Prevention and Management of Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes

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NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #22 Carol Rees Parrish, R.D., MS, Series Editor Prevention and Management of Complications of Percutaneous Endoscopic Gastrostomy (PEG) Tubes

Christopher R. Lynch John C. Fang

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. The majority of PEG tube complications are minor, but several have the potential to cause significant morbidity and even mortality if not recognized and managed correctly. Pre- vention and early identification of PEG complications will reduce morbidity and cost substantially. Expertise in the management of these complications is critical to the prac- ticing gastroenterologist.

INTRODUCTION 10% of nursing home residents and as many as 1.7% ince its introduction in 1980 (1), the use of per- of Medicare patients over the age of 85 years undergo cutaneous endoscopic gastrostomy (PEG) tubes gastrostomy (3). As data demonstrating the benefits of Shas increased exponentially. While an estimated enteral over parenteral nutrition mounts, and our 61,000 PEG tubes were placed in 1988, an estimated elderly population grows, we can expect the use of 216,000 are performed annually today, making PEG PEG tubes to continue to rise. However, the placement placement the second most common indication for of a PEG tube is not without its risks. The overall com- endoscopy of the upper gastrointestinal tract (2). Up to plication rate has remained stable over the last 15-20 years, ranging from 4% to 23.8% of cases (4–7). Three to 4% of all cases are affected by major complications, Christopher R. Lynch, M.D., Department of Internal Medicine, University of Utah School of Medicine, Salt i.e. those that are life threatening and/or require surgi- Lake City, Utah. John C. Fang, M.D., Associate Pro- cal intervention or hospitalization (Table 1) (4,6,8). fessor of Medicine, Division of Gastroenterology, The more common minor complications occur in Department of Internal Medicine, University of Utah between 7.4% and 20.0% of cases (Table 2) (4,6,9). School of Medicine, Salt Lake City, Utah. (continued on page 68)

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traindications include coagulopathy, gastric varices, Table 1 Major Complications morbid obesity, prior gastric surgery, ascites, chronic ambulatory peritoneal dialysis (CAPD), and neoplas- Complication Frequency References tic, infiltrative, or inflammatory disease of the gastric or abdominal wall (17). Aspiration 0.3%–1.0% 4, 27 Hemorrhage 0%–2.5% 5, 29, 30 Peritonitis 0.5%–1.3% 4, 5 PROCEDURE-RELATED COMPLICATIONS Necrotizing fasciitis rare 50–53 The overall success rates for PEG placement are con- Death 0%–2.1% 6, 10–12 sistently reported at 94% to 98% (4,18,19) and com- Tumor implantation rare 67–70 pare favorably with fluoroscopic placement by a radi- ologist (18,20). The pull and push techniques result in While the overall mortality post-PEG placement is similar success rates (21). Factors that can lead to high due to underlying co-morbidity, the rate of proce- unsuccessful PEG placement can include obstruction dure-related mortality and 30-day mortality attribut- of pharynx or esophagus, deterioration of the clinical able to PEG placement itself are extremely low (0% to status of the patient intraprocedurally, poor transillu- 2% and 1.5% to 2.1% respectively) (6,10–12). It mination of the abdominal wall, incidental finding of should be noted that mortality associated with PEG gastric cancer, and development of hematoma at the placement is significantly higher in hospitalized gastrostomy site (4). Prior surgery that results in alter- patients (13), patients with diabetes, poor nutritional ation of esophageal or gastric anatomy can also lead to status, and long-term corticosteroid administration (8). a difficult PEG placement (22). Complication rates of percutaneous gastrostomy tubes Patients undergoing PEG tube placement are sub- placed endoscopically versus radiologically using flu- ject to the complications associated with upper oroscopy are similar (14,15). endoscopy and sedation. While the rate is low (0.1%), Enteral nutritional support is indicated for patients significant morbidity can result from these complica- with poor volitional intake, permanent neurological tions; the most common complications of endoscopy impairment, oropharyngeal dysfunction, short gut syn- include perforation, hemorrhage, and aspiration (23), drome, and major trauma and burns (16). Generally while sedation carries the risks of hypoxia, aspiration, patients who meet one or more of these criteria for and hypotension (24,25). It is not documented, but the more than 30 days are candidates for PEG placement. risks of sedation are likely higher in the more severely Absolute contraindications to PEG placement are debilitated PEG population. the same as those of upper gastrointestinal endoscopy as well as an inability to transilluminate the abdominal Aspiration wall and appose the anterior gastric wall. Relative con- Upper gastrointestinal endoscopy is associated with a significant risk of aspiration. In a report in which 15% Table 2 of 64 patients had aspiration related to PEG placement, Minor Complications only 2 of the patients had aspiration during the procedure while the other 11 did so over the next several Complication Frequency References weeks for reasons unrelated to PEG placement (26). In Ileus 1%–2% 4, 27 other reports, aspiration related to the procedure itself Peristomal infection 5.4%–30% 39–41 occurred in 0.3% to 1.0% of cases (4,27). Risk factors Stomal leakage 1%–2% 54 for intra-procedural aspiration include supine position, Buried bumper 0.3%–2.4% 4, 56, 57 sedation, neurological impairment, and advanced age Gastric ulcer 0.3%–1.2% 4, 29, 31, 60 (17). The endoscopist can minimize the risk of this Fistulous tracts 0.3%–6.7% 71 Inadvertent removal 1.6%–4.4% 4, 60, 61 complication by avoiding over-sedation, minimizing air insufflation of the stomach, thoroughly aspirating

