When is a percutaneous endoscopic gastrostomy (PEG) tube indicated, what are the contraindications, how is the procedure performed, and what are the initial feeding guidelines and alternatives?

Percutaneous Endoscopic Gastrostomy (PEG) Tubes: Indications, Contraindications, Procedure, and Management

When to Place a PEG Tube

PEG tube placement is indicated when a patient's nutritional intake is expected to be inadequate for more than 2-3 weeks, with most authorities recommending consideration at 4-6 weeks of anticipated need. 1

Primary Indications

Neurological disorders (approximately 50% of cases):

• Dysphagia from cerebrovascular stroke, traumatic brain injury, or cerebral tumors 1
• Motor neurone disease, Parkinson's disease, multiple sclerosis, cerebral palsy 1
• Prolonged coma or persistent vegetative state 1

Head and neck malignancies (approximately 30% of cases):

• Stenosing tumors of the oropharynx or upper gastrointestinal tract 1
• Patients undergoing chemotherapy or radiotherapy who require nutritional support 1

Other conditions:

• Short bowel syndrome requiring supplementary intake 1
• Cystic fibrosis, AIDS-related wasting, chronic renal failure 1
• Crohn's disease (no longer considered a contraindication) 1
• Palliative gastric decompression in chronic obstruction or ileus 1

Critical Decision-Making Framework

Before PEG placement, you must confirm:

• The patient has adequate gastrointestinal function to absorb and tolerate feeding 1
• Oral supplementation with nutritional drinks and swallowing therapy has been attempted first 1
• The patient is at high risk of malnutrition and unlikely to recover oral feeding ability in the short term 1
• The procedure will improve or maintain quality of life, not merely prolong dying 1

PEG placement is inappropriate in:

• Patients with short life expectancy or advanced dementia 1
• Terminal patients where it serves as a symbolic rather than therapeutic measure 1
• Situations driven by administrative convenience rather than medical necessity 1

Absolute Contraindications

Do not place a PEG if:

• Distal enteral obstruction exists 2
• Severe uncorrectable coagulopathy is present 3, 2
• Hemodynamic instability 2
• Inability to bring the anterior gastric wall in apposition to the abdominal wall 3
• Peritonitis 3

Relative Contraindications

Exercise caution with:

• Gastro-oesophageal reflux, previous gastric surgery, ascites 1
• Extensive gastric ulceration, gastric outlet obstruction, gastric varices 1
• Small bowel motility problems, malabsorption 1
• Peritoneal dialysis, hepatomegaly, late pregnancy 1
• Obesity (makes procedure technically difficult) 1

Procedure Technique

The "pull" method is the most commonly performed technique and involves endoscopic placement under sedation and local anesthesia. 2, 4

Pre-Procedure Requirements

Antibiotic prophylaxis is mandatory:

• Administer a single dose of co-amoxiclav 2.2g (or first-generation cephalosporin) 30 minutes before insertion 1, 5
• This significantly reduces peristomal wound infection rates 1

Anticoagulation management:

• Adequate management of anticoagulation and antithrombotic agents is essential to prevent bleeding 4

Alternative Placement Methods

If endoscopy is contraindicated:

• Radiological or ultrasound-guided placement 1
• Surgical gastrostomy (though PEG is preferred due to lower complication rates, reduced costs, and shorter procedure time) 5

Initial Feeding Guidelines

Start feeding cautiously to avoid intestinal intolerance:

• Begin with a low flow rate of 10-20 ml/hour maximum 1
• Increase the feeding rate carefully and individually 1
• Reaching target intake may take 5-7 days 1

Formula selection:

• Standard whole protein formula is appropriate for most patients 1
• Home-made diets are not recommended due to tube clotting risk and infection concerns 1
• In malnourished patients undergoing major cancer surgery, use formulas enriched with arginine, omega-3-fatty acids, and ribonucleotides 1

Timing:

• Tube feeding should be initiated within 24 hours after surgery in patients who cannot start early oral nutrition and will have inadequate oral intake (<50%) for more than 7 days 1

Tube Removal

Wait at least 14 days after insertion before removal to ensure a fibrous tract is established that prevents intraperitoneal leakage. 1

Removal technique depends on fixation type:

• Balloon-retained tubes: Deflate balloon and apply gentle traction 1
• Deforming device tubes: May require vigorous pulling 1
• Rigid fixation devices: Usually removed endoscopically, though cutting close to skin and pushing into stomach allows spontaneous passage in 98% of cases (avoid if distal stricturing suspected) 1

Alternatives to Standard PEG

For Aspiration Risk or Gastric Motility Problems

Direct percutaneous endoscopic jejunostomy (PEJ) is the preferred alternative due to significantly lower tube dysfunction and reintervention rates compared to jejunal extension through PEG (JET-PEG). 1, 6

Options in order of preference:

1. Direct PEJ (lowest complication rate) 1, 6
2. JET-PEG (jejunal tube placed through existing PEG, guided beyond ligament of Treitz) 1, 6
3. Percutaneous laparoscopic jejunostomy when endoscopic access is limited 6

Feeding via jejunal tubes:

• Continuous feeding is better tolerated than bolus feeding 6

For Long-Term Surgical Patients

If long-term enteral nutrition exceeds 4 weeks (e.g., severe head injury), PEG placement is recommended. 1

Nasocutaneous jejunostomy (NCJ) advantages:

• Can remain in place after hospital discharge 1
• Allows continuation of supplementary feeding (500-1000 kcal/day overnight) at home 1
• Most patients can self-administer feeds with appropriate training 1

Common Pitfalls to Avoid

High early mortality risk:

• Overall mortality within weeks of PEG placement is very high, usually due to underlying conditions and poor patient selection (e.g., severe stroke) 1
• Deaths are not typically procedure-related but reflect inappropriate patient selection 1

Ethical considerations:

• PEG is not a substitute for good nursing care 1
• Should never be placed for administrative convenience to save time, money, or manpower 1
• Requires careful consideration of prognosis and patient/family wishes 1

Technical complications:

• Most complications are minor, but major life-threatening events can occur including wound infection, bleeding, buried bumper syndrome, colocutaneous fistula, perforation, and volvulus 4
• Complications are more frequent in elderly patients and those with multiple comorbidities 7

Post-Discharge Nutritional Follow-Up

Continue nutritional assessment and support after hospital discharge for patients who received perioperative nutritional therapy and still cannot meet energy requirements orally. 1

Dietary counseling is strongly recommended and appreciated by most patients, particularly after major gastrointestinal or pancreatic surgery where weight loss of 5-12% at 6 months is common. 1