What is the management of a leaking percutaneous endoscopic gastrostomy (PEG) tube?

From the Guidelines

Management of a leaking percutaneous endoscopic gastrostomy (PEG) tube requires prompt attention to prevent skin breakdown and infection, and the most effective approach is to assess the cause of leakage, clean the area, apply a protective barrier, and consider using an external tube stabilizer or bumper to improve positioning, as recommended by the most recent guidelines 1. The cause of leakage may include tube displacement, balloon deflation, increased abdominal pressure, or site infection.

• Clean the area around the tube with mild soap and water, then pat dry.
• Apply a protective barrier such as zinc oxide, petroleum jelly, or a commercial stoma barrier to protect the skin.
• Absorbent dressings like split gauze or specialized stoma dressings can be placed around the tube to manage drainage.
• If the tube has a balloon, check if it needs reinflation with the appropriate amount of sterile water (typically 5-10 mL, but follow specific tube guidelines). For persistent leakage, consider using an external tube stabilizer or bumper to improve positioning.
• Antacid medications like omeprazole 20-40 mg daily may help reduce gastric acid production and minimize irritation, as suggested by previous studies 1.
• If the patient has increased abdominal pressure from coughing or constipation, address these underlying issues.
• Tube replacement may be necessary if the current tube is damaged or improperly sized.
• Seek immediate medical attention if there are signs of infection (redness, warmth, purulent discharge), severe pain, tube dislodgement, or if the tube was placed within the last 4-6 weeks, as the tract may not be fully formed and peritonitis could develop, as highlighted in recent guidelines 1.

From the Research

Management of Leaking Peg Tube

• The management of leaking peg tube is a significant concern in patients with percutaneous endoscopic gastrostomy (PEG) tubes, with persistent leakage from a gastrocutaneous fistula being a common problem in elderly patients 2.
• Conservative methods often prove unsuccessful, and surgical closure is usually not performed due to poor surgical risk, highlighting the need for alternative approaches 2.
• A study published in the Southern Medical Journal in 2009 reported the use of combined electrochemical cautery and endoscopic clip placement to treat persistent leakage from gastrocutaneous fistulas in elderly patients, resulting in complete closure of the fistula in 82% of patients 2.

Prevention of Complications

• The prevention of complications associated with PEG tubes is crucial, with strategies including regular follow-up, pre-discharge instructions, and programmed tube changes 3.
• Antibiotic prophylaxis has been shown to reduce the risk of peristomal wound infection associated with PEG insertion, with studies demonstrating the effectiveness of different antibiotic regimens 4, 5.
• A systematic review published in the JBI Library of Systematic Reviews in 2009 highlighted the need for further research on the prevention and management of complications associated with PEG tubes, including site infection, occlusion, and inadvertent removal 3.

Risk Factors for Complications

• Several studies have identified risk factors for complications associated with PEG tubes, including diabetes mellitus, duration of hospital stay, hypoalbuminemia, and chemotherapy or radiotherapy before PEG placement 6.
• A retrospective study published in the Indian Journal of Gastroenterology in 2018 found that Pseudomonas and Klebsiella were the most common organisms causing peristomal infections, highlighting the need for tailored prophylactic antibiotic protocols 6.