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the gastric contents before the procedure, and perform- Acute gastric distension post-PEG placement can be ing the procedure efficiently (17). Demortier, et al (28) decompressed by simply uncapping the PEG tube (38). have reported promising results using an unsedated transnasal approach to PEG placement, using a small- diameter endoscope, to lower the risks of aspiration. POST-PROCEDURE COMPLICATIONS The PEG site should be cleaned with mild soap and Bleeding water—hydrogen peroxide should not be used as it can irritate the skin and contribute to stomal leaks. Cut drain Acute bleeding during PEG placement is an uncommon sponges should be placed over, rather than under, the complication, occurring in approximately 1% of cases external bumper so as not to apply excessive tension to (5,29,30). A review of 1338 patients reported that less the PEG site. Occlusive dressings should not be used as than 0.5% of cases are complicated by hemorrhage they can lead to peristomal skin maceration and break- requiring transfusion and/or laparotomy (31). Risk fac- down. Should excessive granulation tissue develop at tors include anticoagulation and previous anatomic alter- the PEG site, topical silver nitrate can be applied to ation (32). A case of fatal retroperitoneal hemorrhage reduce irritation and decrease drainage (Figure 1). believed to be associated with surgically altered anatomy has been reported (33). The development of a hematoma at the PEG site complicates roughly 1% of cases (5). PEG Site Infection The most common complication of PEG placement is Perforation of Viscera/Peritonitis infection at the PEG site. As many as 30% of cases are Complete laceration of the stomach, small bowel, or complicated by peristomal wound infection (39–41), colon is a potentially catastrophic complication occur- however more than 70% of these are minor with less ring in 0.5% to 1.3% of cases (4,5). It is recognized, than 1.6% of stomal infections requiring aggressive however, that transient subclinical pneumoperitoneum medical and/or surgical treatment (42). Patients with occurs during PEG placement in as many as 56% of diabetes, obesity, poor nutritional status, and those on procedures and is generally not of any clinical signifi- chronic corticosteroid therapy are at increased risk for cance (34). Peritonitis, manifested in the post-PEG infection (43). Excessive pressure between the PEG’s patient as abdominal pain, leukocytosis, ileus, and external and internal bolsters is associated with a fever, can result in significant morbidity if not identi- higher infection rate—thus setting and maintaining the fied and treated early (35). The prevalence of persis- proper tension can decrease the likelihood of infection. tent subclinical pneumoperitoneum limits the utility of Loose contact of the outer bolster with the skin is all plain films for evaluation of suspected peritonitis. that is required to appose the gastric and abdominal Therefore fluoroscopic imaging of the PEG tube with wall. The introducer technique that does not pull the infusion of water-soluble contrast is most useful to PEG tube through the oropharynx has been shown to evaluate visceral integrity in patients in whom peri- result in fewer infections compared to the pull or push tonitis is a consideration (36). If active leakage of con- techniques (44,45). trast is identified in a patient with clinical signs of peri- The administration of prophylactic antibiotics tonitis, broad-spectrum antibiotics and surgical explo- prior to PEG placement reduces the risk of infection. ration are usually indicated. Several trials have demonstrated the benefit of a single, broad-spectrum antibiotic immediately prior to PEG placement (42,46–48). The use of prophylactic Prolonged Ileus antibiotics is cost-effective as well (49). It is general It has been established that tube feedings may begin as practice to administer a single dose of a first or third soon as 3 hours after PEG placement (37). However, in generation cephalosporin 30 minutes prior to the pro- 1%–2% of cases prolonged ileus may follow PEG cedure. Prophylaxis is not necessary in those patients placement, and should be managed conservatively (4). already receiving comparable antibiotics for other rea-

