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Percutaneous endoscopic gastrostomy (PEG) is an
endoscopic An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
medical procedure A medical procedure is a course of action intended to achieve a result in the delivery of healthcare. A medical procedure with the intention of determining, measuring, or diagnosis, diagnosing a patient condition or parameter is also called a medi ...
in which a tube (PEG tube) is passed into a patient's stomach through the
abdominal wall In anatomy, the abdominal wall represents the boundaries of the abdominal cavity. The abdominal wall is split into the anterolateral and posterior walls. There is a common set of layers covering and forming all the walls: the deepest being the vi ...
, most commonly to provide a means of feeding when
oral The word oral may refer to: Relating to the mouth * Relating to the mouth, the first portion of the alimentary canal that primarily receives food and liquid **Oral administration of medicines ** Oral examination (also known as an oral exam or ora ...
intake is not adequate (for example, because of
dysphagia Dysphagia is difficulty in swallowing. Although classified under " symptoms and signs" in ICD-10, in some contexts it is classified as a condition in its own right. It may be a sensation that suggests difficulty in the passage of solids or l ...
or
sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
). This provides
enteral Enteral administration is food or drug administration via the human gastrointestinal tract. This contrasts with parenteral nutrition or drug administration (Greek ''para'', "besides" + ''enteros''), which occurs from routes outside the GI tract, ...
nutrition (making use of the natural
digestion Digestion is the breakdown of large insoluble food compounds into small water-soluble components so that they can be absorbed into the blood plasma. In certain organisms, these smaller substances are absorbed through the small intestine into th ...
process of the
gastrointestinal tract The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the Digestion, digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascula ...
) despite bypassing the mouth; enteral nutrition is generally preferable to
parenteral nutrition Parenteral nutrition (PN), or intravenous feeding, is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding entities or standard ph ...
(which is only used when the GI tract must be avoided). The PEG procedure is an alternative to open surgical
gastrostomy A gastrostomy is the creation of an artificial external opening into the stomach for nutritional support or gastric decompression. Typically this would include an incision in the patient's epigastrium as part of a formal operation. When originall ...
insertion, and does not require a
general anesthetic General anaesthetics (or anesthetics) are often defined as compounds that induce a loss of consciousness in humans or loss of righting reflex in animals. Clinical definitions are also extended to include an induced coma that causes lack of aware ...
; mild sedation is typically used. PEG tubes may also be extended into the
small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...
by passing a jejunal extension tube (PEG-J tube) through the PEG tube and into the
jejunum The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialized for the absorption by enterocytes of small nutrient molecules which have been pr ...
via the
pylorus The pylorus ( or ) connects the stomach to the duodenum. The pylorus is considered as having two parts, the ''pyloric antrum'' (opening to the body of the stomach) and the ''pyloric canal'' (opening to the duodenum). The ''pyloric canal'' ends a ...
. PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many
stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...
patients, for example, are at risk of
aspiration pneumonia Aspiration pneumonia is a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs. Signs and symptoms often include fever and cough of relatively rapid onset. Complications may incl ...
due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition. PEGs may also be inserted to decompress the
stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...
in cases of
gastric volvulus Gastric volvulus or volvulus of stomach is a twisting of all or part of the stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death. The twisting can oc ...
.


Indications

Gastrostomy may be indicated in numerous situations, usually those in which normal (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g.
stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...
), anatomical (e.g.
cleft lip and palate A cleft lip contains an opening in the upper lip that may extend into the nose. The opening may be on one side, both sides, or in the middle. A cleft palate occurs when the palate (the roof of the mouth) contains an opening into the nose. The ...
during the process of correction) or other (e.g.
radiation therapy Radiation therapy or radiotherapy (RT, RTx, or XRT) is a therapy, treatment using ionizing radiation, generally provided as part of treatment of cancer, cancer therapy to either kill or control the growth of malignancy, malignant cell (biology), ...
for tumors in head & neck region). In certain situations where normal or nasogastric feeding is not possible, gastrostomy may be of no clinical benefit. In advanced
dementia Dementia is a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform activities of daily living, everyday activities. This typically invo ...
, studies show that PEG placement does not in fact prolong life. Instead, oral assisted feeding is preferable. Quality improvement protocols have been developed with the aim of reducing the number of non-beneficial gastrostomies in patients with dementia. A gastrostomy can be placed to decompress the stomach contents in a patient with a malignant bowel obstruction. This is referred to as a "venting PEG" and is placed to prevent and manage nausea and vomiting. A gastrostomy can also be used to treat
volvulus A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. Onset of symp ...
of the stomach, where the stomach twists along one of its axes. The tube (or multiple tubes) is used for gastropexy, or adhering the stomach to the abdominal wall, preventing twisting of the stomach. A PEG tube can be used in providing gastric or post-surgical drainage.


