Percutaneous endoscopic gastrostomy
Encyclopedia
Percutaneous endoscopic gastrostomy is an endoscopic
medical procedure
in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral
intake is not adequate. The procedure is an alternative to surgical gastrostomy
insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine
by passing a jejunal extension tube (PEG-J tube) through the PEG tube and into the jejunum
via the pylorus
.
PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke
patients, for example, are at risk of aspiration pneumonia
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
in cases of gastric volvulus
.
), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy
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
, studies show that PEG placement does not in fact prolong life. 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
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.
Two major techniques for placing PEGs have been described in the literature.
The Gauderer-Ponsky technique involves performing a gastroscopy to evaluate the anatomy
of the stomach
. The anterior stomach wall is identified and techniques are used to ensure that there is no organ
between the wall and the skin
:
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
. 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
is used to place a wire into the stomach, and a series of dilators are used to increase the size of the gastrostomy
. The tube is then pushed in over the wire.
PEG tubes with a collapsible or deflatable bumper can be removed using traction (simply by pulling the PEG tube out through the abdominal wall).
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
medical procedure
Medical procedure
A medical procedure is a course of action intended to achieve a result in the care of persons with health problems.A medical procedure with the intention of determining, measuring or diagnosing a patient condition or parameter is also called a medical test...
in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral
Mouth
The mouth is the first portion of the alimentary canal that receives food andsaliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth....
intake is not adequate. The procedure is an alternative to surgical gastrostomy
Gastrostomy
Gastrostomy refers to a surgical opening into the stomach. Creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression....
insertion, and does not require a general anesthetic; mild sedation is typically used. PEG tubes may also be extended into the small intestine
Small intestine
The small intestine is the part of the gastrointestinal tract following the stomach and followed by the large intestine, and is where much of the digestion and absorption of food takes place. In invertebrates such as worms, the terms "gastrointestinal tract" and "large intestine" are often used to...
by passing a jejunal extension tube (PEG-J tube) through the PEG tube and into the jejunum
Jejunum
The jejunum is the middle section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms middle intestine or mid-gut may be used instead of jejunum.The jejunum lies between the duodenum...
via the pylorus
Pylorus
The pylorus is the region of the stomach that connects to the duodenum . It is divided into two parts:* the pyloric antrum, which connects to the body of the stomach.* the pyloric canal, which connects to the duodenum....
.
PEG administration of enteral feeds is the most commonly used method of nutritional support for patients in the community. Many stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
patients, for example, are at risk of aspiration pneumonia
Aspiration pneumonia
Aspiration pneumonia is bronchopneumonia that develops due to the entrance of foreign materials into the bronchial tree, usually oral or gastric contents...
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
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
in cases of gastric volvulus
Volvulus
A volvulus is a bowel obstruction with a loop of bowel whose nose has abnormally twisted on itself.-Types:* Volvulus Neonatorum.* Volvulus Small Intestine.* Volvulus Caecum.* Volvulus Sigmoid Colon .* Gastric volvulus....
.
Indications
Gastrostomy may be indicated in numerous situations, usually those in which normal or nutrition (or nasogastric) feeding is impossible. The causes for these situations may be neurological (e.g. strokeStroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
), anatomical (e.g. cleft lip and palate during the process of correction) or other (e.g. radiation therapy
Radiation therapy
Radiation therapy , radiation oncology, or radiotherapy , sometimes abbreviated to XRT or DXT, is the medical use of ionizing radiation, generally as part of cancer treatment to control malignant cells.Radiation therapy is commonly applied to the cancerous tumor because of its ability to control...
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
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging...
, studies show that PEG placement does not in fact prolong life. 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
Volvulus
A volvulus is a bowel obstruction with a loop of bowel whose nose has abnormally twisted on itself.-Types:* Volvulus Neonatorum.* Volvulus Small Intestine.* Volvulus Caecum.* Volvulus Sigmoid Colon .* Gastric volvulus....
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
The Gauderer-Ponsky technique involves performing a gastroscopy to evaluate the anatomy
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...
of the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...
. The anterior stomach wall is identified and techniques are used to ensure that there is no organ
Organ (anatomy)
In biology, an organ is a collection of tissues joined in structural unit to serve a common function. Usually there is a main tissue and sporadic tissues . The main tissue is the one that is unique for the specific organ. For example, main tissue in the heart is the myocardium, while sporadic are...
between the wall and the skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
:
- 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
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
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
Mouth
The mouth is the first portion of the alimentary canal that receives food andsaliva. The oral mucosa is the mucous membrane epithelium lining the inside of the mouth....
