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) 66 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2004 Prevention and Management of Complications of PEG Tubes NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #22 (continued from page 66) 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 proce- dure 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 68 PRACTICAL GASTROENTEROLOGY • NOVEMBER 2004 Prevention and Management of Complications of PEG Tubes NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #22 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 sin- gle, broad-spectrum antibiotic immediately prior to PEG placement (42,46–48). The use of prophylactic Prolonged Ileus antibiotics is cost-effective as well (49).