Gastroenterology - Percutaneous Endoscopic Gastrostomy (PEG) - Salford

This leaflet aims to provide you with basic information about having a gastrostomy tube inserted.
Including:

• What is a gastrostomy tube?
• How is it inserted?
• Your feeding regime
• Tube care
• Skin care
• Potential problems
• General information
• Help that is available for you

What is a Gastrostomy tube?

A Gastrostomy tube is a small plastic tube which is inserted into your stomach so that you can feed without swallowing.

It is a safe and effective long-term method of obtaining nutrition.

Is there an alternative?

You can be fed by a tube which is passed through your nose, down into your stomach. However, this type of tube can become uncomfortable, is not as discreet or as safe for long term use as a gastrostomy tube.

What if I don’t have a gastrostomy tube inserted so that I can be fed?

• You will not obtain enough nutrition to sustain your health
• You could inhale any diet taken by mouth resulting in a serious chest infection.

What should you expect?

How the tube is inserted

The procedure is carried out using an endoscope. In order to insert the feeding tube, the tip of the endoscope is passed through your mouth into your stomach.

The endoscope is a long flexible tube (thinner than your little finger) with a bright light at the end.

Looking down the tube, the doctor gets a clear view of the lining of the stomach and can decide on the most suitable area to insert the feeding tube.

The preparation

To allow a clear view, the stomach must be empty. You will therefore be asked not to have anything to drink or any feed at least 6 hours before the procedure. You will be asked to sign a consent form by your doctor on the ward. This is to ensure that you and your relatives have understood the procedure and its implications. Please tell the nurse or the doctor if you have any allergies or bad reactions to drugs. If you have any worries or questions at this stage, do not be afraid to ask. The staff will want you to be as relaxed as possible for the procedure and will be pleased to answer your queries.

During the procedure

To allow a clear view of the stomach, you will be made comfortable resting on your back. A nurse will stay with you throughout the procedure. The back of your throat may be sprayed with a local anaesthetic, to numb the area. The endoscopist may offer you a sedative injection to make you feel sleepy and relaxed.

To keep your mouth slightly open, a plastic mouthpiece will be put gently between your teeth or gums. When the endoscopist passes the endoscope into your stomach it will not cause you any pain or interfere with your breathing at any time.

The area of skin on the abdominal wall will then be cleaned and a local anaesthetic injected into the area. A small cut is then made, and a tube is placed through the skin into the stomach.

A fine thread is passed through this tube and is grasped from the inside by the endoscopist with a pair of forceps which pass through the centre of the endoscope.

The endoscope is then removed from your mouth with the thread. The feeding tube is then tied on to this thread and gently pulled through your mouth until it eventually comes out through your abdominal wall, leaving the other end secured by a disc in your stomach.

Any excess length is trimmed off the tube so that it lies neatly in your abdomen. It is then secured into position with a fixing plate.

Your feeding regime

After the procedure

You will be left to rest in bed for 1-2 hours after the procedure. The back of your throat may feel a little sore for the next 24 to 48 hours. You may also feel a little bloated if some air has remained in your stomach. Both of these discomforts will pass and there is usually no need for medication.

After a new PEG insertion, you will be admitted to the ward if you are not already in hospital. You can expect to stay in for at least a few days or until you feel comfortable with the PEG tube. If you are to care for the tube yourself, instruction will be given by a dietitian or Nutrition Nurse who will assess if you need any help with continuous care.

What are the risks?

There are a number of complications associated with placement of a gastrostomy tube. Many of these are minor such as infection around the tube, some pain or discomfort or minor bleeding.  More serious problems can occur with leakage of stomach contents (peritonitis) or a tear in the stomach (perforation) or more serious bleeding and infection of the abdominal wall (necrotising fasctitis).

Due to the nature of the diseases that cause the swallowing problems, chest infection, pneumonia or heart trouble may develop after this procedure.

These may be serious and overall 1-2 people per 100 may die prematurely as a consequence of gastrostomy tube placement. This sounds like a high figure but it has to be balanced against the risk of not feeding people and the major risks of the underlying disease.

Your feeding regime

The dietitian will prescribe a commercially prepared liquid feed, which contains all the essential nutrients. The amount prescribed will depend on your individual needs. You may require extra fluids or medication via your feeding tube.

The dietitian will also arrange a feeding pump for you. This controls the flow of the feed into your stomach. You may be fed continuously or intermittently, during the day or overnight.

Your first feed can usually be started 6-12 hours after insertion slowly to begin with, to allow your stomach time to adjust.
Sometimes you may have a slight soreness or discomfort in your abdomen during the first 24 hours after insertion and once feeding starts.
 
