What is the appropriate skin care protocol for an adult patient with a percutaneous endoscopic gastrostomy (PEG) tube?

PEG Tube Skin Care Protocol

Initial Post-Placement Care (Days 1-7)

During the first week after PEG placement, perform daily aseptic wound care with sterile dressings to prevent stoma tract infection while the incision heals. 1

Daily Wound Care Technique

• Monitor the exit site daily for bleeding, pain, erythema, induration, leakage, and signs of inflammation 1
• Cleanse the site using 0.9% sodium chloride, sterile water, or freshly boiled and cooled water to remove debris 1
• Apply a sterile Y-shaped dressing (non-shedding) under the external disc plate, followed by a skin-friendly, solvent-free, breathable dressing 1
• Avoid occlusive dressings as they promote moisture accumulation and skin maceration 1
• Ensure proper tension: The external fixation plate should retain the tube without exerting tension, allowing free movement of at least 5 mm 1

Alternative First-Week Option

• Consider glycerin hydrogel or glycogel dressings as a cost-effective alternative to daily standard dressing changes, applied the day after placement and changed weekly for four weeks 1

Tube Mobilization (After Week 1)

Beginning approximately one week post-placement, mobilize the tube to prevent buried bumper syndrome. 1

• Push the tube 2-3 cm (ideally 5-10 cm) into the stomach, then carefully pull back until resistance from the internal bumper is felt 1
• Do NOT rotate the tube if it is a gastrojejunostomy or has a jejunal extension—only push in and out 1
• Delay mobilization until two weeks if gastropexy sutures are present 1

Long-Term Maintenance Care (After Week 1-2)

Once the stoma is healed, reduce dressing changes to 1-2 times weekly and cleanse with soap and drinking-quality water. 1

Routine Cleaning Protocol

• Cleanse the site twice weekly using a clean cloth with fresh tap water and soap 1
• Dry the skin gently and thoroughly after cleansing 1
• Dressings may be omitted entirely and the site left open once fully healed 1
• Showering, bathing, and swimming are permitted after initial healing (1-2 weeks); use waterproof dressing for public pools 1

Tube Maintenance

• Flush the tube with 40 ml of drinking or still mineral water after each feed or medication administration 1
• Maintain 0.5-1 cm free distance between the skin and external bolster to prevent pressure necrosis 1

Managing Peristomal Leakage

If gastric contents leak around the stoma, protect the surrounding skin with zinc oxide-based barrier products. 1

Leakage Management Steps

• Apply zinc oxide-containing cream, paste, or barrier film to prevent skin breakdown from gastric acid exposure 1
• Use foam dressings rather than gauze around the site—foam lifts drainage away from skin while gauze increases maceration 1
• Consider proton pump inhibitors to decrease gastric acid secretion and minimize leakage, with regular review of necessity 1
• Verify proper tension between internal and external bolsters to ensure the tube is not too loose or too tight 1
• Treat fungal infections with topical antifungal agents if present alongside leakage 1

Risk Factors for Leakage

Common causes include skin infection, increased gastric acid secretion, gastroparesis, increased abdominal pressure, constipation, tube torsion, excessive bolster tension, buried bumper syndrome, and granulation tissue 1

Critical Pitfalls to Avoid

• Never apply excessive tension on the external fixation plate immediately after placement—this causes pressure necrosis and buried bumper syndrome 1
• Do not use occlusive dressings during the healing phase as they trap moisture 1
• Avoid rotating tubes with jejunal extensions or gastrojejunostomy configurations 1
• Do not delay mobilization beyond one week (except with gastropexy) as this increases buried bumper syndrome risk 1
• Never ignore difficulty mobilizing the tube—this is an alarming sign of buried bumper syndrome requiring immediate evaluation 1

When to Escalate Care

• Persistent local infection despite antiseptic measures requires microbiological swab and antibiotic therapy 1
• Difficulty mobilizing the tube, resistance when flushing, or leakage during irrigation suggests buried bumper syndrome and requires endoscopic evaluation 1
• Refractory leakage despite barrier protection and PPI therapy may require tube removal for 24-48 hours to allow tract closure, or placement at a new site 1