What are the indications for Percutaneous Endoscopic Gastrostomy (PEG) tube placement?

Indications for PEG Tube Placement

PEG tube placement should be considered when a patient's nutritional intake is expected to be inadequate for more than 2-3 weeks, with the primary goal of improving or maintaining quality of life rather than simply prolonging life. 1, 2

Primary Clinical Indications

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

• Stroke with dysphagia: Early PEG placement is highly effective and allows parallel swallowing rehabilitation, unlike nasogastric tubes; PEG can be removed when swallowing recovers 1
• Motor neuron disease/ALS: Place PEG early before pulmonary function deteriorates; vital capacity >50% predicted is recommended, though experienced operators can place with VC >1L and PCO2 <45 mmHg 1
• Parkinson's disease, cerebral palsy, bulbar paralysis: All neurological dysphagia states where oral intake is inadequate 1
• Head injury, prolonged coma, persistent vegetative state: Consider early PEG to ensure adequate nutrition and avoid complications of prolonged nasogastric feeding 1, 2

Oncological Disorders (~30% of cases)

• Head and neck cancers: Stenosing tumors of the oropharynx, esophagus, or upper GI tract; can be placed before or during chemotherapy/radiotherapy to prevent weight loss 1
• Esophageal obstruction: PEG provides nutrition while esophageal stent allows swallowing of saliva for quality of life 1
• Patients undergoing aggressive cancer treatment: Early PEG prevents catabolic weight loss during chemotherapy/radiotherapy and is more effective than oral supplementation alone 1

Other Established Indications

• Cystic fibrosis: Nocturnal PEG feeding improves nutritional status and stabilizes lung function, superior to nasogastric tubes 1
• AIDS wasting syndrome: Improves nutritional status and medication compliance 1
• Short bowel syndrome, chronic fistulas: Long-term partial intestinal failure requiring supplementation 1
• Reconstructive facial surgery, polytrauma, tracheoesophageal fistula: Mechanical inability to swallow 1

Decision-Making Algorithm

Step 1: Assess Duration and Reversibility

• If expected inadequate intake >2-3 weeks: Proceed to Step 2 1, 2
• If <4-6 weeks: Consider nasogastric tube first (though some advocate PEG at 14 days post-stroke) 1

Step 2: Trial Oral Supplementation First

• Attempt special nutritional drinks and swallowing therapy before PEG 1, 2
• If oral supplementation fails to stabilize weight: Proceed to Step 3 1

Step 3: Evaluate Prognosis and Quality of Life

• Good prognosis with reversible condition: Strong indication for PEG 1
• Terminal illness or life expectancy <6 months: PEG generally not indicated 1
• Advanced dementia: Published evidence shows PEG does NOT improve functional status, prevent aspiration, reduce pressure sores, or improve comfort—use restrictive approach 1

Step 4: Confirm Patient/Family Understanding

• PEG must be acceptable to patient and family; obtain informed consent 1
• Ensure understanding that PEG is for medical benefit, not administrative convenience 1, 2

Critical Timing Consideration

Patients typically lose ~12 kg in the 3 months before PEG placement is considered, and this weight loss can rarely be fully reversed even with PEG feeding. 1 Therefore, consider PEG early in progressive diseases to prevent deterioration rather than attempting reversal after severe malnutrition develops 1.

Absolute Contraindications

• Coagulopathy: INR >1.5, platelets <50,000/mm³, PTT >450s 1
• Anatomical: Interposed organs (liver, colon), severe peritonitis, marked peritoneal carcinomatosis 1
• Psychiatric: Anorexia nervosa, severe psychosis 1
• Prognostic: Clearly limited life expectancy, advanced dementia 1

Relative Contraindications (Not Absolute)

• Mild-to-moderate ascites, ventriculoperitoneal shunt, peritoneal dialysis, pregnancy: All can be managed safely with experienced operators 1
• Low-dose aspirin: Not an established contraindication 1
• Gastroesophageal reflux, previous gastric surgery: Consider jejunal feeding instead 1

Common Pitfalls to Avoid

• Placing PEG for administrative convenience: This is never appropriate; PEG is not a substitute for good nursing care 1, 2
• Delaying too long: Waiting until severe malnutrition develops makes recovery unlikely 1
• Unrealistic expectations in dementia: No evidence supports improved outcomes in advanced dementia 1
• Ignoring swallowing prognosis: Always obtain specialist swallowing assessment before PEG 1