When is a gastrostomy (percutaneous endoscopic gastrostomy or PEG) recommended?

When is Gastrostomy (PEG) Recommended?

A percutaneous endoscopic gastrostomy (PEG) should be placed when enteral nutrition is required for more than 4-6 weeks in patients with a functional gastrointestinal tract who cannot meet nutritional requirements orally. 1, 2

Duration-Based Decision Algorithm

Short-Term Feeding (<4-6 weeks)

• Use nasogastric tube feeding for patients requiring enteral nutrition for less than 4-6 weeks 1, 2
• Nasogastric tubes remain appropriate even for slightly longer periods when long-term PEG placement is not suitable 1

Long-Term Feeding (>4-6 weeks)

• PEG is the preferred access device and should be placed when long-term home enteral nutrition is required 1
• PEG offers lower tube dislodgement rates and possibly better quality of life compared to nasogastric tubes 1
• PEG should be preferred over surgical gastrostomy due to lower complication rates, cost-effectiveness, and shorter operating time 1

Specific Clinical Indications

Neurological Disorders (Most Common - ~50% of cases)

• Stroke with dysphagia - early PEG feeding is highly effective and allows parallel swallowing rehabilitation training 1, 2
• Amyotrophic lateral sclerosis (ALS) - placement should occur early before pulmonary function deteriorates; vital capacity >50% predicted is recommended, though feasible with VC >1L and PCO2 <45 mmHg 1
• Parkinson's disease, multiple sclerosis, cerebral palsy, bulbar paralysis - all warrant PEG consideration for dysphagia management 1, 2
• Prolonged coma, craniocerebral trauma, cerebral tumors - PEG should be considered early in critically ill patients to prevent complications of prolonged nasogastric feeding 1

Oncological Disorders (~30% of cases)

• Head and neck cancers with stenosing tumors requiring radiotherapy or chemotherapy 1
• PEG may be placed palliatively in inoperable cases or prophylactically prior to aggressive cancer treatment 1
• Early supplementary PEG feeding is more effective than oral nutrition alone during chemotherapy/radiotherapy 1

Other Conditions

• AIDS wasting syndrome - significantly increases nutritional status and improves medication compliance 1
• Cystic fibrosis - nocturnal PEG feeding improves nutritional status, stabilizes lung function, and is superior to nasogastric tubes; should be placed early when pulmonary function is still good 1
• Crohn's disease with severe growth retardation - PEG is safe despite historical fears of fistula formation and is the most reliable nutritional measure when supplementary drinks fail 1
• Mentally and physically retarded children - substantially improves nutritional status and quality of life 1
• Short bowel syndrome, chronic gastrointestinal fistulae requiring long-term supplementary intake 2

Absolute Contraindications

Do not place PEG in patients with: 2, 3

• Intestinal obstruction or ileus
• Severe uncorrectable coagulopathy (INR >1.5, Quick <50%, platelets <50,000/mm³, PTT >450s)
• Severe shock or hemodynamic instability
• Intestinal ischemia
• Interposed organs (liver, colon between abdominal wall and stomach)
• Marked peritoneal carcinomatosis
• Severe ascites or peritonitis
• Clearly limited life expectancy

Critical Timing Considerations

The most important pitfall is delayed placement - patients typically lose approximately 12 kg body weight in the 3 months before PEG is finally considered 1. This significant nutritional deterioration can be halted by PEG feeding, but full weight regain is rare even in benign diseases 1, 4.

• Place PEG early in the disease course before significant weight loss occurs 1, 4
• Consider PEG when oral intake is absent or likely absent for 5-7 days in already malnourished patients 2
• Consider PEG when oral intake will be inadequate (<50% of requirements) for more than 7 days 2

Special Considerations for Dementia

Use a critical and restrictive approach to PEG feeding in elderly demented patients 1. Published evidence does not support that PEG achieves stated aims of improving functional status, preventing aspiration, or reducing pressure sores and infections in advanced dementia 1. This requires individualized assessment of whether PEG is truly in the patient's best interest 2.

Alternative Access Routes

• Percutaneous endoscopic jejunostomy (PEJ) or PEG/J should be used instead of standard PEG for patients with gastroduodenal motility disorders, gastric outlet stenosis, or high aspiration risk 1
• Percutaneous laparoscopic assisted gastrostomy (PLAG) is a safe alternative when PEG placement fails or is not suitable 1
• Radiological gastrostomy (PRG/RIG) should be reserved for patients in whom endoscopic technique is not possible, as endoscopic placement lowers peritonitis and mortality risk 1

Key Implementation Points

• Antibiotic prophylaxis should be administered before PEG placement 5
• Feeding can commence within hours after placement 6
• Start with low flow rates (10-20 ml/h) and increase gradually; may take 5-7 days to reach target intake 2
• Monitor the exit site daily for 5-7 days post-procedure for signs of infection, bleeding, or leakage 1
• Patient and legal carer agreement is essential; HEN should not be offered if compliance is unlikely or organizational problems cannot be overcome 1