Techniques

Two major techniques for placing PEGs have been described in the literature. The Gauderer-Ponsky technique involves performing a
gastroscopy Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered ...
to evaluate the
anatomy Anatomy () is the branch of morphology concerned with the study of the internal structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old scien ...
of the
stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...
. The anterior stomach wall is identified and techniques are used to ensure that there is no
organ Organ and organs may refer to: Biology * Organ (biology), a group of tissues organized to serve a common function * Organ system, a collection of organs that function together to carry out specific functions within the body. Musical instruments ...
between the wall and the
skin Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different ...
: * digital pressure is applied to the abdominal wall, which can be seen indenting the anterior gastric wall by the endoscopist. * transillumination (diaphanoscopy): the light emitted from the endoscope within the stomach can be seen through the abdominal wall. * a small (21G, 40mm) needle is passed into the stomach before the larger cannula is passed. An angiocath is used to puncture the abdominal wall through a small incision, and a soft guidewire is inserted through this and pulled out of the
mouth A mouth also referred to as the oral is the body orifice through which many animals ingest food and animal communication#Auditory, vocalize. The body cavity immediately behind the mouth opening, known as the oral cavity (or in Latin), is also t ...
. The feeding tube is attached to the guidewire and pulled through the mouth, esophagus, stomach, and out of the incision. In the Russell introducer technique, the
Seldinger technique The Seldinger technique, also known as Seldinger wire technique, is a medical procedure to obtain safe access to blood vessels and other hollow organ (anatomy), organs. It is eponym, named after Sven Ivar Seldinger (1921–1998), a Sweden, Swedish ...
is used to place a wire into the stomach, and a series of dilators are used to increase the size of the
gastrostomy A gastrostomy is the creation of an artificial external opening into the stomach for nutritional support or gastric decompression. Typically this would include an incision in the patient's epigastrium as part of a formal operation. When originall ...
. The tube is then pushed in over the wire.


Anesthetic management

There are several techniques such as moderate sedation with left transversus abdominis plane block, and moderate sedation with local anesthetic infiltration at feeding tube site.


Contraindications

As with other types of feeding tubes, care must be made to place PEGs into an appropriate population. The following are contraindications to PEG use:


Absolute contraindications

* Inability to perform an
esophagogastroduodenoscopy Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered ...
* Uncorrected
coagulopathy Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding ( bleeding diathesis), which may occur s ...
*
Peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...
* Untreatable (loculated) massive
ascites Ascites (; , meaning "bag" or "sac") is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdo ...
*
Bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...
(unless the PEG is sited to provide drainage)


Relative contraindications

* Massive
ascites Ascites (; , meaning "bag" or "sac") is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdo ...
* Gastric mucosal abnormalities: large
gastric varices Gastric varices are dilated submucosal veins in the lining of the stomach, which can be a life-threatening cause of bleeding in the upper gastrointestinal tract. They are most commonly found in patients with portal hypertension, or elevated p ...
, portal hypertensive gastropathy * Previous
abdominal surgery The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ (see stomach, kidney, liver, e ...
, including previous partial
gastrectomy A gastrectomy is a partial or total surgical removal of the stomach. Indications Gastrectomies are performed to treat stomach cancer and perforations of the stomach wall. For severe duodenal ulcers, it may be necessary to remove the lower ...
: increased risk of organs interposed between gastric wall and abdominal wall * Morbid obesity: difficulties in locating stomach position by digital indentation of stomach and transillumination * Gastric wall
neoplasm A neoplasm () is a type of abnormal and excessive growth of tissue. The process that occurs to form or produce a neoplasm is called neoplasia. The growth of a neoplasm is uncoordinated with that of the normal surrounding tissue, and persists ...
* Abdominal wall
infection An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmis ...
: increased risk of infection of PEG site * Intra-abdominal malignancy with peritoneal involvement (tumor seeding into formed channel with subsequent failure)


