What does PEG (percutaneous endoscopic gastrostomy) refer to and what are its indications?

What is PEG (Percutaneous Endoscopic Gastrostomy)?

PEG is a minimally invasive endoscopic procedure that creates a feeding tube directly through the abdominal wall into the stomach, providing long-term enteral nutrition access for patients unable to maintain adequate oral intake. 1

Definition and Procedure

• PEG stands for Percutaneous Endoscopic Gastrostomy, a technique first described by Gauderer and Ponsky in 1980 that has since replaced traditional surgical gastrostomy methods (Witzel, Stamm, Janeway techniques) due to significantly lower complication rates 1

• The procedure involves passing a feeding tube through the abdominal wall directly into the stomach under endoscopic guidance, allowing nutrients, medications, and fluids to be delivered directly into the gastrointestinal tract 2

• Modern PEG tubes are made of polyurethane or silicone rubber, are simple to insert, and well-tolerated by patients 1

Primary Indications

PEG should be preferred when a patient's nutritional intake is likely to be inadequate and supplementary artificial enteral nutrition is necessary for a period exceeding 2-3 weeks 1

Neurological Dysphagia (Most Common Indication)

• Stroke patients with dysphagia and inadequate oral intake benefit from early PEG feeding, which is highly effective and allows parallel swallowing rehabilitation training, unlike nasogastric tubes 1

• PEG can be removed when swallowing ability recovers in stroke patients 1

Amyotrophic Lateral Sclerosis (ALS)

• PEG placement should be made early in the disease course before pulmonary function deteriorates 1

• Recommended when vital capacity is >50% of predicted, though experienced operators can place PEG with VC of 1L and PCO2 <45 mmHg 1

• Sedation is critical and active gastric desufflation after the procedure is essential since patients cannot lower the raised diaphragm themselves 1

Head and Neck Tumors

• Obstructive causes such as head and neck tumors are common indications after neurogenic dysphagia 3

Dementia (Controversial)

• An individualized but critical and restrictive approach to PEG feeding in elderly demented patients is recommended 1

• No published evidence supports that PEG achieves stated aims of improving functional status, avoiding hunger, improving comfort, preventing nutritional decline, preventing aspiration, or reducing pressure sores and infections in advanced dementia 1

Advantages Over Alternatives

PEG feeding is superior to nasogastric tube feeding in multiple clinically important outcomes 1:

• Higher subjective and social acceptance, less stigmatizing 1
• Reduced rates of oesophageal reflux and aspiration pneumonia 1
• Lower rates of discomfort and complications (irritations, ulceration, bleeding, dislocation, clogging) 1
• Superior nutritional efficacy 1

Absolute Contraindications

Do not place PEG in patients with 1:

• Serious coagulation disorders (INR >1.5, Quick <50%, platelets <50,000/mm³, PTT >450s) 1
• Interposed organs (e.g., liver, colon) 1
• Marked peritoneal carcinomatosis 1
• Severe ascites 1
• Peritonitis 1
• Anorexia nervosa 1
• Severe psychosis 1
• Clearly limited life expectancy 1
• Distal enteral obstruction 4
• Hemodynamic instability 4

Important Clarifications on Contraindications

• Low-dose aspirin is NOT a contraindication for PEG placement, though clinical studies are limited 1

• Mild to moderate ascites, ventriculoperitoneal shunt systems, and peritoneal dialysis are no longer contraindications as increased complication rates have not been demonstrated 1

• Oesophageal stenoses are not contraindications if they can be passed by a thin endoscope or treated with endoscopic dilatation 1

Pre-Procedure Requirements

Patients must fast for a minimum of 8 hours before PEG placement to reduce aspiration risk during endoscopic sedation 5

• Extended fasting may be necessary in patients with impaired gastric motility or gastroparesis 5

• Coagulation parameters must be within normal limits: INR <1.5, Quick >50%, PTT <50 seconds, platelet count >50,000/mm³ 5

• Prophylactic antibiotics with 2g cephalosporin IV are recommended to reduce wound infection risk 5

• IV access must be established for sedation administration 5

Alternative Options for Persistent Aspiration

If aspiration persists after PEG placement, direct percutaneous endoscopic jejunostomy (PEJ) is the preferred alternative due to lower tube dysfunction and reintervention rates compared to jejunal tube through existing PEG (JET-PEG) 6

• JET-PEG involves placing a jejunal extension tube through an existing PEG, but has higher tube dysfunction rates 6

• Percutaneous laparoscopic jejunostomy (PLJ) is an alternative when endoscopic placement isn't feasible 6

• Continuous rather than bolus feeding is typically better tolerated with jejunal tubes 6

Clinical Perspective Shift

Modern practice has shifted toward earlier consideration of PEG placement in appropriate patients when special nutritional advice and supplementary drinks are not effective, rather than waiting until advanced disease stages where benefits to nutritional status and quality of life are minimal 1