From the Guidelines
If a PEG tube is pulled out the day after placement, this is a medical emergency requiring immediate attention, as the tract is not yet mature, creating a risk of peritonitis, and the patient should be taken to the emergency department promptly 1. The patient should not attempt to reinsert the tube at home. At the hospital, healthcare providers will assess for signs of peritoneal contamination and may perform imaging studies. If the patient is stable without signs of peritonitis, a new PEG tube may be placed endoscopically. Alternatively, a temporary nasogastric tube might be used until a new PEG can be safely placed. Some key considerations in managing this situation include:
- Monitoring for signs of infection, such as fever, abdominal pain, or distension, which could indicate complications 1
- The use of antibiotics, such as piperacillin-tazobactam or cefazolin, if infection is suspected, although the specific choice and dosage may vary based on individual patient factors and current guidelines
- Ensuring proper wound care to prevent infection, including daily monitoring and keeping the site clean and dry, typically for up to 5-7 days post-procedure 1 PEG tubes typically require 2-4 weeks to form a mature tract, which is why early dislodgement is concerning - the stomach and abdominal wall haven't adhered properly, potentially allowing gastric contents to leak into the peritoneal cavity. Given the potential for serious complications, including peritonitis, it is crucial to prioritize immediate medical attention and follow evidence-based guidelines for management, such as those outlined in recent clinical nutrition studies 1.
From the Research
PEG Tube Dislodgement
- A PEG tube being pulled out the day after it was placed is a serious complication that requires prompt attention 2, 3.
- If the tube is dislodged within 14 days of insertion, a mature tract has not adequately developed, and blind reinsertion should not be attempted 2.
- Endoscopic replacement is preferred over celiotomy in the absence of peritonitis, and this can be attempted early after dislodgement 2.
- Septic complications are not increased, and gastric leakage does not appear to be clinically significant in patients with premature dislodgement of the gastrostomy tube 2.
Prevention and Management
- Dislodgment of the tube by the patient can be prevented by appropriate patient selection, securing, and protecting the tube after placement 2.
- Patients with a history of pulling tubes and intravenous lines should undergo PEG placement using T-fastners 2.
- In cases of early accidental dislodgement, management options include a period of nasogastric (NG) suction, intravenous antibiotic drugs, and observation, with a new tube placed endoscopically 7-9 days later 3.
- If peritonitis develops, then laparoscopic exploration is recommended 2.
Related Complications
- Peristomal wound infection is a common complication of PEG placement, with an incidence of up to 40% without antibiotic prophylaxis 4, 5.
- Antibiotic prophylaxis can reduce the incidence of peristomal wound infection associated with PEG insertion 6, 4.
- The use of antibacterial gauzes has been shown to be effective in preventing infections after PEG placement, with an infection rate of 9.4% 5.