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The Best in FOAM Education

  • Edgar Lei, MD

The Threes of G's - Troubleshooting the PEG Tube

A 30 year old male with past medical history of a TBI, trach dependent, G-tube dependent is brought in by EMS from the nursing home because the "G-tube isn't flushing." He is well-appearing. No acute distress. Vital signs are within normal limits.

Initial Considerations for G-tube complications

1. When was the G-tube placed?

  • If it was placed >3 weeks ago, you are ok (remember: "PEG" has 3 letters; so 3 weeks is the dividing line); full epithelialization of tract

  • If placed <3 weeks ago, call for backup; may need IR/Surgery/GI replacement

2. If it was dislodged, i.e. fell out, when did it fall out?

  • If < 3-4 hours, easier to replace; stomas can close within minutes to hours; more, and you may need to dilate the stoma or use a smaller tube

3. What is the type/size of original tube. G-J tube is NOT G-tube


1. Flush:

  • Back and forth with warm water; use small syringe to create higher pressure

  • Instill warm water - wait 30-60 min; then flush

  • Pancreatic enzymes (e.g. pancrealipase/Viokace); leave sitting x 30-60 min and then flush

2. Mechanically opening - e.g. using central line guidewire

3. Replace tube

Dislodgements can occur in up to 20% of PEG patients!


1. Maintain patent stoma

  • Foley catheter (or original tube) as place holder; do NOT blow up balloon

2. Dilate closing tract (i.e. >3 hours)

  • Not necessary if you're not comfortable! call for backup!

  • Toomey irrigation syringe (60cc)

  • Cervical/surgical dilating kit with metal dilators

3. Replace

  • Remove old tube: deflate balloon, pull; if painful, stop! call for backup!]

  • Tube size: check original tube size; if you don't have tube, 16F-24F is appropriate

  • Test balloon - balloon failure may be the reason for dislodgement

  • Lubricate and push: use lidocaine jelly; gently push replacement into stoma

  • Balloon: Blow up balloon with sterile water (amount is written on port)

  • Sponge: optional

  • Bumper/Retention Bolster: slider bumper down to skin with ~1 cm of mobility

  • Confirm: XR with gastrografin 20-30cc, fluoroscopy, ultrasound (push saline into tube), or aspiration of gastric contents (only if easy placement in mature tract) (pH <5.5)

Troubleshooting (Replacement):

1. Hold up: do NOT advance forcefully, because you can create a false tract - can lead to peritonitis

2. Tract: advancing non-coude pediatric bougie (7 Fr) to identify tract; then railroading G-tube over it

3. Leakage: make sure the internal balloon is snug against stomach wall; tug a bit more

PEG Pain:

1. Infection - purulence, erythema, tenderness at site

  • Foreign body - may be a source of sepsis; can progress to necrotizing fasciitis

  • Possible in first 2 weeks after tract placement; consider antibiotics and tube removal

  • May also be due to leakage of gastric contents around the tube; may need to upsize tube

  • If fungal infection, can progress to fungal cellulitis, peritonitis, abscess

2. Pressure ulcer/necrosis - inspect the tract; call for backup

3. Buried Bumper Syndrome - internal balloon/bumper is too tight; erosion on gastric side; can feel bumper under skin; skin is usually tender; call for backup


Edgar Lei, MD is a current third year resident at Stony Brook Emergency Medicine.


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