PEG Tube Replacement Confirmation Protocol
After replacing a 16 Fr PEG tube, you must confirm intragastric placement with water-soluble contrast (gastrographin) followed by STAT KUB before administering any medications or enteral feeds. 1, 2
Critical Safety Principle
The gastrocutaneous tract in PEG tubes is more friable than surgical gastrostomy because there is no suture fixation between the gastric and abdominal walls. 2 Even after 4 weeks when the tract is considered mature, blind replacement carries risk of intraperitoneal placement, which can lead to chemical peritonitis and death. 2, 3
Confirmation Methods Required
Primary confirmation method:
- Instill water-soluble contrast (gastrographin) through the tube 1
- Obtain STAT KUB to visualize contrast in the stomach 1
- This is the most reliable method to confirm intragastric tube position before use 1, 2
Alternative confirmation methods (if contrast study cannot be performed):
- pH testing of aspirated gastric content (pH ≤5 indicates gastric placement) 1
- Irrigation with 3-50 mL sterile water without resistance or leakage around the stoma 1
- Assessment of external tube length compared to pre-replacement measurement 1
- Manipulation via rotation and in-out movement to confirm proper positioning 1
Post-Replacement Orders
Immediate monitoring:
- Hold all medications and enteral feeds until placement is confirmed 2, 3
- Monitor vital signs and perform abdominal examination 4
- Watch for abdominal pain, distension, or signs of peritonitis 2, 3
After confirmation of proper placement:
- Flush tube with 40 mL of water to ensure patency 5
- May initiate enteral feeding 3-4 hours after confirmed placement if patient is medically stable 6
- Resume medications once intragastric position is verified 6
Red Flags Requiring Immediate Intervention
If patient develops any of the following after tube replacement:
- Abdominal pain or tenderness beyond minimal site discomfort 2, 3
- Signs of peritonitis (rigidity, guarding, rebound tenderness) 2, 3
- Resistance during flushing or feeding 1
- Leakage of gastric contents around the stoma during irrigation 1
These findings suggest possible intraperitoneal placement and require immediate surgical consultation. 2, 3
External Fixation Management
- Ensure the external fixation plate allows 5-10 mm (0.5-1 cm) of free tube movement 6, 5
- Avoid excessive tension on the external bolster, which increases infection risk and can cause pressure necrosis 6
- Apply sterile Y-dressing under the external disc plate with breathable covering 6
Documentation Requirements
Document the following in the medical record: