How to manage a leaking gastrostomy site in a patient with a history of PEG tube placement?

Management of Chronic PEG Site Leakage

For a patient with a PEG tube placed years ago who has developed persistent leakage, immediately protect the surrounding skin with zinc oxide-containing barrier products, verify proper bolster tension (0.5-1 cm free distance from skin), start a proton pump inhibitor, and systematically address mechanical causes before considering tube removal for tract closure or replacement at a new site. 1, 2

Immediate Skin Protection (First Priority)

• Apply zinc oxide-containing barrier films, pastes, or creams to all exposed skin to prevent acid-induced breakdown from leaking gastric contents 1, 2
• Use foam dressings instead of gauze—foam lifts drainage away from the skin while gauze contributes to maceration and worsens skin breakdown 1, 2
• Clean the affected skin at least once daily using an antimicrobial cleanser 1, 3

Assess and Correct Mechanical Causes (Second Priority)

Check Bolster Tension

• Verify 0.5-1 cm of free distance between the external bolster and skin—excessive compression is the leading cause of tissue necrosis, tract enlargement, and leakage 1, 2, 4
• Ensure the tube can be moved inward at least 2 cm (ideally 5-10 cm) to confirm it's not becoming buried 1, 2, 4
• If the tube cannot be mobilized, suspect buried bumper syndrome and obtain endoscopy for confirmation 4

Verify Balloon Integrity (if applicable)

• Check balloon volume weekly to ensure it corresponds with manufacturer's recommendations—deflation allows tube migration and leakage 1, 4
• Confirm correct tube length is being used, particularly with button gastrostomy devices 1, 4

Assess for Side Torsion

• Side torsion leads to ulceration and progressive tract enlargement—stabilize the tube using a clamping device or switch to a low-profile device 1, 4

Medical Management (Third Priority)

• Start proton pump inhibitors to decrease gastric acid secretion and minimize leakage volume—review regularly if used 1, 2, 4
• Consider prokinetic agents if gastroparesis is contributing to increased gastric residuals 4
• Address constipation to reduce intra-abdominal pressure that forces gastric contents around the tube 1, 4

Identify and Treat Contributing Factors

Infection Assessment

• Obtain swabs for bacterial and fungal cultures if signs of infection are present (erythema, purulent/malodorous exudate, pain) 3
• Apply topical antimicrobial agents under the fixation device 1, 3
• Treat fungal infections with topical antifungal agents—these are commonly associated with chronic leakage 1, 3
• Add systemic broad-spectrum antibiotics if topical treatment fails 3

Excessive Granulation Tissue

• Apply topical corticosteroid cream or ointment for 7-10 days with foam dressing compression to provide pressure to the treatment site 1, 2
• Alternative options include silver nitrate cauterization directly onto the overgranulation tissue 1

Refractory Cases (When Above Measures Fail)

• Consider removing the tube for 24-48 hours to permit slight spontaneous closure of the tract, then replace with a tube that fits more closely 1, 2
• If all measures fail, place a new gastrostomy at a new location 1

Critical Pitfalls to Avoid

• DO NOT upsize to a larger-diameter tube—this is ineffective and results in further tract enlargement with more leakage 2, 4
• DO NOT ignore difficulty mobilizing the tube—this is an alarming signal for buried bumper syndrome requiring immediate endoscopic evaluation 1, 4
• DO NOT use hydrogen peroxide after the first week—it irritates the skin and contributes to stomal leaks 4
• DO NOT routinely check gastric residuals—this increases tube occlusion risk 10-fold and can worsen overflow problems 4

Special Considerations for Long-Standing PEG Tubes

• In a patient with a PEG placed years ago, the gastrocutaneous tract is well-established but may have enlarged over time from chronic irritation, movement, or infection 4, 5
• Patient-related factors that hinder wound healing include diabetes, immunosuppression, and malnutrition—optimize these conditions 1
• If tube replacement is needed, be aware that the gastrocutaneous tract of PEG is more friable than surgical gastrostomy because there is no suture fixation between gastric and abdominal walls 5