What is a PEG (Percutaneous Endoscopic Gastrostomy) tube?

What is a PEG Tube?

A PEG (Percutaneous Endoscopic Gastrostomy) tube is a feeding tube inserted directly through the abdominal wall into the stomach under endoscopic guidance, used to deliver nutrition, fluids, and medications when oral intake is inadequate for periods exceeding 2-3 weeks. 1

Basic Definition and Purpose

• A PEG tube is placed using a minimally invasive endoscopic procedure that creates a direct access point from the skin surface into the stomach 1
• The tube enables delivery of enteral nutrition, hydration, and medications directly into the stomach, bypassing the mouth and esophagus 2, 3
• PEG tubes can also be used for gastric decompression and suction, particularly when large lumen tubes (at least 15 Charrière) are used 4

When PEG Tubes Are Indicated

PEG feeding should be considered when nutritional intake is expected to be inadequate for more than 2-3 weeks, though some authorities suggest 4-6 weeks. 1

Common Clinical Indications

• Neurological disorders affecting swallowing: stroke, multiple sclerosis, motor neurone disease, Parkinson's disease, cerebral palsy 1
• Mechanical obstruction: oropharyngeal or esophageal cancer, radiation enteropathy 1
• Cognitive impairment: head injury, depressed consciousness 1
• Chronic intestinal dysfunction requiring supplementation: short bowel syndrome, fistulae, cystic fibrosis 1

Key Advantages Over Alternatives

• PEG tubes eliminate the discomfort, embarrassment, and frequent dislodgement associated with nasogastric tubes 1
• Patients receive more of their prescribed nutrition compared to nasogastric feeding because PEG tubes don't "fall out" easily 1
• Lower rates of esophageal reflux and aspiration pneumonia compared to nasogastric tubes 1
• Higher subjective and social acceptance with less stigmatization 1

Placement Technique

• The procedure takes approximately 12 minutes using the standard "pull" technique, which is the most common and safest method 1, 2
• Placement is performed under sedation and local anesthesia using endoscopic visualization 1
• The anterior gastric wall is punctured under direct endoscopic control, and the tube is pulled through the mouth, down the esophagus, and out through the abdominal wall 1
• Large lumen tubes (at least 15 Charrière) are strongly recommended to prevent clogging 1, 4

Important Technical Details

• The external fixation plate should allow at least 5 mm of free tube movement to prevent pressure necrosis 1, 4
• The puncture site incision should be at least 8 mm to avoid pressure-related skin lesions 1, 5
• A stable stoma typically forms within 4 weeks after placement 1, 5
• Button systems can replace standard PEG tubes after stoma maturation (at least 4 weeks) for cosmetic reasons, though they require replacement every 6 months 1

Critical Safety Considerations

• High early mortality: Overall mortality within weeks of PEG placement can be very high, usually due to the underlying condition and poor patient selection rather than the procedure itself 1
• Patient selection is crucial: PEG should only be placed in patients at high risk of malnutrition who are unlikely to recover oral feeding ability in the short term 1
• Verification after replacement: Water-soluble contrast study is the most reliable method to confirm proper position after blind tube replacement, especially within the first 4 weeks 5

Common Pitfalls to Avoid

• Inappropriate placement: PEG tubes are sometimes placed in patients with poor prognosis or advanced dementia where they provide no quality of life benefit 1
• Administrative convenience: PEG placement should never be for saving time, money, or manpower—it is not a substitute for good nursing care 1
• Inadequate incision size: Incisions smaller than 8 mm cause pressure-related lesions 5
• Excessive tension: The external fixation plate should retain but not compress the tube against the skin 1, 4

Alternatives When Endoscopy Fails

• Laparoscopic gastrostomy (PLG) can be used when endoscopic placement is not technically possible 1
• Sonographic or fluoroscopic guidance can place tubes when esophageal stenosis prevents endoscope passage 1
• For jejunal feeding needs, direct PEJ (Percutaneous Endoscopic Jejunostomy) is preferred over JET-PEG due to lower tube dysfunction rates 1

Long-Term Management

• PEG tubes can remain in place for many years (exceeding 10 years) with proper care and handling 1
• There is no need for routine tube exchange at regular intervals 1
• Daily monitoring of the exit site is essential during the first week for bleeding, erythema, secretion, or induration 4
• Regular flushing prevents clogging, particularly important when tubes are used for suction 4