What are the indications for a percutaneous endoscopic gastrostomy (PEG) tube versus a gastrojejunostomy (GJ) tube for long-term nutritional support?

Indications for PEG vs GJ Tube for Long-term Nutritional Support

For long-term enteral nutrition (>6 weeks), a percutaneous endoscopic gastrostomy (PEG) is the preferred access device, while gastrojejunostomy (GJ) tubes should be reserved for specific clinical scenarios such as gastroduodenal motility disorders, gastric outlet stenosis, or high risk of aspiration. 1

General Indications for Long-term Enteral Access

• PEG is the first-line choice for long-term enteral nutrition (>6 weeks) due to lower complication rates, better quality of life, and fewer intervention failures compared to nasogastric tubes 1
• PEG placement is preferred over surgical gastrostomy due to lower cost, simplicity, shorter operating time, and fewer complications 1
• For short-term feeding needs (<6 weeks), nasogastric tubes remain appropriate 1

Specific Indications for PEG Tubes

• Standard first-line approach for patients requiring long-term enteral nutrition with normal gastric emptying 1, 2
• Patients with functional gastrointestinal systems who can tolerate gastric feeding 2
• Conditions with normal gastric motility and low aspiration risk 1
• Patients with head and neck cancers, neurologic dysphagia, cancer cachexia, and non-obstructive esophageal disorders 3

Specific Indications for GJ Tubes (PEJ or PEG/J)

• Patients with persistent aspiration after PEG tube placement 4
• Gastroduodenal motility disorders that impair gastric emptying 1
• Gastric outlet stenosis or obstruction 1
• High risk of aspiration with gastric feeding 1, 4
• When continuous rather than bolus feeding is required 4

Types of Jejunal Access and Their Indications

• Direct Percutaneous Endoscopic Jejunostomy (PEJ): Preferred option for patients requiring long-term jejunal feeding due to lower tube dysfunction and reintervention rates 4
• Jejunal Extension Tube through existing PEG (JET-PEG/PEG-J): Option when an existing PEG is in place but patient develops aspiration; has higher tube dysfunction rates than direct PEJ 4
• Percutaneous Laparoscopic Jejunostomy (PLJ): Alternative when endoscopic access is limited or direct PEJ placement isn't feasible 4

Decision Algorithm for Tube Selection

1. Determine expected duration of enteral nutrition:

   • <6 weeks: Consider nasogastric tube 1

   • 6 weeks: Proceed to step 2 1

2. Assess aspiration risk and gastric emptying:

   • Normal gastric emptying, low aspiration risk → PEG 1
   • Impaired gastric emptying, high aspiration risk, or history of aspiration → Direct PEJ 4

3. If PEG is placed but patient develops aspiration:

   • Consider conversion to direct PEJ (preferred) or PEG-J (if endoscopic access is limited) 4

4. If endoscopic placement isn't feasible:

   • Consider percutaneous laparoscopic gastrostomy (PLAG) for gastric feeding 1
   • Consider percutaneous laparoscopic jejunostomy (PLJ) for jejunal feeding 4

Important Considerations and Caveats

• PEG tube placement requires careful patient selection to avoid inappropriate use in patients who won't benefit from long-term enteral nutrition 2
• Absolute contraindications for any enteral access include distal enteral obstruction, severe uncorrectable coagulopathy, and hemodynamic instability 2
• Complications can occur with both PEG and GJ tubes, but direct PEJ has lower tube dysfunction rates compared to PEG-J when jejunal feeding is required 4
• Multiple puncture attempts during PEG placement increase risk of complications such as visceral injuries or bleeding 5
• For patients with PEG tubes, proper exit site care is essential to prevent infections during the first week after placement 1