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

Management of PEG Tube Oozing

For PEG tube leakage, immediately protect the surrounding skin with a hydrocolloid wafer as a keyhole dressing or apply a barrier cream containing zinc oxide, while addressing the underlying cause of the leakage. 1

Immediate Skin Protection Measures

• Apply a hydrocolloid wafer as a keyhole dressing around the tube site to protect skin from gastric contents and absorb exudate 1
• Use a topical skin barrier film or cream containing zinc oxide to prevent chemical irritation and skin breakdown 1
• Apply a powdered absorbing agent if significant moisture is present 1
• Clean the affected skin at least once daily using an antimicrobial cleanser 1

Identify and Address the Underlying Cause

Check Tube Positioning and Tension

• Verify the external fixation plate allows at least 5 mm of free movement to prevent pressure necrosis while maintaining adequate tension 1
• Push the tube approximately 2-3 cm ventrally and carefully pull it back to the resistance of the internal fixation flange to ensure proper positioning 2
• Ensure the incision at the puncture site is sufficiently large (approximately 8 mm) to prevent pressure-related complications 2

Assess for Excessive Granulation Tissue

• Excessive granulation tissue is vascular, bleeds easily, and commonly causes leakage around PEG tubes 1
• Apply silver nitrate cauterization directly onto overgranulation tissue as first-line treatment 1
• Alternatively, use a topical corticosteroid cream or ointment for 7-10 days combined with a foam dressing to provide compression 1
• Apply a topical antimicrobial agent under the fixation device or use a foam or silver dressing over the affected area, changing only when significant exudate is present (minimum weekly) 1
• If these measures fail, consider surgical removal or argon plasma coagulation 1

Rule Out Infection

• Inspect the site daily for signs of infection: erythema >5 mm around the stoma, purulent discharge, or fever 1
• Take a swab for microbiological examination if infection is suspected 1
• Apply topical antimicrobial agents and perform daily sterile dressing changes for peristomal infections 1
• Add systemic broad-spectrum antibiotics if topical treatment fails to resolve the infection 1
• If infection cannot be resolved with combined topical and systemic antibiotics, remove the tube 1

Optimize Tube Care to Prevent Ongoing Leakage

• Use a Y-compress under the tube to avoid formation of a moist cavity under the external fixation plate 1, 2
• Maintain proper tension between internal and external fixation plates, checking regularly to prevent tissue ischemia or excessive leakage 2
• Loosen and rotate the gastrostomy tube weekly to prevent mucosal overgrowth 3
• Remove dressings before washing, rinse away residual soap, and dry the tube well before applying a new dressing 1

When Conservative Measures Fail

• If all measures fail to control leakage, consider placing a new gastrostomy at a different location 1
• For persistent gastrocutaneous fistula leakage after tube removal, combined electrochemical cautery and endoscopic clip placement has shown 82% complete closure rates in elderly patients 4
• Consider tube replacement if there is evidence of tube degradation, breakage, or structural compromise 1

Common Pitfalls to Avoid

• Do not overtighten the external fixation plate against the skin, as this causes pressure necrosis and paradoxically worsens leakage 1, 2
• Avoid using noninvasive ventilation in the early postoperative period (first few days) after PEG placement, as abdominal distention can cause pressure necrosis and tube dislodgement 5
• Recognize that minor redness (<5 mm) around the stoma is common and largely induced by movement, not necessarily infection 1
• Transient leakage in the initial days after placement is common and often resolves with conservative management 1