Prevention and Management of Complications of Percutaneous ... · Prevention and Management of...

PRACTICAL GASTROENTEROLOGY • NOVEMBER 200466

INTRODUCTION

Since its introduction in 1980 (1), the use of per-cutaneous endoscopic gastrostomy (PEG) tubeshas increased exponentially. While an estimated

61,000 PEG tubes were placed in 1988, an estimated216,000 are performed annually today, making PEGplacement the second most common indication forendoscopy of the upper gastrointestinal tract (2). Up to

10% of nursing home residents and as many as 1.7%of Medicare patients over the age of 85 years undergogastrostomy (3). As data demonstrating the benefits ofenteral over parenteral nutrition mounts, and ourelderly population grows, we can expect the use ofPEG tubes to continue to rise. However, the placementof a PEG tube is not without its risks. The overall com-plication rate has remained stable over the last 15-20years, ranging from 4% to 23.8% of cases (4–7). Threeto 4% of all cases are affected by major complications,i.e. those that are life threatening and/or require surgi-cal intervention or hospitalization (Table 1) (4,6,8).The more common minor complications occur inbetween 7.4% and 20.0% of cases (Table 2) (4,6,9).

Prevention and Management of Complications of PercutaneousEndoscopic Gastrostomy (PEG) Tubes

NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #22Carol Rees Parrish, R.D., MS, Series Editor

Christopher R. Lynch, M.D., Department of InternalMedicine, University of Utah School of Medicine, SaltLake City, Utah. John C. Fang, M.D., Associate Pro-fessor of Medicine, Division of Gastroenterology,Department of Internal Medicine, University of UtahSchool of Medicine, Salt Lake City, Utah.

The number of patients with PEG tubes continues to rise, and coincident with that rise,more gastroenterologists are being consulted with complications of PEG tubes. Themajority of PEG tube complications are minor, but several have the potential to causesignificant morbidity and even mortality if not recognized and managed correctly. Pre-vention and early identification of PEG complications will reduce morbidity and costsubstantially. Expertise in the management of these complications is critical to the prac-ticing gastroenterologist.

Christopher R. Lynch

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John C. Fang


NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #22

Prevention and Management of Complications of PEG Tubes

While the overall mortality post-PEG placement ishigh due to underlying co-morbidity, the rate of proce-dure-related mortality and 30-day mortality attribut-able to PEG placement itself are extremely low (0% to2% and 1.5% to 2.1% respectively) (6,10–12). Itshould be noted that mortality associated with PEGplacement is significantly higher in hospitalizedpatients (13), patients with diabetes, poor nutritionalstatus, and long-term corticosteroid administration (8).Complication rates of percutaneous gastrostomy tubesplaced endoscopically versus radiologically using flu-oroscopy are similar (14,15).

Enteral nutritional support is indicated for patientswith poor volitional intake, permanent neurologicalimpairment, oropharyngeal dysfunction, short gut syn-drome, and major trauma and burns (16). Generallypatients who meet one or more of these criteria formore than 30 days are candidates for PEG placement.

Absolute contraindications to PEG placement arethe same as those of upper gastrointestinal endoscopyas well as an inability to transilluminate the abdominalwall and appose the anterior gastric wall. Relative con-

traindications include coagulopathy, gastric varices,morbid obesity, prior gastric surgery, ascites, chronicambulatory peritoneal dialysis (CAPD), and neoplas-tic, infiltrative, or inflammatory disease of the gastricor abdominal wall (17).

PROCEDURE-RELATED COMPLICATIONSThe overall success rates for PEG placement are con-sistently reported at 94% to 98% (4,18,19) and com-pare favorably with fluoroscopic placement by a radi-ologist (18,20). The pull and push techniques result insimilar success rates (21). Factors that can lead tounsuccessful PEG placement can include obstructionof pharynx or esophagus, deterioration of the clinicalstatus of the patient intraprocedurally, poor transillu-mination of the abdominal wall, incidental finding ofgastric cancer, and development of hematoma at thegastrostomy site (4). Prior surgery that results in alter-ation of esophageal or gastric anatomy can also lead toa difficult PEG placement (22).

Patients undergoing PEG tube placement are sub-ject to the complications associated with upperendoscopy and sedation. While the rate is low (0.1%),significant morbidity can result from these complica-tions; the most common complications of endoscopyinclude perforation, hemorrhage, and aspiration (23),while sedation carries the risks of hypoxia, aspiration,and hypotension (24,25). It is not documented, but therisks of sedation are likely higher in the more severelydebilitated PEG population.