In advanced dementia

The American Medical Directors Association, the American Geriatrics Society and the
American Academy of Hospice and Palliative Medicine The American Academy of Hospice and Palliative Medicine (AAHPM) is a professional organization for physicians specializing in Hospice and Palliative Medicine, headquartered in Chicago, Illinois. Membership is open to all health care providers com ...
recommend against inserting percutaneous feeding tubes in individuals with advanced dementia and, instead, recommend oral assisted feedings. Artificial nutrition neither prolongs life nor improves its quality in patients with advanced dementia. It may increase the risk of the patient inhaling food, it does not reduce suffering, it may cause fluid overload, diarrhea, abdominal pain and local complications, and it can reduce the amount of human interaction the patient experiences.


Complications

* Surgical site infection around the gastrostomy site. Administration of intravenous antibiotics can reduce infection around the gastrostomy site.
Prophylaxis Preventive healthcare, or prophylaxis, is the application of healthcare measures to prevent diseases.Hugh R. Leavell and E. Gurney Clark as "the science and art of preventing disease, prolonging life, and promoting physical and mental health a ...
with co-amoxiclav decreases the proportion of people developing MRSA infections compared with no antibiotic prophylaxis (in people without cancer) undergoing percutaneous endoscopic gastrostomy insertion. *
Hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, ...
* Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer") * Perforation of
bowel The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. T ...
(most commonly
transverse colon In human anatomy, the transverse colon is the longest and most movable part of the Large intestine#Structure, colon. Anatomical position It crosses the abdomen from the ascending colon at the right colic flexure (hepatic flexure) with a downward ...
) leading to
peritonitis Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and covering of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One pa ...
* Puncture of the left lobe of the
liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...
leading to liver capsule pain * Gastrocolic fistula: this may be suspected if diarrhea appears a short time after feeding. In this case, the feed goes direct from stomach to colon (usually
transverse colon In human anatomy, the transverse colon is the longest and most movable part of the Large intestine#Structure, colon. Anatomical position It crosses the abdomen from the ascending colon at the right colic flexure (hepatic flexure) with a downward ...
) * Gastric separation * " Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall)


Removal of PEG tubes


Indications

* PEG tube no longer required (recovery of swallow after
stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...
or brain trauma, or after surgery or radiotherapy for
head and neck cancer Head and neck cancer is a general term encompassing multiple cancers that can develop in the head and neck region. These include cancers of the mouth, tongue, gums and lips (oral cancer), voice box ( laryngeal), throat ( nasopharyngeal, orophary ...
) * Persistent infection of PEG site * Failure, breakage or deterioration of PEG tube (a new tube can be sited along the existing track) * "Buried bumper syndrome"


Techniques

PEG tubes with rigid, fixed "bumpers" are removed endoscopically. The PEG tube is pushed into the stomach so that part of the tube is visible behind the bumper. An endoscopy snare is then passed through the endoscope, and passed over the bumper so that the tube adjacent to the bumper is grasped. The external part of the tube is then cut, and the tube is withdrawn into the stomach, and then pulled up into the esophagus and removed through the mouth. The PEG site heals without intervention. PEG tubes with a collapsible or deflatable bumper can be removed using traction (simply by pulling the PEG tube out through the abdominal wall).


History

The first percutaneous endoscopic gastrostomy performed on a child was on June 12, 1979, at the Rainbow Babies & Children's Hospital, University Hospitals of Cleveland. Michael W.L. Gauderer, pediatric surgeon, Jeffrey Ponsky, endoscopist, and James Bekeny, surgical resident, performed the procedure on a -month-old child with inadequate oral intake. The authors of the technique, Michael W.L. Gauderer and Jeffrey Ponsky, first published the technique in 1980. In 2001, the details of the development of the procedure were published, the first author being the originator of the technique itself.


See also

*
Feeding tube A feeding tube is a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral f ...
* Minimally conscious state


References


External links


eMedicine: Percutaneous Gastrostomy and Jejunostomy
{{Authority control Enteral feeding Endoscopy Digestive system surgery