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of infection, ulceration, or a buried b u m p e r. Should the patient not be on acid suppression, proton pump inhibitor therapy should be started. Side torsion resulting in ulceration and enlargement of Figure 1. Granulation tissue around PEG. Figure 2. Local irritation and corrosion around the tract may be (Reprinted with permission from McClave and PEG site. (Reprinted with permission from corrected with a Chang, Gastrointest Endosc 2003;58:739-51.) McClave and Chang, Gastrointest Endosc clamping device to 2003;58:739-51.) stabilize the tube ( Vertical drain/tube sons at the time of PEG placement. An adequate skin attachment device, Hollister, Inc., Libertyville, IL). The incision, 1–2 mm larger than the feeding tube, which same result may also be accomplished by replacing the can allow egress of bacteria and gastric secretions, PEG with a low profile button device. Some practition- may also reduce infection risk. If diagnosed early, oral ers replace the gastrostomy tube with a larger one, but broad-spectrum antibiotics for 5–7 days may be all that this is usually ineffective and can result in continued is required for a PEG site infection. If there are more leakage around an even larger stoma (36). systemic signs, intravenous broad-spectrum antibiotics After the primary cause of the stomal leakage has coupled with local wound care are necessary. Should been addressed, stoma adhesive powder or zinc oxide the patient with local site infection develop signs of can be applied to the site to prevent local skin irritation peritonitis, surgical intervention may be required. (Figure 2). Foam dressing rather than gauze can help A rare but potentially life threatening complication to reduce local skin irritation caused by gastric con- is the development of necrotizing fasciitis. Patients tents (foam lifts the drainage away from the skin while with diabetes mellitus, chronic renal failure, pul- gauze tends to trap it). Local fungal skin infections monary tuberculosis, and alcoholism appeared to be at may also be associated with leakage and can be treated enhanced risk (50–53). Management consists of broad- with topical antifungals. Ostomy nurses are an invalu- spectrum intravenous antibiotics and aggressive surgi- able resource in the management of leaking PEG sites cal debridement. and often are the primary caretakers in this setting. In refractory cases, the PEG tube must be removed for several days to allow the stoma to approximate the PEG Site Leakage/Irritation tube more closely, and occasionally the tube must be Leakage of tube feeding formula and/or gastric con- removed and a repeat PEG placed at a new site. tents around the PEG site can be a significant management problem, and small amounts likely occur more frequently than the 1%–2% reported in the literature Buried Bumper Syndrome (54). Risk factors include infection of the site, Buried bumper syndrome refers to the clinical picture increased gastric acid secretion, excessive cleansing resulting from the partial or complete growth of gastric with hydrogen peroxide, buried bumper syndrome, side mucosa over the internal bolster, or bumper, and occurs torsion on the PEG tube, and the absence of an external in 0.3% to 2.4% of patients with PEG (4,56,57). The bolster to stabilize the tube (55). Evaluation of a leak- bumper may migrate through the gastric wall and may ing PEG site should include examination for evidence (continued on page 72)

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Figure 3. External and internal views of buried bumper syndrome. (Reprinted with permission from 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. lodge anywhere along the PEG tract (Figure 3). B-The replacement PEG is pulled into position while removing the Buried bumper syndrome typically presents with buried PEG out through the abdominal wall. C-Radial incisions are peritubal leakage or infection, an immobile made in the gastric mucosa covering the dome of the PEG using a c a t h e t e r, or abdominal pain or resistance with for- needle-knife. D-A balloon dilates the tract over a guidewire. E-A mula infusion. A case of significant gastrointesti- snare is used for the push-pull T technique. (Reprinted with permission from McClave and Chang, Gastrointest Endosc 2003; nal bleeding secondary to buried bumper has been 58:739-51.) reported (58). Risk factors leading to buried bumper syndrome include excessive tension cally or radiographically. A gastrografin study should be per- between the internal and external bolsters, malnu- formed with the patient prone, as radiocontrast appears to trition, poor wound healing, and significant weight safely pass through the imbedded bumper into the gastric gain secondary to successful enteral nutrition (55). lumen by gravity when the patient is supine. Buried bumpers The buried bumper may be confirmed endoscopi- should be removed by any one of a number of methods (Fig- ure 4). The key principle is to use a technique that minimizes trauma to the PEG tract. If the bumper is completely covered by gastric mucosa, electrosurg i - cal incisions may be necessary to access and remove the bumper endoscopically (59).

