Percutaneous Endoscopic Gastrostomy (PEG) Tube

What Is It?

A PEG tube is a semi-permanent enteral feeding tube placed through the anterior abdominal wall directly into the stomach under endoscopic guidance. It is indicated when specialized nutritional support is required for >4 weeks — compared to nasogastric/nasoenteric tubes (ENETs), which are preferred for shorter durations.

Indications

Neurological dysphagia (stroke, ALS, Parkinson's)
Head and neck malignancy
Prolonged mechanical ventilation / critical illness
Severe burns or trauma
Gastric decompression (e.g., gastroparesis, gastric volvulus — two PEG tubes used to prevent rotation)

Pre-Procedure

Antibiotic prophylaxis: Single dose of a third-generation cephalosporin at time of placement (since an incision is made)
Anticoagulation: Aspirin does not need to be stopped. Warfarin → switch to LMWH 1 week prior (hold morning dose). Clopidogrel may continue with added precautions (epinephrine added to local anesthetic for vasoconstriction; external bolster set more firmly)
Site planning: Injecting 500 mL of air via NG tube + abdominal film (with coin at umbilicus as landmark) helps identify the stomach location and select the ideal site

Site Selection

Traditional site: Left upper quadrant (vortex of midline and left costal margin)
Preferred site: Just above or slightly right of the umbilicus, in the gastric antrum — this provides the shortest, most perpendicular tract and facilitates later conversion to a PEG-J (jejunostomy) if gastric feeding becomes intolerable
Confirmed by transillumination and finger palpation (the endoscopist must visualize the indentation from inside)
If neither transillumination nor palpation confirms a safe site, the procedure must be abandoned

Placement Techniques

1. Pull Technique (Ponsky) — ~90% of PEGs

Endoscope advanced into stomach; site identified
Skin incision made; trocar inserted into stomach under direct visualization
A double-stranded wire loop passed through the trocar and snared
Endoscope + wire withdrawn through the mouth
Feeding tube loop attached to wire ("blue through" — blue double wire passed through silver loop of tube)
Wire pulled from abdomen, drawing the tube down through the esophagus and out the abdominal wall
Internal bumper seats against gastric wall; external bumper placed snugly (but not tightly)

2. Push Technique (Sachs-Vine)

Virtually identical; uses a single-stranded wire and a plastic-tipped feeding tube that is pushed (not pulled) over the wire

3. Russell Introducer Technique

Preferred for patients with oropharyngeal/esophageal malignancy to avoid tumor seeding of the tract
Uses Seldinger technique, T-fasteners to fix the stomach to the abdominal wall, and a peel-away sheath with balloon-tip tube — the tube never passes through the tumor

Post-Procedure Care

External bolster: must allow a gloved index finger to slip between bumper and skin — too tight → pressure necrosis, buried bumper syndrome, site infection, leakage
Feedings can begin 4 hours after placement
Dressing: split 4×4 gauze placed around (not under) the external bolster; changed daily
Tube length: trim to ~13–15 cm (also accommodates jejunal extension tube if needed)
Document the tube's position number on the external bolster in the medical record

Complications

Endoscopy-Related

Aspiration, hypoxemia, hypotension, hemorrhage, esophageal perforation (primarily sedation-related)

Direct PEG Complications

Complication	Details
Wound infection	Most common; treat with local care ± antibiotics
Peritonitis	Rare; requires surgical evaluation
Inadvertent colon/bowel perforation	Prevented by safe-tract technique (saline bubble test with 22-gauge spinal needle)
Hemorrhage	Avoided by visual inspection of abdominal wall vessels
Tumor seeding	Abdominal wall metastasis — use Russell technique in head/neck malignancy

Post-Procedure Complications

Complication	Details
Buried bumper syndrome	Internal bumper erodes into gastric wall from excessive tension
Pressure ulcer / necrosis	Over-tight external bolster
Leakage around site	Infection, necrosis, or too-loose fit
Necrotizing fasciitis	Rare but life-threatening; caused by tube pressure and infection
Tube dislodgement (< 4 weeks)	Tract not mature → surgical/endoscopic urgency
Tube dislodgement (≥ 4 weeks)	Mature tract — can replace at bedside promptly before closure

Survival Context

PEG placement itself carries significant perioperative mortality in the target population: ~5.6% die within 7 days, ~22% at 30 days, ~48% at 1 year. PEG placement does not significantly alter survival — informed consent must address both technical risks and the natural course of the underlying disease.

PEG-J and Direct Jejunostomy (DPEJ)

A jejunal extension tube (PEG-J) can be advanced through the PEG, past the pylorus and ligament of Treitz — minimizes aspiration risk in patients with gastroparesis or reflux
Antral PEG site selection facilitates this conversion
DPEJ (direct percutaneous endoscopic jejunostomy) places the tube directly into the jejunum without a gastric component

— Pfenninger and Fowler's Procedures for Primary Care, 3rd ed. | Clinical Gastrointestinal Endoscopy, Expert Consult 3e

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