This is because it has stimulated your digestive tract into working again, particularly if you have not been eating for some time.

When you are going home, the dietitian will advise you on your feeding regime. She will also arrange for you or your carers to be trained on how to use the pump.

Tube care

Positioning

The position you are in when having your feed is important. You should be in an upright position if in bed or sitting up in a chair. This helps to prevent the reflux of your feed into your upper digestive tract (gullet), which could cause you problems with heartburn and possibly a chest infection as your respiratory passages are very close by. If you lean towards your right side this helps to encourage the emptying of food from your stomach, into your intestines.

Tube care

If well cared for the feeding tube can last for several years. The gastrostomy tube should be flushed with 30-50mls of cooled boiled water before and after each feed, to prevent the feed blocking the tube.

Medication

Depending on your medical condition you may be required to take medication. Wherever possible this should be in the form of a solution, syrup or dispersible medication. Your pharmacist will be happy to advise you. When medication is dispersed via your tube it MUST be flushed before and after, just the same as when having a feed.

Methods for flushing the tube

It is recommended that a 50ml purple enteral syringe is used must be used.

1.    Using the syringe via the drug port of the giving set. Insert syringe and turn the drug port 90° in order to administer.

2.    We now use ENFIT syringes for all tubes, which can be screwed onto the tube.

NEVER put anything down your tube other than:

1. FEED
2. WATER
3. LIQUID MEDICATION otherwise you risk blocking your tube

Skin care

The area of skin around where the tube enters your stomach is called the stoma site. You may experience a discharge at the stoma site for the first few days. This area should be cleaned daily with sterile saline.

A loose absorbent dry dressing may be used until the stoma has healed. When the stoma site has fully healed (usually 7 days after tube insertion) a dressing is not needed.

Continue to clean the area daily with mild soap and water. Don’t forget to dry well. Pay special attention to the fixation plate as part of your daily cleaning routine - keep it clean and dry and position 1cm from the stoma site.

Some manufacturers advise you to rotate the tube daily whilst cleaning the area, check if this is the case with your tube.

To clean the fixation plate and rotate tubes

• Loosen the clamp device on the outer fixation plate and pull back plate, carefully clean the puncture site (stoma) and the fixation plate on both sides
• Let the puncture site dry properly
• Push the tube carefully 2-3cm into the stoma and rotate. It is important for the tube to move freely in the stoma
• Then pull back the tube gently until resistance is felt. Push the fixation plate back into position 1cm from the stoma site and secure the clamp device

Potential problems

Wound infection

If you notice any signs of swelling, irritation, redness, skin- breakdown or soreness this may indicate a wound infection. Cleanse the area twice daily, drying well. If the condition persists for more than a couple of days, your doctor, or nurse should be informed. They may well take a swab of the area.

Blocked tube

Syringe down warm water. Do not use coke or any fizzy liquids. Do not use too much force. Do not poke anything down the tube.

*If you cannot unblock your tube, ask for advice from your healthcare professional or homecare enteral feeding company.

Nausea, vomiting, diarrhoea or constipation

Stop feeding and contact your nurse or dietitian immediately.

Leakage of food from your gastrostomy site

Stop feeding and contact your nurse or doctor immediately.

Lost parts from tube

Keep spare parts available should you need them.

Damage to tube

Don’t use safety pins to secure tube to garments, or use scissors close to tube. If the tube is tugged or falls out. Please seek medical advice immediately before the tract closes up which can occur in a matter of hours otherwise a further endoscopy will be required to place the tube.

Compatibility

Always check the compatibility of feeding tubes, giving sets and pumps. The nurses on the wards or the company representative can advise you on this.

General information

Bathing and showering

After the site is fully healed (usually about 7 days after tube insertion), you can shower as normal and bath as normal (as long as the bath water is below your tube site for the first 6 weeks).

Check that the tube is fully closed and the clamp applied. Dry the area thoroughly afterwards.

Swimming

You can go swimming 6 weeks post insertion. However, it is advisable to cover the site with a waterproof dressing. Make sure the tube is closed and the clamp applied.

Regular oral hygiene

Clean your teeth twice a day to remove the build up of plaque. If you do not have any teeth, gentle brushing with a soft tooth brush of your mouth and tongue will help to keep it clean and healthy.

Frequent mouthwashes may also be of help in keeping your mouth moist, fresh and in good condition.

Accessories

Clean any adaptors or accessories in a mild detergent and store dry.

Help available

Many people on home feeding are able to manage with very little help. However, help can be given by relatives and friends or by a District Nurse. Your general health and welfare will be checked at regular intervals, either at home or at the hospital.

If you are unsure about information given or have any other queries, please contact your dietitian, nutrition nurse or community nurse advisor.