. 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
Seldinger technique
The Seldinger technique is a medical procedure to obtain safe access to blood vessels and other hollow organs. It is named after Dr. Sven-Ivar Seldinger , a Swedish radiologist from Mora, Dalarna County, who introduced the procedure in 1953....
is used to place a wire into the stomach, and a series of dilators are used to increase the size of the gastrostomy
Gastrostomy
Gastrostomy refers to a surgical opening into the stomach. Creation of an artificial external opening into the stomach for nutritional support or gastrointestinal compression....
. The tube is then pushed in over the wire.
Contraindications
As with the case of 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 esophagogastroduodenoscopyEsophagogastroduodenoscopyFor other expansions of the initialism "OGD", see the disambiguation page.In medicine , esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum...
- Uncorrected coagulopathyCoagulopathyCoagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
- PeritonitisPeritonitisPeritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of...
- Untreatable (loculated) massive ascitesAscitesAscites is a gastroenterological term for an accumulation of fluid in the peritoneal cavity.The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis and severe liver...
- Bowel obstructionBowel obstructionBowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency...
(unless the PEG is sited to provide drainage)
Relative contraindications
- Massive ascitesAscitesAscites is a gastroenterological term for an accumulation of fluid in the peritoneal cavity.The medical condition is also known as peritoneal cavity fluid, peritoneal fluid excess, hydroperitoneum or more archaically as abdominal dropsy. Although most commonly due to cirrhosis and severe liver...
- Gastric mucosal abnormalities: large gastric varicesGastric varicesGastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis...
, portal hypertensive gastropathy - Previous abdominal surgeryAbdominal surgeryThe term abdominal surgery broadly covers surgical procedures that involve opening the abdomen. Surgery of each abdominal organ is dealt with separately in connection with the description of that organ Diseases affecting the abdominal cavity are dealt with generally under their own names The term...
, including previous partial gastrectomyGastrectomyA gastrectomy is a partial or full surgical removal of the stomach.-Indications:Gastrectomies are performed to treat cancer and perforations of the stomach wall....
: 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
- Abdominal wall infectionInfectionAn infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
: increased risk of infection of PEG site - Intra-abdmominal malignancy with peritoneal involvement (tumor seeding into formed channel with subsequent failure)
Complications
- CellulitisCellulitisCellulitis is a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Cellulitis can be caused by normal skin flora or by exogenous bacteria, and often occurs where the skin has previously been broken: cracks in the skin, cuts, blisters,...
(infection of the skin) around the gastrostomy site - Haemorrhage
- Gastric ulcer either at the site of the button or on the opposite wall of the stomach ("kissing ulcer")
- Perforation of bowelIntestineIn human anatomy, the intestine is the segment of the alimentary canal extending from the pyloric sphincter of the stomach to the anus and, in humans and other mammals, consists of two segments, the small intestine and the large intestine...
(most commonly transverse colonTransverse colonThe transverse colon, the longest and most movable part of the colon, passes with a downward convexity from the right hypochondrium region across the abdomen, opposite the confines of the epigastric and umbilical zones, into the left hypochondrium region, where it curves sharply on itself beneath...
) leading to peritonitisPeritonitisPeritonitis is an inflammation of the peritoneum, the serous membrane that lines part of the abdominal cavity and viscera. Peritonitis may be localised or generalised, and may result from infection or from a non-infectious process.-Abdominal pain and tenderness:The main manifestations of... - Puncture of the left lobe of the liverLiverThe liver is a vital organ present in vertebrates and some other animals. It has a wide range of functions, including detoxification, protein synthesis, and production of biochemicals necessary for digestion...
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 colonTransverse colonThe transverse colon, the longest and most movable part of the colon, passes with a downward convexity from the right hypochondrium region across the abdomen, opposite the confines of the epigastric and umbilical zones, into the left hypochondrium region, where it curves sharply on itself beneath...
) - Gastric separation
- "Buried bumper syndrome" (the gastric part of the tube migrates into the gastric wall)
Indications
- PEG tube no longer required (recovery of swallow after strokeStrokeA stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
or surgery for laryngeal cancer) - 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 oesophagus 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).