PEG tube placement
Formal Definition
Percutaneous Endoscopic Gastrostomy (PEG) — a minimally invasive procedure for placing a feeding tube into the stomach through the abdominal wall, performed endoscopically by passing a gastroscope into the stomach, transilluminating the abdominal wall to identify an appropriate puncture site against the anterior gastric wall, advancing a needle or introducer system (most commonly the "pull" technique but also "push" and introducer techniques), and securing the tube so that medication, fluids, and nutrition can be administered directly into the stomach when oral intake is inadequate or unsafe; commonly performed in patients with dysphagia from stroke, head/neck cancer, ALS, advanced dementia where nutrition and medication need to bypass oral/oropharyngeal route.
How It's Used on the Ward
"PEG tube" or "PEG placement" — what GI does when the patient can't safely eat by mouth (stroke with dysphagia, head-and-neck cancer post-radiation, advanced dementia, severe malnutrition with refusal to eat); placed at bedside with endoscopy; provides enteral access for medication, hydration, nutrition; doesn't prevent aspiration entirely (oral secretions still drain into trachea).
Example
""74-year-old with advanced ALS, progressive dysphagia over 6 months, now aspirating thin liquids, no longer able to safely meet caloric needs by mouth. Family meeting: oral nutrition failing, aspiration risk high; PEG placement discussed and family elects to proceed. Procedure: PEG placed by GI under moderate sedation using pull technique, 20 Fr tube, no complications, tolerated procedure well. Started on continuous tube feeds at goal rate over 24 hours; oral intake discontinued; aspiration events ceased. Patient transferred to home with home health for tube feeding.""
Clinical Context
Indications for PEG: inability to maintain adequate oral intake (>3-4 weeks anticipated need), safe swallowing not possible, normal GI function (absorbs in small intestine), life expectancy compatible with benefit (typically >30 days). Common causes: stroke with persistent dysphagia, head/neck cancer post-resection/radiation, neurodegenerative disease (ALS, advanced Parkinson's), severe anorexia from cancer/HIV, prolonged ICU admission with persistent ventilator dependence, advanced dementia (controversial; benefits may be overestimated). Procedure steps: (1) Endoscopy. (2) Abdominal wall transillumination. (3) Site selection with finger indentation visualization. (4) Local anesthesia. (5) Incision and needle introduction. (6) Guidewire/snare capture in stomach. (7) Pull technique: traction on guidewire brings tube through mouth, esophagus, stomach, and out through abdominal wall. (8) Internal bumper seats against gastric wall; external bolster secures at skin level. Complications: bleeding, infection at insertion site, ileus, peritonitis, buried bumper syndrome (internal bumper migrates into tract), aspiration (still possible from oral secretions), tube dislodgement, clogging, leakage. Ethical considerations in advanced dementia: evidence for benefit is modest; many societies recommend careful shared decision-making; surrogate decision-makers should understand PEG does not necessarily prevent pneumonia, improve survival, or improve pressure ulcer healing in advanced dementia. Counter-concept: nasogastric tube (temporary, less invasive, high dislodgement risk, often uncomfortable); jejunostomy (J-tube; bypasses stomach; for severe gastroparesis or post-gastric surgery).