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Chapter 6

Clogged and Dislodged: A Guide to PEG Tube Badassery

Mike Phillips, MD, Rob Orman, MD, and Walker Foland, MD
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We may not place PEG tubes but we certainly encounter their complications.  From blockages to dislodgement, PEG issues are a frequent occurrence in the emergency department. In this episode, we get perspectives from emergency physician Walker Foland, as well as gastroenterologist Mike Phillips, on troubleshooting and managing the misbehaving G-tube.

 

Pearls:

  • Before you replace a dislodged PEG tube, you need to know when it was put in, how long ago it fell out, and the type and size of the original tube

  • Tubes dislodged < 3-4 hours ago should be easy to replace with the identical size tube.  The greater the duration since dislodgement, the more likely you will need to dilate the stoma or downsize to a smaller tube.

  • Plugged tubes can be managed by trying to flush with warm water. If unsuccessful, other options include dissolving the blockage with pancreatic enzymes, mechanically opening the obstruction with a guidewire or commercial device, or replacing with a new tube.

  • Pain from a PEG tube may be due to infection, pressure necrosis, or Buried Bumper Syndrome.

 

  • Percutaneous endoscopic gastrostomy (PEG) tube complications commonly warrant an ED evaluation. In this episode, we hear from Walker Foland, an emergency physician, and Mike Phillips, a gastroenterologist, getting both of their perspectives on what to do when these tubes are dislodged, clogged, or cause pain.

  • Reinserting a dislodged PEG tube:

    • Foland:  

      • Before you replace a PEG tube, you need to know when it was placed and how long ago it fell out.

        • If a PEG tube has been in for less than 3 weeks, there has not been enough time for the stomach to have become adherent to the inner abdominal wall, and you shouldn’t attempt to replace it. This should be done by a specialist. (3 weeks is much shorter than the 2 months recommended by our GI specialist as explained later in the show)

        • Tubes placed greater than 3 weeks ago should have a well-developed tract; you should be able to slide a PEG tube in without difficulty.

        • If a tube fell out more than a few hours ago, it is going to be much more difficult to place a new tube due to contraction of the skin.

          • Suggested technique for dilating the skin:

            • A small cervical dilation kit with metal dilator rods ranging in size from 1 to 7 mm can be inserted superficially into the constricted stoma to stretch the skin. They should not be put in deeply as this could create a false passage.

            • After using the last dilator, lube the PEG tube and attempt insertion.

            • If you don’t have a cervical dilation kit, you can stretch the skin with the tip or cap of a 60cc Toomey syringe.

          • If you are unable to place the tube after dilating the skin, you likely are inserting it at an angle that is different from the actual path of the tract.

            • It is imperative that you not force the tube -- creating a false tract can be very dangerous.

            • You can determine the angle of the tract by gently inserting and slowly advancing the non-coude tip of a pediatric (7 French) bougie.  Once you’ve identified the tract, you can either 1) remove the bougie and insert the PEG tube or 2) advance the PEG tube over the bougie using the Seldinger technique.

          • Once the new tube is placed, the intraluminal position should be confirmed with a contrast enhanced  x-ray.

    • Phillips:

      • If consulted about a dislodged PEG tube, the first thing Dr. Phillips wants to know is how long ago did it fall out and is the tube still available. It is very helpful to know the size, type, and brand of the original tube.

        • The timing is important because the gastrostomy hole will begin to close within a few hours. Tubes dislodged less than 3-4 hours ago should be easy to replace with the identical size tube.  The greater the duration since dislodgement, the less likely it will be able to be replaced transabdominally (versus endoscopically).

        • Even if you are given the original tube, you should replace with a new tube.  If the tube has been out for a long time and the stoma has started to constrict, you may need to downsize to a smaller tube.

        • If a new tube is not readily available, the original tube or a foley catheter can be temporarily inserted as a placeholder.

      • Tips for placing and securing a PEG tube.

        • Before replacing the tube, inspect the stoma to ensure there is a functioning hole. There is no need to sterilize the area.

        • Lubricate the tube with K-Y Jelly before insertion. If the tube doesn’t go in easily, try the next smaller one until you find one that fits.

          • The standard adult tube size is 24 French. The smallest tub used for adults is 16 French.

