Can a percutaneous endoscopic gastrostomy (PEG) tube placement be visualized on x-ray without contrast?

Visualization of PEG Tube on X-ray Without Contrast

Yes, you can see a PEG tube on plain x-ray without contrast, as the tube itself is radiopaque and visible on standard radiographs, but this does NOT confirm proper positioning within the stomach—contrast study remains the gold standard for verifying correct placement. 1

What You Can See on Plain X-ray

• The PEG tube itself is radiopaque and will be visible as a linear density extending from the abdominal wall into the gastric region on plain abdominal radiographs 2
• Plain films can show the general course and location of the tube, including whether it appears to be in the expected anatomic position 2
• An abdominal plain film after gastric insufflation with 500 mL of air can help assess the stomach position and optimal puncture point before PEG placement 2

Critical Limitation: Plain X-ray Cannot Confirm Proper Positioning

Water-soluble contrast study using CT abdomen and pelvis is the most reliable radiographic method to confirm proper PEG tube position, as recommended by the American Gastroenterological Association. 1

• Plain x-ray alone cannot definitively confirm that the tube is actually within the gastric lumen versus misplaced in the peritoneal cavity, colon, or other structures 1
• Never rely solely on visualization of the tube on plain film—this is a common pitfall that can lead to serious complications including peritonitis 1

When Verification With Contrast Is Mandatory

• After any blind replacement of a PEG tube, especially within the first 4 weeks when the tract may not be fully mature 1, 3
• When a PEG tube has been inadvertently removed or dislodged, particularly within the first 4 weeks after initial placement 1
• In high-risk patients with previous gastric surgery, ascites, VP shunts, peritoneal dialysis, morbid obesity, or large hiatal hernias 1
• Whenever there is any doubt about proper positioning before using the tube 1

When Verification Is NOT Needed

• Routine imaging verification is unnecessary after uncomplicated PEG placement performed under direct endoscopic visualization 1
• For standard PEG placement using the pull-through technique with direct endoscopic guidance, no additional X-ray confirmation is needed if the procedure was completed without complications 1
• The endoscopic visualization during placement provides real-time confirmation that the internal bumper has properly apposed the gastric wall to the abdominal wall 1

Alternative Bedside Verification Methods (Not Radiographic)

• pH confirmation of gastric content (pH 5 or less) can be used as a bedside method to verify gastric placement 1, 3
• Irrigation of the tube with 3-50 mL sterile water without resistance or leakage can help assess proper positioning 1, 3
• Warning: Never rely solely on auscultation or aspiration of gastric contents as these can be misleading with misplaced tubes 1

Advanced Imaging for Complex Cases

• CT can provide detailed anatomy and orientation along the PEG tube and show detailed anatomical images along the PEG tract 2
• CT-guided PEG tube placement is used when there is difficulty insufflating the stomach, or the patient had previous surgery or anatomical problems 2
• Pre-PEG CT with air injected into the stomach can help assess the course of the colon and classify patients into low-risk versus high-risk groups for complications 4