Gastric Ulcer/Hemorrhage Bleeding that occurs after PEG placement is reported to compli- cate 0.3%–1.2% of cases (4,29, Figure 5. Excessive side torsion on PEG causing ulceration. (Reprinted with permission 31,60). It is typically caused by from McClave and Chang, Gastrointest Endosc 2003;58:739-51.) peptic ulcer disease, traumatic

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erosion of the gastric wall opposite the internal bolster, or ulceration beneath the internal bolster. To reduce risk of ulcerations at the gastrostomy site, excessive lateral traction on the tube should be avoided (Figure 5). In post-PEG patients with upper gastrointestinal bleeding, endoscopy is tolerated well. During endoscopy, the mucosa under the internal bolster should be visualized by externally manipulating the PEG (35).

Fistulous Tracts Fistulae connecting the stomach, colon, and skin are uncommon but potentially disastrous complications of PEG placement. Gastrocolocutaneous fistulae may occur when the colon is inadvertently punctured and traversed Figure 6. Gastrocolocutaneous fistula creation by passage during PEG placement or less commonly with subse- of trocar through loop of colon prior to entering the stom- quent erosion of the tube into juxtaposed colon (Figure ach. (Reprinted with permission from McClave, Tech Gas - trointest Endosc 2001;3:62-8.) 6). Patients may present acutely with colonic perforation or obstruction. More commonly, patients present chroni- cally with stool leaking around the PEG tube and diar- ach and anterior abdominal wall can separate from each rhea resembling formula. Another typical presentation is o t h e r, resulting in free perforation. If recognized imme- when a colocutaneous fistula results from a replacement d i a t e l y, a new PEG tube may be placed through, or near, PEG that is advanced through a previously created gas- the original PEG site, sealing the stomach against the trocolocutaneous fistula and stops in the colon. A feed- anterior abdominal wall. If recognition is delayed, man- ing tube misplaced into the colon may be identified radi- agement consists of nasogastric suction, broad-spec- ographically (Figure 7). Management consists of remov- trum antibiotics, and repeat PEG placement in 7–10 ing the tube and allowing the fistula to close. Should the days. Surgical exploration is reserved for patients with patient develop signs of peritonitis or the fistula fail to signs of decompensation or peritonitis. After stoma tract close, surgery is often required. Prevention is para- mount—Foutch recommends elevation of the head of the 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 with saline can identify intervening bowel between the skin and the stomach if air bubbles appear in the syringe prior to endoscopic visualization of the needle in the gastric lumen (“the safe track technique”) (35).

Inadvertent Removal Accidental PEG tube removal occurs 1.6% to 4.4% of the time (4,60,61). PEG tract maturation usually occurs within the first 7–10 days but may be delayed up to 4 weeks in the presence of malnutrition, ascites, or corticosteroid treatment. A PEG tube that is accidentally Figure 7. Contrast study demonstrating gastrocolocuta- removed during this period should be replaced endo- neous fistula, as contrast infused through the PEG appears in s c o p i c a l l y, as the tract may be immature and the stom- the colon.

