What to do if a percutaneous endoscopic gastrostomy (PEG) tube comes out

Management of Dislodged PEG Tubes

Inadvertent removal of a recently placed percutaneous gastrostomy tube (less than four weeks old) is a medical emergency that requires immediate intervention to maintain patency of the tract and prevent closure. 1

Timing-Based Management Algorithm

PEG Tube Dislodgement Within First 2 Weeks

• Immediate action required - This is a true emergency
• The tract is immature and the stomach may not be adherent to the abdominal wall
• Management steps:
  • Cover the stoma site with sterile gauze
  • Keep patient NPO (nothing by mouth)
  • Seek immediate medical attention - emergency department/hospital
  • Replacement should be performed endoscopically or radiologically through the same site 1
  • Do not attempt blind reinsertion as this may lead to peritonitis 2

PEG Tube Dislodgement Between 2-4 Weeks

• Urgent action required - The tract is partially mature but still at risk
• Management options:
  • Endoscopic replacement is preferred
  • Blind replacement may be attempted by medical professionals if:
    • The tract appears well-formed
    • Position is confirmed afterward by water-soluble contrast study 1
  • Balloon-type replacement tubes are typically used for replacement 1

PEG Tube Dislodgement After 4 Weeks

• Prompt but less urgent action - The tract is usually mature
• Management steps:
  • Insert a replacement tube promptly to maintain tract patency
  • Can often be performed in home care settings by trained personnel 1

Temporary Measures to Maintain Tract Patency

If immediate replacement with a proper gastrostomy tube is not possible:

• Insert a balloon-tipped Foley catheter of the same size to temporarily keep the tract open 1
• This can be used for emergency enteral nutrition, fluids, or medications if necessary
• Note: Universal safety connectors (e.g., ENFit®) may make this more challenging 1

Confirmation of Proper Tube Placement

After blind replacement, confirm proper positioning by one or more of these methods:

• Water-soluble contrast study (gold standard) 1
• pH confirmation of gastric content (pH 5 or less)
• Irrigation with 3-50 ml sterile water without resistance or leakage
• Assessment of external tube length
• Manipulation of the tube via rotation and in-out movement 1

Warning Signs of Complications

Monitor for signs of improper placement or complications:

• Abdominal pain
• Peritoneal signs
• Resistance when flushing the tube
• Leakage around the stoma site
• Inability to aspirate gastric contents

Prevention Strategies

For patients at high risk of tube dislodgement (dementia, delirium):

• Implement preventive measures to protect the tube
• Consider abdominal binders, tube securement devices, or protective clothing
• More frequent monitoring may be necessary 1

Remember that adherence of the stomach to the abdominal wall normally takes 7-14 days but can be delayed in patients with impaired wound healing (malnutrition, ascites, corticosteroid treatment) 1. This makes proper assessment of the maturity of the tract critical when determining the appropriate management strategy.