What is a PEG Tube (percutaneous endoscopic gastrostomy tube)
A tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient.
Giving food through a PEG tube is a type of enteral nutrition. Also called the gastrostomy tube and percutaneous endoscopic tube.
Source: National Cancer Institute
The important parts of PEG tube are:
- PEG/Gastronomy feeding tube.
- Two small discs that are on the outside and the inside of the gastrostomy opening (or stoma) in patient stomach wall. These discs prevent the feeding tube from moving. The disc on the outside is very close to the skin.
- Close off feeding tube clamp.
- A device to attach the tube to the skin when not feeding.
- Two openings at the end of the tube. One is for the foods, drinks, and medicines, the other for flushing the tube. (On some tubes may be third opening end. Because when there is a balloon instead of an internal disc).
PEG Tube Vs NG Tube
Nasogastric tube and percutaneous endoscopic gastrostomy
Nasogastric Tube (NG Tube)
The most common method of enteral nutrition is to place a nasogastric tube. Although this method is effective but also brings many difficulties and complications in clinical application. Because these nutrient tubes are relatively large in diameter and are made of hard rubber or plastic. They cause a lot of discomfort to the patient, often clogging the lumen and forcing the tube to be changed continuously, and the tube is often displaced.
The wall of the tube stimulates the esophageal mucosa for a long time and is prone to esophagitis, and the gastroesophageal reflux often occurs because the nutrient tube destroys the normal cardiac function. Frequent reflux can easily lead to aspiration pneumonia. Long-term use of nasogastric tubes can also easily lead to the destruction of mumps and nasal cartilage.
Percutaneous Endoscopic Gastrostomy (PEG Tube)
Percutaneous endoscopic gastrostomy (PEG) has been used clinically since 1980, providing a safe, effective, and non-surgical approach to establishing long-term enteral nutrition pathways. Clinical application. About 200,000 patients in the United States perform this technology each year. Pon-sky and Gauderer used the drag-and-drop technique for the first time.
Although there are many improved techniques based on this, the drag-and-drop method is still the most commonly used method.
Proper preoperative preparation can help reduce complications. Patients shall fast 8 hours before surgery. The conventional application of antibiotics against G + bacteria, cefazolin can kill such bacteria and other common microorganisms. The patient should take the supine position and raise the head to reduce aspiration.
Since the position is not easy to insert the gastroscope into the esophagus, it usually starts with the left lateral position and then returns to the supine position. The aspirator should promptly absorb the secretions from the pharynx and ensure that the patient maintains sufficient oxygen supply.
During the intravenous anesthesia, nurses should monitor the blood pressure, pulse and oxygen partial pressure during the whole operation.
Patient’s posture, the lidocaine glue or intravenous sedative take and the abdominal puncture site clean and disinfect. Reduce the brightness of the room after inserting the gastroscope. When the translucent point of the gastroscope see from the abdominal wall, it indicates that the tissue between the stomach and the abdominal wall has pushed open, and the stomach wall is directly in contact with the abdominal wall.
The puncture point of the gastrostomy shall be select at the brightest point of the gastroscope, usually the upper left abdomen. When the finger presses the puncture site of the abdominal wall, the fingertip on the stomach wall can see through the gastroscope. After the optimal puncture point select, local infiltration anesthesia performs, and the needle pulls back while the needle is drawing.
When the air is drawn, the needle tip can see in the stomach at the same time.
If the air draws before the needle tip sees, the puncture usually indicates. The needle enters a gas-filled hollow organ (such as the colon or small intestine). That interpose between the stomach and the abdominal wall, at which point the puncture point shall reselect.
After the local anesthetic injects at the puncture site. An incision of about 1 cm is cut in the local skin, and then the cannulated needle inserted into the gastric cavity. Then, a long wire is built into the stomach cavity from the inside of the cannula. After the wire enters the stomach, the wire clamps under the gastroscope with a biopsy forceps. Then the oral cavity takes out as the gastroscope withdraw.
PEG Tube Insertion
The end of the PEG tube fast to the lead wire outside the mouth. Then the wire tight from the puncture site of the abdominal wall. The PEG tube introduces from the esophagus into the stomach and pulls out of the body from the puncture site. At this point, insert the gastroscope again, check the position of the PEG tube head, and pay attention to the excessive tension of the gasket in the catheter head.