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Table 3 Summary Guidelines to Avoid Complications Associated with PEG Placement Procedure Related Complications • For excessive granulation tissue, topical silver nitrate Aspiration may be beneficial • Avoid over-sedation PEG site infection • Minimize air insufflation • Prophylactic antibiotics • Perform procedure efficiently • Adequate preoperative skin sterilization Bleeding • Consider introducer technique • Correct coagulopathy • Set/maintain proper tension between internal and • Consider any alteration of anatomy secondary to prior external bolsters surgery PEG site leakage/irritation Perforation • Prevent infection • Early recognition • Avoid local administration of hydrogen peroxide • Consider any alteration of anatomy secondary to prior • Prevent excessive side torsion on the PEG tube surgery Buried Bumper Syndrome Prolonged ileus • Avoid excessive tension between internal and external • Wait 3–4 hours before beginning feeding post-PEG bolsters placement • Account for nutritional weight gain • If gastric distension occurs, uncap the PEG tube for Gastric ulceration easy decompression • Acid suppression • Avoid lateral traction on the tube Post Procedure Complications Fistulous tracts Care of PEG site • Elevate the head of the bed during placement • Use mild soap and water—NOT hydrogen peroxide • Utilize the “safe track technique” • Place drain sponges over, not under, external Inadvertent removal bumper • Consider use of an abdominal binder • Avoid the use of occlusive dressings • Utilize low profile button at initial placement maturation (generally >2–4 weeks) a replacement tube Like the replacement PEG tubes, the internal “bolster” can be placed at the bedside without endoscopy. can be either a balloon or a soft dome. Either can be Balloon-type replacement PEGs have two ports—one placed at the bedside. PEG buttons are of fixed length, for feeding and the other for inflating an internal balloon so prior to placement, a measuring device is carefully that acts as an internal bolster. A non-balloon-type inserted into the tract so as not to risk damage to the replacement, which has a soft internal dome instead of a tract. Also as a patient gains weight, the tension on the balloon, is an alternative. This type of replacement bolsters can increase. Replacement PEGs or PEG but- device tends to function longer, a fact attributable to tons should be confirmed radiographically or endoscop- breakage of the balloons in the balloon-types (62). ically if there is any concern for incorrect placement. In patients prone to pulling at tubes, an abdominal binder can secure the PEG tube in place. Also consider cutting the tube down to 6–8 inches to decrease the Fungal Tube Infection likelihood that the tube is inadvertently caught on Fungal colonization and/or infection of PEG tubes another object. Finally, an initial placement low profile may lead to tube degradation and failure. This long- device (button) may be beneficial. term complication of PEG tubes has been reported to Low profile PEG buttons, which lay flush with the cause up to 70% tube failure by 450 days. Histologic skin, can reduce the risk of future inadvertent removal. studies have demonstrated actual fungal growth into

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the tube wall leading to brittleness, dilation and crack- 4 . Larson DE, Burton DD, Schroeder KW, DiMagno EP. Percuta- neous endoscopic gastrostomy. Indications, success, complications, ing with eventual puncture of the tube (63). No treat- and mortality in 314 consecutive patients. G a s t r o e n t e r o l o g y , ment has shown to be useful, but polyurethane initial 1 9 8 7 ; 9 3 : 4 8 - 5 2 . 5 . Rabeneck L, Wray NP, Petersen NJ. Long-term outcomes of placement and replacement devices may be more resis- patients receiving percutaneous endoscopic gastrostomy tubes. tant to fungal infection (64,65). J Gen Intern Med, 1 9 9 6 ; 1 1 : 2 8 7 - 2 9 3 . 6 . Loser C, Wolters S, Folsch UR. Enteral long-term nutrition via percutaneous endoscopic gastrostomy in 210 patients: a four-year prospective study. Dig Dis Sci, 1 9 9 8 ; 4 3 : 2 5 4 9 - 2 5 5 7 . Tumor Implantation at PEG Site 7 . Lockett MA, Templeton ML, Byrne TK, Norcross ED. 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Singapore Med J, 1 9 9 8 ; 3 9 : 5 6 0 - 5 6 3 . develop unexplained skin changes at the PEG site. The 1 1 . Kohli H, Bloch R. Percutaneous endoscopic gastrostomy: a community hospital experience. Am Surg, 1 9 9 5 ; 6 1 : 1 9 1 - 1 9 4 . mechanism of implantation is most likely direct seed- 1 2 . Davis JB Jr, Bowden TA Jr, Rives DA. Percutaneous endoscopic ing of tumor at the PEG site after the tube shears tumor gastrostomy. Do surgeons and gastroenterologists get the same results? Am Surg, 1 9 9 0 ; 5 6 : 4 7 - 5 1 . cells as it passes through the aerodigestive tract (68). It 1 3 . Abuksis G, Mor M, Segal N, Shemesh I, Plout S, Sulkes J, Fraser is reasonable in these patients to consider using the GM, Niv Y. Percutaneous endoscopic gastrostomy: high mortality rates in hospitalized patients. Am J Gastroenterol, 2 0 0 0 ; introducer technique, in which the PEG is placed 9 5 : 1 2 8 - 1 3 2 . directly through the abdominal wall. However, 1 4 . 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