PEG Placement Principle Indications and Contraindications

PEG provides a rapid, simple method for long-term enteral feeding. Although the method can generally be used without complications, there are still some significant risks that should be kept in mind.

PEG placement is a technically simple procedure (Figs. 4.32, 4.33). A cannula is passed through the abdominal wall, and a guide suture is threaded into the stomach through the cannula. It is retrieved endoscopi-cally, withdrawn through the mouth, and used to pull the PEG tube down the esophagus and through the anterior abdominal wall, where it is anchored in place.

PEG placement can usually be performed under conscious sedation, but selected cases may require general anesthesia. If the patient has had a gastrectomy, the tube may also be placed ina loop of jejunum (percutaneous endoscopic jejunostomy [PEJ]), in the duodenum, or in an interposed colon segment (Figs. 4.35-4.37).

PEG tubes are available in various sizes and designs.

In the simplest case, the tube ends at the retention bumper on the inner wall of the stomach. If the tube is large enough, a second, thinner tube can be threaded through the gastrostomy tube and placed endoscopically in the duodenum to reduce the risk of aspiration (Fig. 4.34). From there the tube will be carried into the jejunum by spontaneous peristalsis. All-in-one tubes with an internal component that is placed endoscopically in the duodenum are not recommended because they may bend back toward the esophagus, creating a risk of aspiration.

■ Alternative Methods of Tube Placement

Computed tomography (CT)-guided gastrostomy and ultrasound-guided gastrostomy are options that may be considered in cases where endoscopy cannot be performed.

■ Indications

A PEG tube is indicated for maintaining enteral nutrition in patients with swallowing difficulties, alimentary obstructions, or wasting diseases. PEG placement in geriatric patients with

Table 4.10 Indications for PEG placement

► Neurogenic dysphagia

- Multiple sclerosis

- Amyotrophic lateral sclerosis

- Stroke

► Malignant obstruction

- ENT malignancy

- Esophageal carcinoma

- Gastric carcinoma

► Oncological diseases not affecting the alimentary tract

► HIV infection

► Chronic inflammatory bowel disease

► Cystic fibrosis multiple morbidity is problematic. The indications are reviewed in Table 4.10.

■ Contraindications

PEG placement is contraindicated in moribund patients, in certain types of comorbidity, and in cases where the procedure cannot be done for technical reasons (Table 4.11).

■ Informed Consent

Written informed consent should be obtained at least 24 hours before the procedure. Disclosure should be in accordance with general rules and should include a reference to other treatment options.

■ Complications

Mild complaints, especially pain and local inflammation at the puncture site, are not uncommon and are seen in up to 10 % of patients. The mortality figures range from 0.5 % to 2 %, depending on the population, but are significant. Serious complications are technical or infectious in nature (Table 4.12; Fig. 4.38).

■ Preparations

► Check the indications and contraindications.

► Obtain blood count and coagulation status.

► Discontinue proton pump inhibitors (PPI) and H2 blockers 48 hours before PEG placement.

► Obtain written informed consent 24 hours before the procedure.

► Provide antibiotic coverage if desired (e.g., metronidazole and cefotaxim).

► Patient should fast for 12 hours before the procedure.

► No solid foods for a variable period (six hours to three days after PEG placement)

► Afterward, use the tube to feed a gradually progressive diet.

► After two days, reexamine by endoscopy.

Table 4.11 Contraindications to PEG placement

Table 4.12 Complications of PEG placement

Table 4.11 Contraindications to PEG placement

► Very short life expectancy

► Technical com

► Comorbidity

plications

- Sepsis

- Aspiration

- Coagulation disorders

- Faulty punc

- Multisystem failure

ture tech

- Bowel obstruction

nique

- Peritonitis

- Perforation

- Ascites

- Bleeding

- Peritoneal carcinomatosis

- Leak

► Stomach inaccessible for

► Infections

percutaneous puncture

- Generalized

► Inability to transilluminate

peritonitis

the stomach wall

- Wound infec-

► Certain types of prior gastric

tion

surgery

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Responses

  • genet
    Is carcinomatosis a contraindication for peg?
    10 months ago
  • nora
    Is PEG placement done under general anesthesia?
    7 months ago
  • taina
    Why peg contraindicated esophageal cancer?
    4 months ago
  • Selam
    Is stomach cancer a contraindication for peg?
    4 months ago
  • sarah
    When is feed via a peg tube contraindicated?
    4 months ago
  • aatifa
    Is active c. diff infection a contraindication to PEG tube placement?
    3 months ago
  • ambrogio
    Is gist contraindicated in peg tube?
    3 months ago
  • Isembard Goold
    When to place PEG in esophageal cancer?
    2 months ago
  • janet brown
    Is ascites a contraindication to peg?
    20 days ago
  • selamawit
    Is candidal esophagitis a contraindication in placing a gastrostomy tube?
    3 days ago
  • murron
    Is EGJ outflow obstruction indication for PEG tube?
    2 days ago

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