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
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
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)
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)
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
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.
Edited by Bassam Zahid, MD