PEG tubes are used as long term feeding options (and medication administration) for those in whom NG tubes are unsuitable or too short term. Indications might include head & neck cancers resulting in altered anatomy not allowing a safe swallow or long term neurological conditions (such as MS, stroke, MND) that also impair the patient’s swallow.
Placement might be endoscopically achieved (percutaneous endoscopic gastrostomy) or with radiological guidance (RIG).
What to do if they come out
Ensure you inform your seniors as urgent action is required. The aim is to keep the stoma patent, thus a lubricated catheter is gently inserted & the balloon inflated to keep it in place. Position of the catheter is checked by testing the pH of an aspirate. Do NOT use the catheter for medication or feeding.
Contact gastroenterology to arrange PEG replacement. Additionally, you may need to consider antibiotics to prevent peritonitis if the PEG was inserted within the last 2 weeks (discuss this with the gastroenterology team).
What to do if they’re blocked
Blockages usually occur due to inadequate flushing after feed or medications. Try to unblock the tube by:
- Using the purple nutrition syringe to aspirate the blockage
- Trying to flush with warm water
- Gently massaging the tube as you flush to break down the blockage
- Trying to push & pull on the plunger to break up the blockage
- If unsuccessful, contact gastroenterology & consider maintenance fluids
What to do if you’re concerned patient may be aspirating
It is possible for feed to reflux into the oesophagus and for the patient to aspirate. Reposition the patient so they are sitting or at 30 degrees to reduce this risk and you may need to leave them in this position after feeding (until the feed passes beyond the stomach).
What to do if the tube is split
If the break or split is close to the bung/external end, the gastroenterology team may advise cutting where it is split & re-attaching the bung (assuming there is a sufficient length of remaining tube). If the split is close to the skin, gastroenterology will advise accordingly.
What to do if there’s leakage around the PEG site
This could be because
- The tube is smaller than the stoma (allowing leaking from the sides)
- The external fixation plate isn’t flush with the skin
- There is an infection of the site (usually with inflammation, pain and purulent discharge)
- Constipation or obstruction has led to a build-up of pressure in the GI tract preventing stomach contents passing
Consider the above situations, particularly managing constipation or site infection. Also, do obtain gastroenterology support early to prevent harm. Discharging stomach contents can be quite irritating so do ensure the skin is cleaned.
The internal bumper can erode into the lining of the stomach if the external fixation plate is placed too tightly. The bumper can be partially buried allowing feed, but once fully buried the tip of the tube is blocked completely. Signs of a buried bumper include not being able to flush or feed through the tube, the tube not freely moving or leakage around the site on flushing. A buried bumper occurs in less than 2% of patients with a PEG tube.
This is why it is vital to properly look after a PEG tube following insertion. Those looking after a PEG tube are asked once the tract is matured to once weekly to rotate the tube (this involves advancing the tube about 4cm, rotating & pulling it back to secure it in position).
Written by Dr Nicola Conquest (GPST1)
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