Alternative Routes for Administering Duodopa Gel in Patients with Blocked PEG Tubes
When a percutaneous endoscopic gastrostomy (PEG) tube becomes blocked in a patient receiving Duodopa gel (levodopa/carbidopa intestinal gel), the most appropriate alternative is to replace the tube as soon as possible through the existing stoma tract if it has been in place for more than 4 weeks.
Immediate Management Options
For Mature Stoma Tracts (>4 weeks old)
- Direct replacement through the existing tract should be attempted before the tract closes completely 1
- Replacement should be executed expeditiously to maintain patency and prevent closure of the tract 1
- Balloon-type replacement tubes are most commonly used for blind replacement 1
Temporary Measures
- If no commercially available gastrostomy tube with similar diameter is available for immediate replacement, a balloon-tipped Foley catheter of the same size can be used temporarily to keep the tract open 1
- This temporary solution allows for administration of enteral nutrition, fluids, or medications until proper replacement can be performed 1
For Recent PEG Placements (<4 weeks)
- Inadvertent removal or blockage of a recently placed PEG tube (less than 4 weeks old) is considered a medical emergency 1
- In the first two weeks, replacement should be done endoscopically or radiologically through the same site 1
- Between two and four weeks after initial placement, blind repositioning can be attempted if the tube position is afterward checked by a water-soluble contrast study 1
Alternative Placement Options
Radiological Placement
- Percutaneous radiological gastrostomy (PRG) can be used as an alternative technique if endoscopic tube placement cannot be performed 1
- While PRG is effective for long-term enteral nutrition support, it has higher rates of tube dislodgement compared to PEG 1
Jejunal Placement Options
- For patients with advanced Parkinson's disease on Duodopa, direct percutaneous endoscopic jejunostomy (DPEJ) or PEG with jejunal extension (PEG-J) are appropriate alternatives 1, 2
- These approaches allow for continuous jejunal infusion of levodopa/carbidopa intestinal gel, which ensures reduction in motor fluctuations compared to oral administration 2, 3
Verification of Tube Placement
- After blind replacement, proper positioning must be confirmed before use 1
- Verification methods include:
Prevention of Future Blockages
- Routine water flushing after feedings can prevent tube occlusion 1
- This is especially relevant in small-caliber tubes like jejunostomies 1
- If the tube becomes clogged, simple water flushing should be the first attempt to regain patency 1
- For persistent obstruction, a guide wire or commercially available tube declogger can be used by an expert in case of PEG tubes 1
Caution
- Infusion with cola-containing carbonated drinks or pancreatic enzymes to unclog tubes is not recommended due to the sugar content enhancing the risk of tube contamination with bacteria 1
- Similarly, the use of 8.4% w/v sodium bicarbonate solution to unblock tubes is not evidence-based 1
- Home-made blenderized admixtures should not be utilized as they are less safe and effective than commercial enteral nutrition formulas 1
Long-term Considerations
- The durability of a PEG tube system is primarily linked to careful handling 1
- There is no need to exchange a tube system at regular intervals 1
- With adequate handling, PEG tubes can remain functional for many years, even exceeding 10 years 1
- For patients with advanced Parkinson's disease, continuous jejunal infusion of levodopa/carbidopa intestinal gel through PEG-J has been shown to significantly improve quality of life and reduce motor fluctuations 2, 4, 5