Indications for Percutaneous Endoscopic Gastrostomy (PEG) Tube Placement
PEG tube placement should be considered when a patient's nutritional intake is expected to be qualitatively or quantitatively inadequate for a period exceeding 2-3 weeks, and when the intervention is likely to improve or maintain the patient's quality of life. 1
Primary Indications
Neurological Disorders
- Dysphagia following cerebrovascular stroke 1
- Craniocerebral trauma 1
- Amyotrophic lateral sclerosis (ALS) 1
- Should be placed early in disease course when vital capacity >50% of predicted capacity
- Parkinson's disease 1
- Cerebral palsy 1
- Other neurological disorders causing dysphagia 1
Oncological Conditions
- Head and neck cancers 1
- Especially in high-risk situations (hypopharyngeal primary site, T4 tumor, combined radiochemotherapy) 1
- Obstructing tumors in the upper gastrointestinal tract 1
- Expected severe radiation-induced oral or esophageal mucositis 1
- Cancer cachexia 2
Other Clinical Conditions
- Wasting in AIDS 1
- Short bowel syndrome 1
- Reconstructive facial surgery 1
- Prolonged coma 1
- Polytrauma 1
- Crohn's disease, especially with growth retardation 1
- Cystic fibrosis 1
- Chronic renal failure 1
- Congenital abnormalities (e.g., tracheo-esophageal fistula) 1
- Mentally and physically retarded children and adults 1
- Palliative drainage of gastric juices in chronic gastrointestinal stenosis or ileus 1
Decision Algorithm for PEG Placement
Assess nutritional status and swallowing function:
- Determine if oral intake is inadequate
- Evaluate if dysphagia is present and severity
- Assess weight loss (significant if >12kg in 3 months) 1
Determine expected duration of feeding support:
Evaluate patient's prognosis and quality of life:
Rule out contraindications:
Special Considerations
Dementia
- The most controversial indication for PEG placement 1
- PEG in dementia patients does not improve nutritional status, mortality rates, or rehospitalization rates compared to other indications 3
- An individualized, critical, and restrictive approach is recommended 1
Head and Neck Cancer
- PEG is superior to nasogastric tubes for long-term feeding 2
- Prophylactic PEG placement should be considered in high-risk patients undergoing radiochemotherapy 1
- Early PEG placement can reduce weight loss and treatment interruptions 1
Stroke Patients
- PEG is helpful and effective in stroke patients with dysphagia 1
- Allows for swallowing training in parallel with feeding 1
- Can be removed when swallowing function recovers 1
Advantages of PEG Over Other Feeding Methods
- Better patient comfort and psychological tolerance than nasogastric tubes 2
- Lower risk of tube dislodgement compared to nasogastric tubes 1
- Possibly better quality of life compared to nasogastric tubes 1
- No general anesthesia required (unlike surgical gastrostomy) 2
- Cost-efficient with shorter hospitalization 2
- Can be performed on an outpatient basis 2
Important Caveats and Pitfalls
- PEG should never be placed for administrative convenience or as a substitute for good nursing care 1
- Placement in dementia patients should be carefully considered as it may not improve outcomes 3
- PEG should not be a terminal or symbolic measure in patients with unfavorable prognosis 1
- Supplementary oral nutrition should be tried first before considering PEG 1
- Early placement is beneficial as significant nutritional deterioration is difficult to fully reverse 1
- Prophylactic antibiotics should be administered to prevent wound infection 4
- Proper management of anticoagulation and antithrombotic agents is essential to prevent bleeding 4
By following these guidelines for PEG tube placement, clinicians can ensure appropriate patient selection and improve outcomes while minimizing complications and unnecessary procedures.