What are the indications for a percutaneous endoscopic gastrostomy (PEG) tube?

Indications for Percutaneous Endoscopic Gastrostomy (PEG) Tube

PEG feeding should be considered when a patient's nutritional intake is expected to be inadequate for a period exceeding 2-3 weeks, with the primary goal of improving or maintaining quality of life. 1

Primary Indications

Neurological Disorders (approximately 50% of cases)

• Dysphagia following cerebrovascular stroke or craniocerebral trauma 1
• Cerebral tumors 1
• Bulbar paralysis 1
• Parkinson's disease 1, 2
• Amyotrophic lateral sclerosis 1, 3
• Cerebral palsy 1
• Persistent vegetative state or slow recovering consciousness 1

Oncological Disorders (approximately 30% of cases)

• Stenosing tumors in the ear, nose, and throat region 1
• Upper gastrointestinal tract tumors 1
• Patients undergoing chemotherapy or radiotherapy with poor nutritional status 1
• Cancer cachexia 4

Other Clinical Conditions

• Wasting in AIDS 1
• Short bowel syndrome 1
• Reconstructive facial surgery 1
• Prolonged coma 1
• Polytrauma 1
• Crohn's disease 1
• Cystic fibrosis 1
• Chronic renal failure 1
• Congenital abnormalities (e.g., tracheo-esophageal fistula) 1
• Palliative drainage in chronic gastrointestinal stenosis or ileus 1
• Dementia (with careful consideration - not usually appropriate for advanced dementia) 1, 3

Decision-Making Algorithm

1. Assess nutritional inadequacy: Determine if the patient will be unable to meet nutritional requirements orally for >2-3 weeks 1
2. Try oral supplementation first: Attempt special nutritional drinks and swallowing therapy before considering PEG 1
3. Evaluate prognosis and quality of life: PEG should improve or maintain quality of life 1
4. Consider timing: Early PEG placement is recommended to prevent significant weight loss, as regaining lost weight is difficult even with optimal nutritional support 1
5. Evaluate contraindications: Check for absolute contraindications including distal enteral obstruction, severe uncorrectable coagulopathy, and hemodynamic instability 5, 6

Important Considerations

• PEG placement should be for medical reasons, not administrative convenience or as a substitute for good nursing care 1
• PEG is generally not appropriate for patients with advanced cancer, end-stage diseases, or advanced dementia 1
• Early consideration of PEG is important as patients typically lose approximately 12kg of body weight in the 3 months before PEG placement is considered 1
• PEG tubes can remain in place for many years (>10 years) with proper care and do not require routine replacement 1
• For Parkinson's disease patients, special consideration must be given to medication-nutrition interactions when using standard PEG tubes 2

Benefits of PEG

• Improves nutritional status as evidenced by increases in body weight, mid-upper arm circumference, calf circumference, and serum albumin levels 3
• Associated with low complication rates (5.6% local insertion site infection, 1.1% systemic inflammatory symptoms) 3
• Better psychological tolerance than nasogastric tubes 4
• Can be performed without general anesthesia 4
• Cost-efficient with short hospitalization requirements 4

PEG is a safe, effective procedure that can significantly improve nutritional status and quality of life when appropriately indicated, but the decision should be made early in the disease course rather than as a last resort 1.