Percutaneously placed endogastric tubes can be placed in suitable
patients in the intensive care unit (ICU) with the guidance of a
- ▪ Percutaneous endoscopic gastrostomy (PEG): PEG tube
- ▪ Pull technique: An approach whereby the feeding tube is
pulled from the stomach out through the abdominal wall under endoscopic
- ▪ 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.
- ▪ Indications:
- —Requirement for long-term enteral feeding
in a patient who is unable to sustain adequate caloric intake by
- ▪ Contraindications:
- —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
- —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
- ▪ The PEG tube is then pushed into stomach over wire and
- ▪ Complications:
- —Gastroenteric fistula
- —Bowel peroration with peritonitis
- —Device malposition
Graphic showing PEG tube in position.
Clinical Pearls and Pitfalls
- ▪ 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.
Gopalan S, Khanna S. Enteral nutrition delivery technique. Curr
Opin Clin Nutr Metab Care.
Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal,
percutaneous endoscopic gastrostomy, or jejunostomy: its indications
and limitations. Postgrad Med J.