How do you manage PEG (Percutaneous Endoscopic Gastrostomy) irritation or soreness?

Management of PEG Site Irritation and Soreness

PEG site irritation and soreness should be managed with daily monitoring, proper cleaning, appropriate dressing, and addressing underlying causes such as infection, leakage, or excessive granulation tissue. 1

Initial Assessment of PEG Site Irritation

When evaluating PEG site irritation or soreness, look for:

• Signs of infection: erythema, induration, purulent discharge, pain, fever
• Leakage of gastric contents
• Excessive granulation tissue (overgranulation)
• Improper tube positioning (tension between internal and external bolsters)
• Fungal colonization
• Buried bumper syndrome

Management Algorithm

1. Routine PEG Site Care

• For newly placed PEG (first 5-7 days):

  • Monitor the site daily for signs of bleeding, pain, erythema, induration, leakage, and inflammation 1
  • Clean the site daily with 0.9% sodium chloride, sterile water, or freshly boiled and cooled water 1
  • Apply a sterile Y-dressing under the external disc plate 1
  • Use a skin-friendly, solvent-free breathable dressing 1
  • Avoid occlusive dressings as they promote moisture and can lead to skin maceration 1

• For established PEG sites (after healing):

  • Reduce dressings to once or twice weekly 1
  • Clean with soap and water of drinking quality 1
  • Consider leaving the site open without dressings 1

2. Management of Specific Complications

For Infection:

• Clean the site with antimicrobial cleanser 1
• Apply topical antimicrobial agent to the entry site and surrounding tissue 1
• If infection persists, obtain a swab for microbiological examination and consider systemic broad-spectrum antibiotics 1

For Leakage:

• Apply a topical skin product such as a powdered absorbing agent or a barrier film, paste, or cream containing zinc oxide 1
• Use foam dressings rather than gauze to reduce local skin irritation 1
• Check proper tension between the two bolsters 1
• Verify balloon volume if using a balloon-type tube (check weekly) 1
• For persistent leakage, consider temporarily removing the tube for 24-48 hours to allow slight closure of the tract 1

For Excessive Granulation Tissue:

• Apply a barrier film or cream to protect surrounding skin 1
• Clean the affected skin at least once daily with antimicrobial cleanser 1
• Treatment options include:
  • Topical antimicrobial agent under the fixation device 1
  • Foam or silver dressing over the affected area 1
  • Cauterization with silver nitrate directly onto the granulation tissue 1
  • Topical corticosteroid cream or ointment for 7-10 days with foam dressing for compression 1
  • For refractory cases, consider surgical removal, argon plasma coagulation, or changing to an alternative type of gastrostomy tube 1

3. Preventive Measures

• Tube Positioning:

  • Maintain proper tension between internal and external bolsters 1
  • Allow 0.5-1 cm free distance between the skin and external bolster 1
  • Rotate the tube daily and move it inward at least once weekly (2-10 cm) to prevent buried bumper syndrome 1

• Tube Maintenance:

  • Flush the tube with 30-40 ml of water before and after each feeding and medication administration 2
  • Avoid using hyperosmolar medications directly through the tube 2
  • Check balloon volume weekly if using a balloon-type tube 1

Special Considerations

• For fungal infections, apply topical antifungal agents 1
• For side torsion resulting in an enlarged stoma tract, stabilize the tube using a clamping device or switch to a low-profile device 1
• For refractory cases not responding to conservative measures, consider placing a new gastrostomy at a new location 1

Common Pitfalls to Avoid

• Applying excessive traction to freshly inserted PEG tubes (not necessary for the first 24 hours) 1
• Using occlusive dressings that promote moisture and lead to skin maceration 1
• Placing dressings under the exterior bumper with excessive tension 1
• Neglecting daily rotation and weekly inward movement of established tubes 1
• Failing to recognize buried bumper syndrome, which requires prompt intervention 1
• Using carbonated drinks or acidic juices to unclog tubes, which may cause tube degradation 2

By following this systematic approach to PEG site irritation and soreness, most complications can be effectively managed, improving patient comfort and preventing more serious complications.