AspirationUpper gastrointestinal endoscopy is associated with asignificant risk of aspiration. In a report in which 15%of 64 patients had aspiration related to PEG placement,only 2 of the patients had aspiration during the proce-dure while the other 11 did so over the next severalweeks for reasons unrelated to PEG placement (26). Inother reports, aspiration related to the procedure itselfoccurred in 0.3% to 1.0% of cases (4,27). Risk factorsfor intra-procedural aspiration include supine position,sedation, neurological impairment, and advanced age(17). The endoscopist can minimize the risk of thiscomplication by avoiding over-sedation, minimizingair insufflation of the stomach, thoroughly aspirating

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Table 1Major Complications

Complication Frequency References

Aspiration 0.3%–1.0% 4, 27Hemorrhage 0%–2.5% 5, 29, 30Peritonitis 0.5%–1.3% 4, 5Necrotizing fasciitis rare 50–53Death 0%–2.1% 6, 10–12Tumor implantation rare 67–70

Table 2Minor Complications

Complication Frequency References

Ileus 1%–2% 4, 27Peristomal infection 5.4%–30% 39–41Stomal leakage 1%–2% 54Buried bumper 0.3%–2.4% 4, 56, 57Gastric ulcer 0.3%–1.2% 4, 29, 31, 60Fistulous tracts 0.3%–6.7% 71Inadvertent removal 1.6%–4.4% 4, 60, 61

the gastric contents before the procedure, and perform-ing the procedure efficiently (17). Demortier, et al (28)have reported promising results using an unsedatedtransnasal approach to PEG placement, using a small-diameter endoscope, to lower the risks of aspiration.

BleedingAcute bleeding during PEG placement is an uncommoncomplication, occurring in approximately 1% of cases(5,29,30). A review of 1338 patients reported that lessthan 0.5% of cases are complicated by hemorrhagerequiring transfusion and/or laparotomy (31). Risk fac-tors include anticoagulation and previous anatomic alter-ation (32). A case of fatal retroperitoneal hemorrhagebelieved to be associated with surgically altered anatomyhas been reported (33). The development of a hematomaat the PEG site complicates roughly 1% of cases (5).

Perforation of Viscera/PeritonitisComplete laceration of the stomach, small bowel, orcolon is a potentially catastrophic complication occur-ring in 0.5% to 1.3% of cases (4,5). It is recognized,however, that transient subclinical pneumoperitoneumoccurs during PEG placement in as many as 56% ofprocedures and is generally not of any clinical signifi-cance (34). Peritonitis, manifested in the post-PEGpatient as abdominal pain, leukocytosis, ileus, andfever, can result in significant morbidity if not identi-fied and treated early (35). The prevalence of persis-tent subclinical pneumoperitoneum limits the utility ofplain films for evaluation of suspected peritonitis.Therefore fluoroscopic imaging of the PEG tube withinfusion of water-soluble contrast is most useful toevaluate visceral integrity in patients in whom peri-tonitis is a consideration (36). If active leakage of con-trast is identified in a patient with clinical signs of peri-tonitis, broad-spectrum antibiotics and surgical explo-ration are usually indicated.

Prolonged IleusIt has been established that tube feedings may begin assoon as 3 hours after PEG placement (37). However, in1%–2% of cases prolonged ileus may follow PEGplacement, and should be managed conservatively (4).

Acute gastric distension post-PEG placement can bedecompressed by simply uncapping the PEG tube (38).

POST-PROCEDURE COMPLICATIONSThe PEG site should be cleaned with mild soap andwater—hydrogen peroxide should not be used as it canirritate the skin and contribute to stomal leaks. Cut drainsponges should be placed over, rather than under, theexternal bumper so as not to apply excessive tension tothe PEG site. Occlusive dressings should not be used asthey can lead to peristomal skin maceration and break-down. Should excessive granulation tissue develop atthe PEG site, topical silver nitrate can be applied toreduce irritation and decrease drainage (Figure 1).

PEG Site InfectionThe most common complication of PEG placement isinfection at the PEG site. As many as 30% of cases arecomplicated by peristomal wound infection (39–41),however more than 70% of these are minor with lessthan 1.6% of stomal infections requiring aggressivemedical and/or surgical treatment (42). Patients withdiabetes, obesity, poor nutritional status, and those onchronic corticosteroid therapy are at increased risk forinfection (43). Excessive pressure between the PEG’sexternal and internal bolsters is associated with ahigher infection rate—thus setting and maintaining theproper tension can decrease the likelihood of infection.Loose contact of the outer bolster with the skin is allthat is required to appose the gastric and abdominalwall. The introducer technique that does not pull thePEG tube through the oropharynx has been shown toresult in fewer infections compared to the pull or pushtechniques (44,45).

