Who is a candidate for Percutaneous Endoscopic Gastrostomy (PEG) tube placement?

Candidates for PEG Tube Placement

PEG tubes should be placed in patients who require enteral nutrition for more than 4-6 weeks and have adequate gastrointestinal function to absorb feeds, with the primary goal of improving or maintaining quality of life. 1

Primary Clinical Indications

Neurological Disorders (Most Common)

• Stroke with dysphagia - the most frequent indication for PEG placement 2, 3
• Motor neurone disease (ALS) - placement recommended early before pulmonary function deteriorates (vital capacity >50% predicted) 2
• Multiple sclerosis 1
• Parkinson's disease 1, 2
• Cerebral palsy 1
• Head injury with cognitive impairment or depressed consciousness 1
• Bulbar paralysis 2
• Persistent vegetative state or slow recovering consciousness 2

Mechanical Obstruction to Swallowing

• Oropharyngeal or esophageal cancer 1
• Head and neck cancers, particularly when undergoing concurrent chemoradiation 1, 2
• Radiation enteropathy 1

Oncological Conditions Requiring Nutritional Support

• Patients undergoing chemotherapy or radiotherapy with poor baseline nutritional status 2, 3
• Wasting in AIDS 2

Gastrointestinal and Metabolic Disorders

• Short bowel syndrome requiring supplementary intake 1, 2
• Fistulae 1
• Cystic fibrosis 1
• Crohn's disease (early placement recommended) 3
• Chronic renal failure 2

Other Indications

• Reconstructive facial surgery 2
• Prolonged coma or polytrauma 2
• Congenital abnormalities (e.g., tracheo-esophageal fistula) 2
• Severe growth retardation in children when nutritional drinks fail 3

Patient Selection Criteria

Essential Requirements

• High risk of malnutrition with inability to recover oral feeding ability in the short term 1
• Adequate gastrointestinal function to absorb and tolerate enteral feeding 1
• Expected duration of feeding >4-6 weeks (some suggest consideration at 14 days post-acute dysphagic stroke) 1
• Patient and family acceptance of the concept of gastrostomy feeding 1

High-Risk Patients Requiring Prophylactic PEG (Head and Neck Cancer)

• Severe pretreatment weight loss 1
• Ongoing dehydration or dysphagia 1
• Significant comorbidities 1
• Severe aspiration 1
• Anticipated severe swallowing problems from intense multimodality therapy (concurrent chemoradiation) 1

Critical Timing Considerations

Early placement is essential - patients typically lose approximately 12 kg of body weight in the 3 months before PEG placement is considered, and this weight loss is rarely fully reversed even with PEG feeding 2, 3. Do not wait for significant weight loss to occur 3.

Absolute Contraindications

• Peritonitis or active systemic infection/sepsis 4, 3
• Serious coagulation disorders (INR >1.5, Quick <50%, platelets <50,000/mm³) 3
• Interposed organs preventing safe access 3
• Marked peritoneal carcinomatosis 3
• Severe ascites 3
• Anorexia nervosa 3
• Severe psychosis 3
• Clearly limited life expectancy (advanced dementia, end-stage diseases, advanced cancer with anorexia-cachexia syndrome) 2, 3, 5

Relative Contraindications

• Gastro-oesophageal reflux 1
• Previous gastric surgery 1
• Mild-to-moderate ascites (can be managed safely with experienced operators) 2, 3
• Extensive gastric ulceration 1
• Gastric outlet obstruction 1
• Ventriculoperitoneal shunt 2
• Peritoneal dialysis 2
• Pregnancy 2
• Obesity (technically difficult) 1
• Hepatomegaly 1
• Gastric varices 1

Special Considerations for Septic Patients

Do not place PEG in actively septic patients - wait until the patient is afebrile, hemodynamically stable without vasopressor requirement, and all complicating conditions (DIC, paralytic ileus) are optimized 4. Continue nasogastric feeding until stabilization and probable discharge 4.

Decision-Making Algorithm

1. Assess duration of anticipated inadequate oral intake - if >4-6 weeks, consider PEG 1, 2
2. Try oral supplementation first - special nutritional drinks and swallowing therapy before PEG 2
3. Evaluate prognosis and quality of life - PEG should provide medical benefit, not just administrative convenience 2, 3
4. Confirm adequate GI function to absorb feeds 1
5. Obtain patient/family acceptance and informed consent 1
6. Confirm by experienced gastroenterologist or nutrition support team 1
7. Assess swallowing prognosis by specialist 1

Common Pitfalls to Avoid

• Do not delay placement until significant weight loss has occurred - early placement prevents malnutrition 2, 3
• Do not place PEG in advanced dementia - no evidence supports improved outcomes 2, 3
• Do not place PEG for administrative convenience or as substitute for good nursing care 2, 3
• Do not place PEG in anorexia-cachexia syndrome where no physiologic benefit is expected 5
• Do not place PEG in permanent vegetative state where intervention has no effect on quality of life 5