How to manage Percutaneous Endoscopic Gastrostomy (PEG) tube side oozing?

Management of PEG Tube Site Oozing

For PEG tube site oozing, immediately assess and optimize the tension between the internal and external bolsters (ensuring 0.5-1 cm free movement), apply zinc oxide-based skin protectants to the surrounding skin, use foam dressings instead of gauze, and address underlying causes such as infection, excessive granulation tissue, or improper tube positioning. 1

Initial Assessment and Immediate Management

Check Tube Positioning and Tension

• Verify that the external fixation plate has proper tension with 0.5-1 cm (5mm) of free movement between the skin and external bolster to prevent pressure necrosis and tissue ischemia that can cause leakage 1, 2
• Push the tube approximately 2-3 cm inward and carefully pull it back to the resistance of the internal fixation flange to ensure proper positioning 3
• Excessive compression between internal and external bolsters is a primary cause of leakage and must be corrected immediately 1

Protect the Surrounding Skin

• Apply a topical skin product such as zinc oxide-based barrier cream, paste, or film to minimize skin breakdown from gastric content leakage 1
• Use powdered absorbing agents as an alternative barrier method 1
• Switch from gauze to foam dressings, as foam lifts drainage away from the skin while gauze contributes to skin maceration 1, 2

Identify and Address Underlying Causes

Common Risk Factors for Peristomal Leakage

• Skin infection, increased gastric acid secretion, gastroparesis, increased abdominal pressure, constipation, side torsion of the tube, buried bumper syndrome, and granulation tissue in the tract 1
• Patient-related factors including diabetes, immunosuppression, and malnutrition that hinder wound healing 1

Assess for Infection

• Monitor daily for signs of infection including erythema, purulent discharge, pain, and fever 1, 2
• If infection is suspected, apply topical antimicrobial agents to the entry site and surrounding tissue 1, 2
• Swab the area for bacterial and fungal cultures to guide treatment 2
• If topical treatment fails, add systemic broad-spectrum antibiotics 1, 2
• Local fungal skin infections may be associated with leakage and should be treated with topical antifungal agents 1

Check for Excessive Granulation Tissue

• Granulation tissue is vascular and bleeds easily, often caused by excess moisture, friction from poorly secured tubes, or infection 1
• Clean the affected skin at least once daily using an antimicrobial cleanser 1, 3
• Treatment options include silver nitrate cauterization applied directly to the overgranulation tissue, topical antimicrobial agents under the fixation device, or topical corticosteroid cream/ointment for 7-10 days combined with foam dressing for compression 1

Tube-Specific Interventions

For Balloon-Type Tubes

• Verify the balloon volume corresponds with manufacturer's recommendations and check regularly (weekly) 1
• Ensure correct balloon size and tube length are being used 1

For Side Torsion Issues

• Side torsion resulting in an enlarged stoma tract can be corrected by stabilizing the tube using a clamping device or switching to a low-profile device 1

Refractory Cases

• If all measures fail, remove the tube for 24-48 hours to permit slight spontaneous closure of the tract, then replace with a tube that will fit more closely 1
• If this approach is unsuccessful, a new gastrostomy must be placed at a new location 1

Ongoing Maintenance and Prevention

Daily Care Protocol

• Monitor the exit site daily for signs of bleeding, pain, erythema, induration, leakage, and inflammation 1, 2
• Cleanse with 0.9% sodium chloride, sterile water, or freshly boiled and cooled water 1, 2
• Use a sterile Y-dressing under the external disc plate to avoid formation of a moist cavity, followed by a breathable (non-occlusive) dressing 1, 2
• Avoid occlusive dressings as they promote a moist wound environment and lead to skin maceration 1

Long-Term Management

• Once the tract has healed (after approximately one week), rotate the tube daily and move it inward at least once weekly (2-10 cm) to prevent buried bumper syndrome 1
• Use additional fixation or securement devices to minimize traction on the stoma site 1

Critical Warning Signs Requiring Immediate Attention

• Difficulty mobilizing the tube, resistance when flushing, frequent feeding pump alarms, abdominal pain, or chronic site infections may indicate buried bumper syndrome 1
• Persistent leakage despite conservative measures may lead to tube loss and requires urgent intervention 1
• If infection cannot be resolved with topical and systemic antibiotics, the tube must be removed 1, 2