What are percutaneous ultrasound gastrostomy (PEG) tubes?

Percutaneous Ultrasound Gastrostomy Tubes

Percutaneous ultrasound gastrostomy (PUG) tubes are a method of providing direct access to the stomach through the abdominal wall for long-term enteral nutrition when endoscopic placement is not possible, offering a safe alternative for patients who need nutritional support for more than 2-3 weeks. 1

Types of Percutaneous Gastrostomy Tubes

Percutaneous gastrostomy tubes can be placed using several techniques:

1. Percutaneous Endoscopic Gastrostomy (PEG) - Most common method, uses endoscopic guidance
2. Percutaneous Sonographic Gastrostomy (PSG) - Uses ultrasound guidance
3. Percutaneous Fluoroscopic Gastrostomy (PFG) - Uses fluoroscopic guidance
4. Percutaneous Laparoscopic Gastrostomy (PLG) - Uses laparoscopic techniques

Ultrasound-guided placement (PSG) is particularly valuable when endoscopic placement is not feasible due to upper gastrointestinal obstruction or other anatomical limitations 2.

Indications for Percutaneous Gastrostomy

Gastrostomy tubes should be considered when:

• Enteral nutrition is needed for more than 2-3 weeks 1
• Patient is at high risk of malnutrition
• Oral intake is inadequate or impossible
• Patient has a functional gastrointestinal system

Common specific indications include:

• Neurological disorders affecting swallowing (stroke, MS, ALS, Parkinson's)
• Cognitive impairment and depressed consciousness (head injury)
• Mechanical obstruction to swallowing (oropharyngeal or esophageal cancer)
• Long-term partial intestinal failure requiring supplementary intake 1

Contraindications

Relative contraindications include:

• Gastroesophageal reflux
• Previous gastric surgery
• Ascites
• Extensive gastric ulceration
• Neoplastic/infiltrative disease of the stomach
• Gastric outlet obstruction
• Small bowel motility problems
• Malabsorption
• Peritoneal dialysis
• Hepatomegaly
• Gastric varices
• Coagulopathy
• Late pregnancy 1

Absolute contraindications include:

• Distal enteral obstruction
• Severe uncorrectable coagulopathy
• Hemodynamic instability 3

Placement Procedure for Ultrasound-Guided Gastrostomy

The procedure typically involves:

1. Filling the stomach with water through a nasogastric tube
2. Using ultrasound to identify a suitable puncture site
3. Direct puncture of the stomach under ultrasound guidance
4. Placement of the gastrostomy tube using the Seldinger technique
5. Securing the tube in place

In cases of complete upper GI obstruction, initial stomach insufflation may be required through direct puncture 2.

Advantages of Percutaneous Ultrasound Gastrostomy

• Allows placement when endoscopic access is not possible
• Minimally invasive procedure
• Avoids the discomfort and embarrassment of nasogastric tubes
• Patients receive more of their prescribed feed compared to nasogastric tubes
• Can stabilize nutritional parameters in patients with malignant diseases 1, 2

Complications and Management

Minor Complications:

• Tube dislodgement
• Tube blockage
• Local infection
• Material breakage (typically after 6 months)

Major Complications:

• Aspiration pneumonia
• Subcutaneous abscess
• Buried bumper syndrome 4

Important Considerations

• Percutaneous gastrostomies should not be removed for at least 14 days after insertion to ensure a fibrous tract is established 1
• Mortality within weeks of PEG placement can be high due to poor patient selection
• Deaths are usually related to the underlying condition rather than the procedure itself
• Consider delaying PEG insertion until 30 days after hospital discharge in appropriate patients, as this approach has been shown to reduce 30-day mortality by 40% 5
• Antibiotic prophylaxis (e.g., single dose of 2.2g co-amoxiclav) 30 minutes before insertion is recommended to reduce peristomal wound infections 1

Special Considerations for Jejunal Feeding

If there are concerns about gastric reflux, delayed gastric emptying, or aspiration risk, consider:

• Percutaneous Endoscopic Jejunostomy (PEJ)
• Jejunal extension through existing PEG (JET-PEG)

Direct PEJ has significantly lower tube dysfunction and reintervention rates compared to JET-PEG for long-term jejunal feeding 6.

Ethical Considerations

The decision to place a gastrostomy tube should always prioritize the patient's quality of life and be made after careful consideration of:

• Prognosis of the underlying condition
• Expected benefit to the patient
• Patient's wishes and preferences
• Family/caregiver input

Gastrostomy placement is rarely indicated in patients with short life expectancy or advanced dementia 1.