Percutaneous Endoscopic Gastrostomy - Indications, Contraindications, and Procedure

Introduction:

Dysphagia, the difficulty in swallowing foods and liquids, occurs in people in the throat or esophagus. This can range from mild to moderate, and sometimes, it can block the passage of food completely. Sometimes individuals are unable to swallow food due to coughing, choking while eating or drinking, or bringing back food up occasionally through the nose. Individuals with certain systemic conditions also face dysphagia. Percutaneous endoscopic gastrostomy helps in all the above conditions to provide adequate nutrition to the required individual.

What Is Percutaneous Endoscopic Gastrostomy (PEG)?

Percutaneous endoscopic gastrostomy is a type of enteral feeding in cases of difficulty swallowing and conditions where the individual fails to receive nutrition through the mouth and needs enteral nutrition. In this state, surgery is performed to place a feeding tube. These feeding tubes (PEG tubes or G tubes) allow the absorption of nutrition from the stomach. This medical procedure is called percutaneous endoscopic gastrostomy.

Who Is Often in Need of Percutaneous Endoscopic Gastrostomy?

Individuals who are suffering from dysphagia (difficulty in swallowing) or conditions that lead to dysphagia need percutaneous endoscopic gastrostomy. Conditions like:

• Stroke.

• Head and neck injury.

• Brain injury.

• Chronic appetite loss due to severe illness like cancer.

• Individuals also get benefits in conditions of cystic fibrosis or dialysis in kidney failure.

• Individuals in the condition of coma may receive percutaneous endoscopic gastrostomy to receive nutrition and be alive.

What Is Done Prior to Percutaneous Endoscopic Gastrostomy?

Before the procedure starts, your health care provider will consult with you regarding your medical conditions related to the heart, medical allergies, or bleeding disorders. Depending on your medical history and underlying conditions, some medical adjustment is required. The changes and restrictions are made like insulin dosage, NSAIDs (nonsteroidal anti-inflammatory drugs) like Aspirin, and blood thinners like Warfarin. Avoid eating or drinking at least eight hours before the procedure.

What Is the Procedure Done for Percutaneous Endoscopic Gastrostomy?

Percutaneous endoscopic procedures are placed using a small incision. A long flexible instrument, an endoscope, is used. Before the procedure, IV (intravenous) anesthesia and antibiotics (to prevent infection) are administered, which will make the individual numb during the procedure. Along with it, you may also receive local anesthesia.

After that, a small incision is made in the upper abdomen. Placing the tube through the incision is done, connecting the tube to the stomach. Occasionally contrast is injected via the PEG to determine the position, called a PEGogram. This entire procedure takes around 30 to 20 minutes. Usually, the patient can return home the same day or the next morning.

What Happens After the Procedure of Percutaneous Endoscopic Gastrostomy?

Pain persists after percutaneous endoscopic gastrostomy. This pain may be a result of the incision made for the tube placement or cramps due to the gas build-up in the digestive tract. This pain may subside within 24 to 48 hours. Some drainage around the site of incision is noticed till 48 hours. A bandage is placed over the site of the incision. The health care provider will instruct you regarding the removal of the bandage, which may probably be within two days.

You will have a session with the dietician, who will guide you on using the PEG tube and how to get started on internal nutrition.

How Long Does Percutaneous Endoscopic Gastrostomy Last?

Percutaneous endoscopic gastrostomy lasts for months or years. In cases of any breakdown or clogging over extended periods of time, the tubes need to be replaced, and health care providers may remove and replace the tube without sedation, but in rare cases, sedation is required. The provider may remove the tube using firm traction and insert a new tube. In cases of new tube replacement, the opening closes on its own. The percutaneous endoscopic gastrostomy site closes quickly on its own, so immediate attention is required in cases of accidental dislodgement.

What Are the Indications of Percutaneous Endoscopic Gastrostomy?

• Percutaneous endoscopic gastrostomy is indicated in conditions in which normal nasogastric feeding is not possible. Conditions like stroke, cleft lip, palate, and tumors of the head and neck.

• In advanced dementia (a condition affecting memory thinking capacity that severely interferes with daily life activities), percutaneous endoscopic gastrostomy does not result in prolonged life. Instead, oral assisted feeding is preferred. In patients with malignant bowel obstruction, venting PEG is used and is placed to prevent nausea and vomiting.

• Gastrostomy can be used to treat the volvulus of the stomach when the stomach twists along one of its axes.

What Are the Contraindications of Percutaneous Endoscopic Gastrostomy?

Care must be taken while the placement of the PEG tubes. The contraindications of the usage of percutaneous endoscopic gastrostomy are:

Absolute Contraindications:

• Peritonitis (inflammation of the peritoneum- inner abdominal wall).

• Uncorrected coagulopathy.

• Untreatable massive ascites.

• Inability to perform an esophagogastroduodenoscopy.

• Bowel obstruction.

Relative Contraindications:

• Gastric wall neoplasm.

• Massive ascites.

• Infection of the abdominal wall.

• Gastric mucosal abnormalities, large gastric varices.

• Portal hypertensive gastropathy.

• Previous abdominal surgery along with partial gastrectomy.

• Morbid obesity.

• Intra-abdominal malignancy with peritoneal involvement.

What Are the Complications of Percutaneous Endoscopic Gastrostomy?

The complications of percutaneous endoscopic gastrostomy are:

• Hemorrhage.

• A gastric ulcer on the site or on the opposite wall of the stomach is also known as a kissing ulcer.

• Perforation of the bowel leads to peritonitis.

• Infection at the site of surgery around the gastrostomy site. Intravenous antibiotics can reduce infection around the gastrostomy site.

• A puncture on the left lobe of the liver leads to liver capsule pain.

• Gastric separation.

• The gastric part of the tube migrates into the gastric wall- buried bumper syndrome (caused due to overgrowth of gastric mucosa over the inner bumper of gastrostomy tubes).

• Gastrocolic fistula (rare presentation of malignant and benign gastric conditions).

How to Take Care of Percutaneous Endoscopic Gastrostomy Site?

Drainage sound at the site of the PEG tube is common in the initial one or two days. The area around heals in two to three weeks.

• You need to clean the skin around the tube one to three times a day. Use mild soap or saline water along with a cotton swab or gauze.

• Gently remove any drainage or crusting over the skin and tubes. Do not pull the tube on your own and prevent it from being pulled.

• Dry the skin with a clean towel or gauze. Avoid bulky dressings, and do not put the gauze under the disc.

• Do not use any kind of ointments, sprays, or powders around the tubes. Consult your provider and ask whether it is okay to shower or to take a bath.

When to Contact Your Health Care Provider in Cases of Percutaneous Endoscopic Gastrostomy?

You should contact your health care provider if you have the following issues:

• Redness or irritation on the skin surface around the tube.

• Leakage around the tube or system.

• If the PEG tube is blocked.

• Any signs of bleeding from the tube insertion site.

• Diarrhea after feedings.

• Worsening pain.

• Hard and swollen belly even after one hour after feeding.

• Feeling constipated, passing hard and dry stools.

• Coughing more than usual or feeling of shortness of breath.

Conclusion:

Percutaneous endoscopic gastrostomy permits fluids, nutrition, and medications directly into the stomach by passing through the mouth and esophagus, which is typically performed on patients who are unable to eat or drink directly or consume nutrition orally. It is necessary to imagine complications associated with percutaneous endoscopic gastrostomy soon after insertion or later. Most of the time, complications are associated with displacement, including buried bumper syndrome.