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EASING FEEDING FOR PATIENTS BY USING PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

21 October 2020

EASING FEEDING FOR PATIENTS BY USING PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Feeding Gastrotomy

A tube is placed into the stomach through the abdominal wall for feeding purposes. Proper adequate nutrition is of utmost importance for the recovery of immuno-compromised, bedridden, cancer, stroke, or neurological patients who are unable to tolerate by mouth.

What is a Percutaneous Endoscopic Gastrostomy (PEG) and how it performed?

PEG is an acronym for Percutaneous Endoscopic Gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach under the vision thru a Gastroscope.

Endoscopic Technique

Types of Gastrostomy tubes : 

They can be as simple self retaining tubes  to expensive tubes/button.

What is the process?

Feeding G-Tube can be inserted through the skin of abdominal wall into the stomach, and a thin feeding Jejunal tube will be inserted into the small intestine through the G-tube. This can be done through open surgery; Laparoscopic, Endoscopic and Radiological guidance.

Who benefits from a PEG?

Patients of any age who cannot tolerate oral feeding, from a small baby to an old age person.

  1. Unable open mouth.
  2. Difficulty in swallowing /risk of aspirations into lungs due to stroke/cancer.
  3. Problems with their appetite due to neurological disease.
  4. Inability to take adequate nutrition through the mouth.
  5. Cancers of head /neck.
  6. Narrowing of upper digestive system.

What is the purpose of a feeding tube?

Feeding Gastrostomy tube or PEG allows feeding adequate nutrition, fluids, and medications to be put directly into the stomach, bypassing the mouth and esophagus of patients who are unable to swallow due to stroke, brain disease/cancer in upper digestive system and etc.

Is Anesthesia required?

Yes, patients are to be under local anesthesia IV sedation and IV antibiotic. Some may require general anesthetic care to protect the lungs of the patient during the procedure.

When can patients be discharged?

Patients can usually go home within the same day or the next day after the procedure.

When can feeding be started?

Feeding starts after six hours once no procedure-related complications are noted. Feeding can begin with clear fluids in small quantity. Within 24 hours, if no evidence of complications, dietitian prescribed nutrition can be started.

Are there any complications from PEG placement?

  1. Pain at the PEG site are not very significant as the tube is made of soft and human friendly material.
  2. Leakage of stomach contents around the tube area.
  3. Dislodgment or malfunction of the tube. So accidental dislodgment requires immediate attention.
  4. Aspiration (inhalation of gastric contents into the lungs) the risk is less than nasogastric tube.
  5. Bleeding around the tube or inside are very infrequent.
  6. Perforation (an unwanted hole in the bowel wall) requires open or laparoscopic surgery.
  7. Wound Infection of the PEG area.
  8. Patients on steroids/immuno-compromised are prone for bacterial & fungal Infection and may require antibiotics for a few days.

How Long a PEG tube can last?

Can be temporary or permanent. PEG tubes can last for months or years. However, because they can break down or become clogged over extended periods, they might need to be replaced. It can be easily removed or replaced with or without sedatives or anesthesia.

How to take  care of the PEG tube?

A dressing will be placed on the PEG site following the procedure. This dressing is usually removed after one or two days. Once wound is dry and no leak or discharge, clean the area once a day with diluted soap and water and keep the site dry between cleansings. Use cotton swab /gauze to clean. Rotate and clean under the bolster. No special dressing or covering is needed. Special colloidal/foam dressings are patient friendly.

When and how patients can shower:

The patient can shower after three days if the wound is minimal and waterproof dressings are used. Supposed any suturing is done, it would be safe after two weeks.

How are feedings given?

Can patient still eat and drink?

Preferably liquid nutrition, as well as fluids, are given through the PEG tube. If the PEG tube is placed because of swallowing difficulty (e.g., after a stroke) there will still be restrictions for oral intake.

Although a few PEG patients may continue to eat or drink after the procedure, this is a very important issue to discuss with your physician.

Position while Feeding

  1. Sitting -upright
  2. 30 degree up

Syringe feeding method

  1. Aspirate the G-Tube with feeding syringe to know the amount of Stasis.
  2. Feed if aspiration is less than 30cc.
  3. Flush tube with 30-50 ml of Warm water. Before & after feed
  4. Hold the syringe upright and pour the formula into the syringe.
  5. Refill the syringe as the formula reaches the bottom of the syringe, no air allowed in the tube.
  6. Repeat the process until the prescribed amount of formula is given
  7. Flush the tube with 10-30ml of Warm water.
  8. Lock the Tube & close all the adapters of the G-tube or button.
  9. Medications are dissolved in 30-50°C warm water. Push through flushing port/universal adapter & re flush with 30ml of warm water, lock and close the adopters.

Be Aware of:

  1. Leak
  2. Pain
  3. Redness
  4. Swelling
  5. Any Pus
  6. Any Fever
  7. If doubt contact the healthcare worker

Trouble shooting

  • The tube comes out
  • The tube is blocked
  • Vomiting
  • Fever above 100.4°F (38.0°C) or higher, or as directed by your provider
  • Diarrhea that lasts more than 2 days
  • Signs of infection (redness, swelling, or warmth at the tube site)
  • Drainage from the tube site

Care of mouth

  • Oral hygiene by frequent mouth wash very important as in a normal person.
  • Brushing teeth, gums & cleaning tongue
  • Lips moistened with water/moisturizing lotion/lip-balms

Stomach upset

  • Feel of Vomiting sensation – wait for 30 minutes and retry feeding.
  • Vomiting – wait for 30 minutes and retry feeding.
  • Try dilute formula.
  • Feed slowly between 10-20 min
  • If still Vomiting STOP feeding
  • If Vomiting occurs even after 24 hours, immediately contact your consultant.

Aspiration

Means Inhaling food pieces into Lungs (Airways). Burping up small amount of food can cause aspiration in to lungs.

If patient Chokes/Difficulty to feed, stop feeding. Put the patient upright position and suck-clear the throat and contact healthcare worker or go to hospital A&E department immediately.

How to close?

After simple removal of the PEG tube, the hole closes by itself. PEG sites close quickly once the tube is removed. Simple dressings are required for the first few days.

Article By: Dr. Anantha Kumar Chinnaswamy,

Consultant General & Endo-Laparoscopic Surgeon