The administration of prophylactic antibioticsprior to PEG placement reduces the risk of infection.Several trials have demonstrated the benefit of a sin-gle, broad-spectrum antibiotic immediately prior toPEG placement (42,46–48). The use of prophylacticantibiotics is cost-effective as well (49). It is generalpractice to administer a single dose of a first or thirdgeneration cephalosporin 30 minutes prior to the pro-cedure. Prophylaxis is not necessary in those patientsalready receiving comparable antibiotics for other rea-

PRACTICAL GASTROENTEROLOGY • NOVEMBER 2004 69



sons at the time of PEG placement. An adequate skinincision, 1–2 mm larger than the feeding tube, whichcan allow egress of bacteria and gastric secretions,may also reduce infection risk. If diagnosed early, oralbroad-spectrum antibiotics for 5–7 days may be all thatis required for a PEG site infection. If there are moresystemic signs, intravenous broad-spectrum antibioticscoupled with local wound care are necessary. Shouldthe patient with local site infection develop signs ofperitonitis, surgical intervention may be required.

A rare but potentially life threatening complicationis the development of necrotizing fasciitis. Patientswith diabetes mellitus, chronic renal failure, pul-monary tuberculosis, and alcoholism appeared to be atenhanced risk (50–53). Management consists of broad-spectrum intravenous antibiotics and aggressive surgi-cal debridement.

PEG Site Leakage/IrritationLeakage of tube feeding formula and/or gastric con-tents around the PEG site can be a significant manage-ment problem, and small amounts likely occur morefrequently than the 1%–2% reported in the literature(54). Risk factors include infection of the site,increased gastric acid secretion, excessive cleansingwith hydrogen peroxide, buried bumper syndrome, sidetorsion on the PEG tube, and the absence of an externalbolster to stabilize the tube (55). Evaluation of a leak-ing PEG site should include examination for evidence

of infection, ulcera-tion, or a buriedb u m p e r. Should thepatient not be onacid suppression,proton pumpinhibitor therapyshould be started.Side torsion result-ing in ulcerationand enlargement ofthe tract may becorrected with aclamping device tostabilize the tube( Vertical drain/tube

attachment device, Hollister, Inc., Libertyville, IL). Thesame result may also be accomplished by replacing thePEG with a low profile button device. Some practition-ers replace the gastrostomy tube with a larger one, butthis is usually ineffective and can result in continuedleakage around an even larger stoma (36).

After the primary cause of the stomal leakage hasbeen addressed, stoma adhesive powder or zinc oxidecan be applied to the site to prevent local skin irritation(Figure 2). Foam dressing rather than gauze can helpto reduce local skin irritation caused by gastric con-tents (foam lifts the drainage away from the skin whilegauze tends to trap it). Local fungal skin infectionsmay also be associated with leakage and can be treatedwith topical antifungals. Ostomy nurses are an invalu-able resource in the management of leaking PEG sitesand often are the primary caretakers in this setting. Inrefractory cases, the PEG tube must be removed forseveral days to allow the stoma to approximate thetube more closely, and occasionally the tube must beremoved and a repeat PEG placed at a new site.

Buried Bumper SyndromeBuried bumper syndrome refers to the clinical pictureresulting from the partial or complete growth of gastricmucosa over the internal bolster, or bumper, and occursin 0.3% to 2.4% of patients with PEG (4,56,57). Thebumper may migrate through the gastric wall and may




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Figure 1. Granulation tissue around PEG.(Reprinted with permission from McClave andChang, Gastrointest Endosc 2003;58:739-51.)

Figure 2. Local irritation and corrosion aroundPEG site. (Reprinted with permission fromMcClave and Chang, Gastrointest Endosc2003;58:739-51.)




cally or radiographically. A gastrografin study should be per-formed with the patient prone, as radiocontrast appears tosafely pass through the imbedded bumper into the gastriclumen by gravity when the patient is supine. Buried bumpersshould be removed by any one of a number of methods (Fig-

ure 4). The key principle is touse a technique that minimizestrauma to the PEG tract. If thebumper is completely coveredby gastric mucosa, electrosurg i-cal incisions may be necessaryto access and remove thebumper endoscopically (59).

