Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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Copyright 2019 Designed by Michael Beck MD

The Best in FOAM Education

The Threes of G's - Troubleshooting the PEG Tube

August 1, 2019

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.

 

PEG = Percutaneous Endoscopic Gastrostomy

 

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

 

Obstruction

  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!

 

Replacement:

  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.

 

 

References

 

Edited by Bassam Zahid, MD

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