What is the management for percutaneous endoscopic gastrostomy (PEG) site leakage?

Management of PEG Site Leakage

For PEG site leakage, immediately protect the surrounding skin with zinc oxide-based barrier products, verify proper bolster tension (0.5-1 cm free distance from skin), use foam dressings instead of gauze, and consider proton pump inhibitors to reduce gastric acid secretion. 1

Immediate Skin Protection Measures

• Apply zinc oxide-containing barrier films, pastes, or creams to prevent skin breakdown from leaking gastric contents 1
• Use foam dressings rather than gauze—foam lifts drainage away from the skin while gauze contributes to maceration 1
• Clean the affected skin at least once daily with antimicrobial cleanser 2, 3
• Apply topical antimicrobial agents if signs of infection develop (erythema, purulent drainage, malodor) 2, 3

Assess and Correct Mechanical Causes

Check bolster tension first—this is the most common correctable cause of leakage: 1

• Verify 0.5-1 cm of free distance between the external bolster and skin 1
• Ensure the tube can be moved inward at least 2 cm (ideally up to 5-10 cm) 1
• Avoid excessive compression between internal and external fixation devices 1
• For balloon-type tubes, verify balloon volume matches manufacturer recommendations and check weekly 1
• Ensure correct tube length is being used for button gastrostomy devices 1

Address side torsion of the tube: 1

• Side torsion leads to ulceration and tract enlargement 1
• Stabilize the tube using a clamping device or switch to a low-profile device 1

Medical Management

Consider proton pump inhibitors to decrease leakage by minimizing gastric acid secretion—review regularly if used 1

• In severe cases with obvious leakage immediately after placement, delay or stop enteral nutrition temporarily 1
• Use gastric decompression and prokinetics while optimizing nutritional status (consider parenteral nutrition if needed) 1

Identify and Treat Contributing Factors

Common risk factors that worsen leakage include: 1

• Skin infection—treat with topical antimicrobials; add systemic antibiotics if not resolving 2, 3
• Excessive granulation tissue—apply topical corticosteroid cream for 7-10 days with foam dressing compression 1
• Local fungal infections—treat with topical antifungal agents 1
• Patient factors: diabetes (hyperglycemia), immunosuppression, malnutrition 1
• Increased abdominal pressure, constipation, gastroparesis 1

Refractory Cases

If all conservative measures fail: 1

• Do NOT upsize to a larger-diameter tube—this is ineffective and results in enlarged stoma tract with more leakage 1
• Consider removing the tube for 24-48 hours to permit slight spontaneous closure of the tract, then replace with a tube that fits more closely 1
• If this fails, place a new gastrostomy at a different location 1

Critical Pitfalls to Avoid

• Avoid excessive traction or tension on the external fixation plate immediately after placement 1
• Do not ignore buried bumper syndrome warning signs: difficulty mobilizing tube, leakage when flushing, frequent pump alarms, abdominal pain 1
• Small peristomal drainage in the first week after placement is normal and not necessarily pathological 1
• Less than 5 mm of reddening around the stoma is often movement-related, not infection 1