Gastric Ulcer/HemorrhageBleeding that occurs after PEGplacement is reported to compli-cate 0.3%–1.2% of cases (4,29,31,60). It is typically caused bypeptic ulcer disease, traumatic

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Figure 3. External and internal views of buried bumpersyndrome. (Reprinted with permission from McClaveand Chang, Gastrointest Endosc 2003;58:739-51.)

Figure 5. Excessive side torsion on PEG causing ulceration. (Reprinted with permissionfrom McClave and Chang, Gastrointest Endosc 2003;58:739-51.)

Figure 4. Techniques for managing buried bumper syndrome. A-The tapered tip of a push-type PEG engages the embedded PEG.B-The replacement PEG is pulled into position while removing theburied PEG out through the abdominal wall. C-Radial incisions aremade in the gastric mucosa covering the dome of the PEG using aneedle-knife. D-A balloon dilates the tract over a guidewire. E-Asnare is used for the push-pull T technique. (Reprinted with per-mission from McClave and Chang, Gastrointest Endosc 2003;58:739-51.)

lodge anywhere along the PEG tract (Figure 3).Buried bumper syndrome typically presents withperitubal leakage or infection, an immobilec a t h e t e r, or abdominal pain or resistance with for-mula infusion. A case of significant gastrointesti-nal bleeding secondary to buried bumper has beenreported (58). Risk factors leading to buriedbumper syndrome include excessive tensionbetween the internal and external bolsters, malnu-trition, poor wound healing, and significant weightgain secondary to successful enteral nutrition (55).The buried bumper may be confirmed endoscopi-




erosion of the gastric wall opposite the internal bolster,or ulceration beneath the internal bolster. To reduce riskof ulcerations at the gastrostomy site, excessive lateraltraction on the tube should be avoided (Figure 5). Inpost-PEG patients with upper gastrointestinal bleeding,endoscopy is tolerated well. During endoscopy, themucosa under the internal bolster should be visualizedby externally manipulating the PEG (35).

Fistulous TractsFistulae connecting the stomach, colon, and skin areuncommon but potentially disastrous complications ofPEG placement. Gastrocolocutaneous fistulae may occurwhen the colon is inadvertently punctured and traversedduring PEG placement or less commonly with subse-quent erosion of the tube into juxtaposed colon (Figure6). Patients may present acutely with colonic perforationor obstruction. More commonly, patients present chroni-cally with stool leaking around the PEG tube and diar-rhea resembling formula. Another typical presentation iswhen a colocutaneous fistula results from a replacementPEG that is advanced through a previously created gas-trocolocutaneous fistula and stops in the colon. A feed-ing tube misplaced into the colon may be identified radi-ographically (Figure 7). Management consists of remov-ing the tube and allowing the fistula to close. Should thepatient develop signs of peritonitis or the fistula fail toclose, surgery is often required. Prevention is para-mount—Foutch recommends elevation of the head ofthe bed during placement to displace the colon inferiorly.A d d i t i o n a l l y, the use of an aspirating syringe filled withsaline can identify intervening bowel between the skinand the stomach if air bubbles appear in the syringe priorto endoscopic visualization of the needle in the gastriclumen (“the safe track technique”) (35).

Inadvertent RemovalAccidental PEG tube removal occurs 1.6% to 4.4% ofthe time (4,60,61). PEG tract maturation usually occurswithin the first 7–10 days but may be delayed up to 4weeks in the presence of malnutrition, ascites, or corti-costeroid treatment. A PEG tube that is accidentallyremoved during this period should be replaced endo-s c o p i c a l l y, as the tract may be immature and the stom-

ach and anterior abdominal wall can separate from eacho t h e r, resulting in free perforation. If recognized imme-d i a t e l y, a new PEG tube may be placed through, or near,the original PEG site, sealing the stomach against theanterior abdominal wall. If recognition is delayed, man-agement consists of nasogastric suction, broad-spec-trum antibiotics, and repeat PEG placement in 7–10days. Surgical exploration is reserved for patients withsigns of decompensation or peritonitis. After stoma tract

Figure 6. Gastrocolocutaneous fistula creation by passageof trocar through loop of colon prior to entering the stom-ach. (Reprinted with permission from McClave, Tech Gas -trointest Endosc 2001;3:62-8.)

