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Introduction

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Percutaneously placed endogastric tubes can be placed in suitable patients in the intensive care unit (ICU) with the guidance of a gastroscope.

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Definitions and Terms

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  • ▪  Percutaneous endoscopic gastrostomy (PEG): PEG tube (Figure 44-1).
  • ▪  Pull technique: An approach whereby the feeding tube is pulled from the stomach out through the abdominal wall under endoscopic guidance.
  • ▪  Push technique: An approach whereby the feeding tube is pulled through the abdominal wall from the skin surface into the stomach, again under endoscopic guidance.

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Techniques

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  • ▪  Indications:
    • —Requirement for long-term enteral feeding in a patient who is unable to sustain adequate caloric intake by mouth.
  • ▪  Contraindications:
    • —Coagulopathy
    • —Unfavorable gastric anatomy
    • —Gastric pathology
      • • Neoplasm
      • • Varices
      • • Gastritis
    • —Abdominal wall infection or burn
    • —Previous gastric or intra-abdominal surgery
  • ▪  Technique:
    • —This procedure requires the participation of a skilled endoscopist.
    • —Prior to the procedure, patient consent should be obtained, skin should be prepped and draped, and universal protocol should be performed as per Section I.
    • —A gastroscope is introduced into the stomach, entire content of the stomach is suctioned out, air insufflated to distend abdomen and the endoscopic light is used to transilluminate the anterior abdominal wall.
    • —The skin is anesthetized over the point of maximal light.
    • —An Angiocath is pushed through skin into stomach.
      • • Pull technique:
        • ▪  Guidewire is introduced through the Angiocath and pulled out through the mouth, where it is attached to feeding tube.
        • ▪  The PEG tube is then pulled back into stomach and out through abdominal wall and secured (Figure 44-2).
      • • Push technique:
        • ▪  Guidewire introduced into stomach through Angiocath and a series of dilators are used with Seldinger technique to dilate gastrostomy.
        • ▪  The PEG tube is then pushed into stomach over wire and secured.
        • ▪  Complications:
    • —Cellulitis
    • —Pneumoperitoneum
    • —Gastroenteric fistula
    • —Bowel peroration with peritonitis
    • —Device malposition

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Figure 44-2.
Graphic Jump Location

Graphic showing PEG tube in position.

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Clinical Pearls and Pitfalls

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  • ▪  Gastroscopically guided procedure should be abandoned if the anterior stomach wall does not transilluminate—this indicates that there is some organ or other impediment (ie, ascites, scars) to passage of needle directly through skin into stomach wall.

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Suggested Reading

Gopalan S, Khanna S. Enteral nutrition delivery technique. Curr Opin Clin Nutr Metab Care. 2003;6:313–317.  [PubMed: 12690265]
Pennington C. To PEG or not to PEG. Clin Med. 2002;2:250–255.  [PubMed: 12108477]
Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J. 2002;78:198–204.  [PubMed: 11930022]

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