding, hemodynamic or respiratory instability, presence of ascites, and ventriculoperitoneal shunts 4.
• Advanced dementia and a life expectancy shorter than 30 days are also considered contraindications for PEG tube placement 4.

Risks Associated with G-Tubes and PEG Tubes

• G-tubes and PEG tubes are associated with different risks, including infection, bleeding, and tube dysfunction 2, 3.
• PEG tubes are generally considered safer and more effective than G-tubes, especially for patients with oropharyngeal dysphagia, as they reduce the risk of aspiration pneumonia 6.
• However, the choice between a G-tube and a PEG tube ultimately depends on the individual patient's needs and medical condition, and should be made after careful consideration of the potential benefits and risks associated with each option 5.

Considerations for Patients with Oropharyngeal Dysphagia

• Patients with oropharyngeal dysphagia are at increased risk of aspiration pneumonia, and the choice of enteral feeding tube can significantly impact this risk 6.
• PEG tubes have been shown to be a better choice than nasogastric tubes (NGT) for patients with oropharyngeal dysphagia, as they reduce the risk of pneumonia requiring hospitalization 6.
• However, the decision to use a PEG tube or a G-tube should be based on individual patient factors, including the presence of any contraindications and the anticipated need for enteral nutrition 4, 5.