Management of PEG Tube Torsion with Clamping Device
When side torsion of a PEG tube occurs, stabilize the tube using a clamping device to prevent further ulceration and tract enlargement. 1
Understanding the Problem
Side torsion of the PEG tube is a mechanical complication that leads to ulceration and progressive enlargement of the gastrostomy tract, creating pathways for leakage of gastric contents around the tube. 1 This occurs when the tube rotates laterally rather than maintaining proper alignment through the tract, causing chronic irritation and tissue damage. 2
Primary Management Strategy
Immediate Intervention
- Apply a clamping device directly to the external portion of the tube to stabilize it and prevent rotational movement. 1 This mechanical stabilization stops the ongoing ulceration process and allows the tract to begin healing. 2
Alternative Option if Clamping Fails
- Switch to a low-profile button device if the clamping device does not adequately control the torsion. 1 Low-profile devices have shorter external components that are less prone to rotational forces and provide better stability. 2
Concurrent Management Steps
While addressing the torsion mechanically, you must simultaneously manage the consequences:
Skin Protection
- Apply zinc oxide-based barrier cream, paste, or film to all exposed skin around the stoma to prevent acid-induced breakdown from any leaking gastric contents. 1, 3
- Use foam dressings rather than gauze, as foam lifts drainage away from the skin while gauze contributes to maceration. 1, 3
Reduce Gastric Output
- Start proton pump inhibitors to decrease gastric acid secretion and minimize leakage volume. 1, 3
- Consider prokinetic agents if gastroparesis is contributing to increased gastric residuals. 2, 3
Verify Proper Tension
- Check that the distance between the internal and external bolsters allows 0.5-1 cm of free movement without excessive compression. 1 Excessive tension between bolsters is a major risk factor for complications. 2
When Clamping Device Management Fails
If the clamping device and low-profile device options both fail to control the problem:
- Remove the tube for 24-48 hours to permit slight spontaneous closure of the enlarged tract. 1, 3 This allows the tract to contract somewhat before replacing with a tube that will fit more closely. 1
- If all measures fail, place a new gastrostomy at a different location. 1
Critical Pitfalls to Avoid
- Never upsize the tube in response to leakage from torsion, as this will further enlarge the tract and worsen the problem. 2
- Do not ignore difficulty mobilizing the tube, as this may indicate buried bumper syndrome requiring immediate evaluation. 2
- Avoid using hydrogen peroxide after the first week, as it irritates the skin and contributes to stomal leaks. 2, 3