After the examination completes, the gastroscope withdraw. The root of the PEG tube attaches to the card outside the abdominal wall so that the stomach wall and the abdominal wall are kept in close contact and the PEG tube fixe.
PEG originally designed to provide a long-term enteral nutrition pathway for patients with normal gastrointestinal function but not oral feeding. All patients who expect to have no nutrients for more than 2 weeks or more shall receive nutritional support.
If the patient has a normal gastrointestinal function and the enteral nutrition support time is not more than 30 days. A nasogastric tube or a nasogastric tube can place for nutritional support. If the enteral nutrition time expects to be 30 days, a gastrostomy shall consider.
These patients may be severe neurological dysphagia or developmental disorders, oropharyngeal traumatic or neoplastic obstruction, or critically ill patients who require prolonged tracheal intubation.
The range of PEG indications has been expanding and has applied to burn patients (even though the skin of burn sites). Facilitating the implementation of high-calorie nutrition support in the intestine. It has also used in patients with esophageal cancer and head and neck cancer who are receiving adjuvant therapy. Patients with severe maxillofacial trauma can also benefit from PEG.
Non-nutritive applications of PEG include gastric emptying disorders, inoperable intestinal obstruction for gastrointestinal decompression; can also apply to children taking medication and biliary fistula. Patients with external drainage bile reinfusion; an esophageal hiatal hernia and gastric torsion Multiple PEG placed in the patient as a method of gastric fixation.
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Contraindications to PEG fall into three categories:
- Potential contraindications.
Absolute contraindications include coagulopathy, peritonitis, peritoneal dialysis, gastric varices, no stomach, and any disease that cannot be examined by gastroscopy.
Relative contraindications and those previously considered to be absolute contraindications. But can treated with PEG after ultrasound imaging, good preoperative preparation, and aggressive treatment.
Gastrostomy Tube Feeding
Once the PEG tube safely places, the next question is how to feed through it. The preferred interstitial feeding is because it is easier to implement (no pumping required), well tolerated, and physiologically compliant. The choice of formula shall base on the patient’s energy needs, tolerance, and the specific conditions of the systemic disease.
The amount of gastric residue shall measure routinely until it fully tolerates. If it finds to be greater than 100 ml. The problem of intolerance shall consider.
Peg Tube Replacement
Replace the PEG tube when it is worn, obstructed, and paralyzed.
When the PEG tube prematurely and rashly remove, it prone to peritonitis. It must be discovered in time, and the nasogastric tube negative pressure drainage, intravenous rehydration, and antibiotic treatment. If the patient has signs of peritonitis or bacteremia, an emergency laparotomy shall perform at this time.
Some PEG tubes require endoscopic removal when they are removed or replaced. The design is now more practical and does not require endoscopic extraction. But directly remove from the body. Gauderer et al. invented a low profile gastrostomy tube with a skin fixation device with an anti-reflux valve that allows nutrient solution infusion near the skin stoma.
The device can place after the previously placed gastrostomy tube remove or place directly upon the establishment of the PEG channel. For patients in need of monitoring, it is more appropriate to place a standard nutrient tube in the device, which is convenient for the caregiver to operate.
PEG Tube Complications:
(1) Incision infection, stenosis of the fistula, displacement of the fistula, obstruction of the fistula, and hematoma of the incision. Wound infections are more common.
(2) Serious complications include: bleeding, aspiration, peritonitis, internal cushion syndrome, stomach cramps, etc.
(3) Attention to prevent infection, aseptic operation, strict adherence to operating procedures, postoperative care, etc. can effectively prevent complications. (Read more…)
The following conditions are not contraindications for PEG, but care must be taken when handling, as complications are likely to occur.
1. Including postoperative surgery, dilated small intestine fistula, ventriculomegaly shunt, and severe heart disease. If you can accurately operate and see the light transmission point, abdominal surgery is not a contraindication. But such patients must find a safe puncture site when puncture.
2. Good skin care after gastrostomy is very important. It’s often seeing that secretions or granulation occur around the orifice due to rejection. This is easier to handle, and the secretions can be scrubbed with hydrogen peroxide and exposed locally. The granulation tissue can cauterize with a silver nitrate solution to avoid the use of an airtight dressing. Because it tends to damage the underlying skin.
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