How can we prevent self‑removal of a PEG tube and manage persistently high gastric residual volumes (>120 mL) in a 66‑year‑old woman with severe intellectual disability?

Management of Recurrent PEG Tube Self-Removal and High Gastric Residuals

Switch to a low-profile button gastrostomy device and implement physical barriers (mittens) to prevent tube access, while simultaneously addressing the high residuals with prokinetics and proton pump inhibitors. 1

Preventing Tube Self-Removal

The most effective strategy is converting to a low-profile button device, which is significantly harder for patients to grasp and pull compared to standard PEG tubes. 1

Physical Prevention Measures:

• Place soft mittens on the patient's hands to reduce her ability to grasp the tubing—this is specifically recommended for patients with altered mental status or dementia who are at risk for inadvertent removal. 2
• Avoid abdominal binders, as they paradoxically increase side torsion and can enlarge the stoma, making dislodgement more likely. 2
• Stabilize the tube using a clamping device if side torsion is contributing to tract enlargement. 1

Tube Maintenance to Reduce Manipulation:

• Verify proper tension between internal and external bolsters—allow at least 5mm of free movement to prevent pressure-related discomfort that may prompt the patient to pull at the tube. 3
• Check balloon volume weekly (should be 5-10 mL per manufacturer specifications) to prevent spontaneous deflation and tube migration. 1, 2

Managing High Gastric Residuals

The facility's protocol of holding feeds for residuals >120 mL may be contributing to inadequate nutrition and should be reconsidered in conjunction with medical management.

Medical Interventions:

• Start proton pump inhibitors to reduce gastric acid secretion, which can contribute to delayed gastric emptying and high residuals. 1, 3
• Initiate prokinetic agents (such as metoclopramide or erythromycin) to improve gastric emptying and reduce residual volumes. 1, 3
• Consider gastric decompression if residuals remain persistently elevated despite medical management. 1, 3

Feeding Strategy Adjustments:

• Verify tube position is correct—malposition can cause pooling and high residuals. 3
• Ensure the external fixation plate has proper tension (push tube 2-3 cm ventrally, then pull back to resistance) to optimize gastric positioning. 3
• Evaluate for constipation and increased abdominal pressure, both of which contribute to gastroparesis and high residuals. 1

Site Care and Complication Prevention

Given the multiple replacements, the stoma tract may be enlarged and prone to complications:

• Apply zinc oxide-containing barrier cream or paste around the site to prevent skin breakdown from any leakage. 1
• Use foam dressings rather than gauze to reduce skin maceration if drainage is present. 1
• Clean the site daily with antimicrobial cleanser and monitor for infection (erythema, purulent discharge, fever). 1, 4
• If excessive granulation tissue develops, apply silver nitrate cauterization or topical corticosteroid cream for 7-10 days. 1, 4

Critical Pitfall to Avoid

If the patient pulls the tube out again within 4 weeks of the most recent replacement, this is an emergency requiring endoscopic or radiologic replacement—blind bedside replacement should NOT be attempted as the tract may not be mature. 1, 2, 5 However, if the tract is mature (>4 weeks), immediate insertion of a Foley catheter of the same size can maintain patency until proper replacement. 2

Long-term Considerations

For patients with severe intellectual disability and recurrent self-removal, T-fasteners at initial placement may provide additional security if the tube requires future replacement. 5 Additionally, optimizing her nutritional status with the interventions above may improve wound healing and reduce complications from the enlarged tract caused by multiple replacements. 1