Figure 7. Contrast study demonstrating gastrocolocuta-neous fistula, as contrast infused through the PEG appears inthe colon.


maturation (generally >2–4 weeks) a replacement tubecan be placed at the bedside without endoscopy. Balloon-type replacement PEGs have two ports—onefor feeding and the other for inflating an internal balloonthat acts as an internal bolster. A non-balloon-typereplacement, which has a soft internal dome instead of aballoon, is an alternative. This type of replacementdevice tends to function longer, a fact attributable tobreakage of the balloons in the balloon-types (62).

In patients prone to pulling at tubes, an abdominalbinder can secure the PEG tube in place. Also considercutting the tube down to 6–8 inches to decrease thelikelihood that the tube is inadvertently caught onanother object. Finally, an initial placement low profiledevice (button) may be beneficial.

Low profile PEG buttons, which lay flush with theskin, can reduce the risk of future inadvertent removal.

Like the replacement PEG tubes, the internal “bolster”can be either a balloon or a soft dome. Either can beplaced at the bedside. PEG buttons are of fixed length,so prior to placement, a measuring device is carefullyinserted into the tract so as not to risk damage to thetract. Also as a patient gains weight, the tension on thebolsters can increase. Replacement PEGs or PEG but-tons should be confirmed radiographically or endoscop-ically if there is any concern for incorrect placement.

Fungal Tube InfectionFungal colonization and/or infection of PEG tubesmay lead to tube degradation and failure. This long-term complication of PEG tubes has been reported tocause up to 70% tube failure by 450 days. Histologicstudies have demonstrated actual fungal growth into



Procedure Related ComplicationsAspiration• Avoid over-sedation• Minimize air insufflation• Perform procedure efficientlyBleeding• Correct coagulopathy • Consider any alteration of anatomy secondary to prior

surgeryPerforation• Early recognition• Consider any alteration of anatomy secondary to prior

surgeryProlonged ileus• Wait 3–4 hours before beginning feeding post-PEG

placement• If gastric distension occurs, uncap the PEG tube for

easy decompression

Post Procedure ComplicationsCare of PEG site• Use mild soap and water—NOT hydrogen peroxide• Place drain sponges over, not under, external

bumper• Avoid the use of occlusive dressings

• For excessive granulation tissue, topical silver nitratemay be beneficial

PEG site infection• Prophylactic antibiotics• Adequate preoperative skin sterilization• Consider introducer technique• Set/maintain proper tension between internal and

external bolstersPEG site leakage/irritation• Prevent infection• Avoid local administration of hydrogen peroxide• Prevent excessive side torsion on the PEG tubeBuried Bumper Syndrome• Avoid excessive tension between internal and external

bolsters• Account for nutritional weight gainGastric ulceration• Acid suppression• Avoid lateral traction on the tubeFistulous tracts• Elevate the head of the bed during placement• Utilize the “safe track technique”Inadvertent removal• Consider use of an abdominal binder• Utilize low profile button at initial placement

Table 3 Summary Guidelines to Avoid Complications Associated with PEG Placement

the tube wall leading to brittleness, dilation and crack-ing with eventual puncture of the tube (63). No treat-ment has shown to be useful, but polyurethane initialplacement and replacement devices may be more resis-tant to fungal infection (64,65).

Tumor Implantation at PEG SitePlacement of prophylactic gastrostomy feeding tubesin patients with head and neck cancer has been shownto be beneficial (66). However, implantation of headand neck cancer at the stoma site has been reported in25 cases between 1989 and 2002 (67), and should besuspected in patients with head and neck cancer whodevelop unexplained skin changes at the PEG site. Themechanism of implantation is most likely direct seed-ing of tumor at the PEG site after the tube shears tumorcells as it passes through the aerodigestive tract (68). Itis reasonable in these patients to consider using theintroducer technique, in which the PEG is placeddirectly through the abdominal wall. However,implantation has also been reported after open gastros-tomy with no manipulation of the tumor by the PEGtube (69). Should a patient develop tumor at the gas-trostomy site, no treatment is usually given, but pallia-tive radiotherapy has been reported in one case (70).See Table 3 for a summary of suggested guidelines.

SUMMARYThe PEG tube is an important tool in the armamentar-ium of the gastroenterologist. While very safe and welltolerated, it is not without its complications. It is vitalthat gastroenterologists minimize complications ofPEG placement by utilizing optimal technique duringplacement and appropriate post-placement care. Whencomplications do arise, early recognition and aggres-sive management are essential to optimize outcomes. ■

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