        • Dr. Phillips does not think that ED providers should be expected to dilate a constricted stoma. Gastroenterologists have specific dilators designed to do this over a wire.

        • Once placed, fill the balloon with saline or water (not air), snug the tube up against the anterior stomach, and slide the bumper down so it is resting against the skin of the abdominal wall. Ask the patient if he/she prefers a drain sponge (or a 4 x 4 cut halfway across) under the bumper. If so, allow space for that.

        • Phillips does not suture the bumper to the skin. Some bumpers have a twist tie or a zip tie that can be tightened so the tube doesn’t move up and down.

      • What pitfalls does Dr. Phillips see when he follows up on patients who had PEG tubes placed in the ED?

        • The most common is the placement of a Foley catheter which doesn’t function like a gastrostomy tube and causes difficulty for the patient.

        • Sometimes the bumper isn’t snug enough against the anterior abdominal wall and there’s too much play in the tube. This can result in leakage around the tube.

        • The balloon can get sucked through the pylorus, causing shortening of the external portion of the tube and obstructive symptoms.  If this happens, you simply deflate the balloon, pull it back, and reinflate.

      • Why might a feeding tube end up in the peritoneal cavity?

        • When the tube initially goes in, the internal balloon is pulling the gastric wall up against the anterior abdominal wall. Over time, scar tissue develops between the stomach and the abdominal wall, creating a tract. If the tube falls out before the scar has formed (ie. within 6-8 weeks of placement), the gastric wall can separate and a new tube may enter the peritoneum.

        • A tube that has been in for under 2 months should not be replaced blindly. Instead, use an endoscopic or radiographic approach.

      • If a tube is replaced through a mature tract, does its placement always need to be confirmed radiographically?  

        • If there’s any difficulty or trauma placing the tube, then its location should be confirmed radiographically.  Ideally, this is done by a radiologist using water soluble contrast (such as gastrografin) and fluoroscopy.

        • If it’s placed easily, it is reasonable to confirm placement by aspirating gastric contents.

      • A gastrojejunostomy(G-J) tube feeds distally into the small bowel.  These should not be placed blindly and should be done by interventional radiology.

  • Unclogging a PEG tube:

    • Foland:

      • The chemical method involves putting an enzyme solution (or Coca-Cola) into the tube in the hopes of dissolving the obstruction.  This doesn’t usually work well.

      • The mechanical method is preferable.  While there are commercial devices designed for this purpose, they are expensive and often not readily available in the ED.  Foland recommends using a central line guidewire to unclog the tube.

    • Phillips:

      • Chemical methods.

        • The success of Coca-Cola is an urban legend. If it works, it’s probably due to the pressure of pushing it through.

        • You can try premixed, non-enteric coated pancreatic enzymes, such as Viokase. Let the enzymes sit in the tube for 20-30 minutes, and then flush with warm water using a 20 or 60cc syringe, pushing hard.

      • When managing a clogged PEG or G-J tube, Phillips typically starts by trying to flush with warm water using gentle, steady pressure.  If unsuccessful, his next step is to use a mechanical device to relieve the obstruction or simply replace it with a new tube.

        • If you’re replacing a PEG tube that has an internal flange rather than a balloon to secure the tube against the wall of the stomach, you have to use quite a bit of force to pull the tube out. Removal can be uncomfortable and usually causes slight bleeding.

          • You can verify that the tube has an internal bumper because there is no separate balloon port.

        • Replacing a G-J tube needs to be done by someone with fluoroscopic ability, such as an interventional radiologist or gastroenterologist.

  • What to do when a feeding tube is causing pain.

    • Phillips:

      • Pain within the first week or two after placement is most likely due to an infection of the tract.  Antibiotics and removal of the tube need to be contemplated.

      • If the tube has been in for a long time, pain could be due to a pressure ulcer along the side of the tube.  These may be visible if you carefully inspect the tract.

      • Buried Bumper Syndrome is another cause of pain.  This occurs when the internal bumper or balloon has been pulled up so tight against the internal aspect of the stomach that it causes pressure necrosis and ulceration. Sometimes you can feel the bumper under the skin, since it is lodged in the subcutaneous tissue of the anterior abdominal wall.  Skin is usually red and tender.

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