Complications Associated with Percutaneous Endoscopic Gastrostomy Tubes

Introduction

No disease process improves with prolonged starvation. Tube feeding has been practiced in various forms for more than 400 years, and technical advances during the past two decades have made this method a less expensive alternative to parenteral nutrition and more acceptable to patients.¹ Since its introduction in 1980 by Gauderer and Ponsky^2,3 use of percutaneous endoscopic gastrostomy (PEG) tubes has increased consistently. More than 200,000 PEG tubes are placed annually in the United States.^4,5 As literature demonstrating the benefits of enteral over parenteral nutrition mounts, we expect a continuous rise in the use of PEG tubes. However, this procedure is not risk-free. The overall complication rate ranges from 4-24% of cases. Up to 4% of patients are affected by a major complication.^6-10

A literature review was performed via the PubMed™ search engine, using the terms PEG, PEG tube, PEG tube complications, PEG morbidity, and PEG mortality. Cross-referenced non-PubMed™–listed articles were also reviewed. A total of 1318 articles were found, which were analyzed for relevance for and goals of this review. PEG tube−related complications were divided into specific groups: (1) upper endoscopy−related complications; (2) procedure-related complications; and (3) post-procedural complications, including PEG tube usage and wound care.

Complications of Upper Endoscopy

The most common complications of upper endoscopy include aspiration, hemorrhage, perforation, and cardiopulmonary complications related to sedation. Mortality associated with upper endoscopy is very low (0.005-0.01%).^11,12 Risk of aspiration is low but significant (0.3-1.0%).¹³ Advanced age, altered mental status, chronic debilitating conditions, supine position, and sedation increase aspiration risk. Aspiration can be minimized by judicious use of sedation, optimizing air-insufflation of stomach, suctioning gastric contents before and after the procedure, and minimizing procedure time by performing the procedure efficiently. An unsedated transnasal approach using small-caliber endoscopy has been reported to lower aspiration rates.^14,15

Mild, controllable bleeding is common during the procedure. Severe hemorrhage is rare (0.02-0.06%).^11,12 Anticoagulation, antiplatelet agents, and anatomic anomalies increase such risk. Elective PEG placement should be deferred in presence of coagulopathy or thrombocytopenia.

Perforation of the esophagus is rare (0.008-0.04%).^11,12 Common sites of iatrogenic perforation are cricopharyngeus, aortic knob, and diaphragmatic hiatus. Esophageal diverticulum, esophageal strictures, and tumors/mass lesions increase such risk. Treatment with broad-spectrum antibiotics and surgical debridement and repair are indicated. In patients without systemic evidence of sepsis, small contained perforations can be managed medically. Prolonged ileus may follow PEG placement in up to 1-2% of cases,⁶ and it should be managed conservatively. Acute gastric distension has also been described, which uncapping the PEG tube can decompress.^6,16

Procedure-Related Complications

Laceration of the stomach, small bowel, or colon occurs in 0.5-1.3% cases.⁶ Pneumoperitoneum is seen in up to 56% of patients post-procedure and is of no clinical significance.¹⁷ However, peritonitis manifests as abdominal pain, ileus, tachycardia, hypotension leukocytosis, and fever and should be identified early to prevent significant morbidity or mortality. Subclinical pneumoperitoneum limits utility of plain films, thus imaging of the PEG tube with water-soluble contrast should be used to evaluate visceral integrity. Broad-spectrum antibiotics and surgical exploration are required in cases of peritonitis.

Colonic injury occurs when the transverse colon is displaced over the anterior gastric wall.^18,19 These injuries commonly present as peritonitis and require surgical intervention. In patients without hemodynamic instability, with no signs/symptoms of systemic infection, nonoperative management may be appropriate. This complication can be minimized with adequate gastric insufflation, appropriate transillumination, and endoscopically visualized finger indentation. Morbid obesity can prevent adequate transillumination and finger indentation. Computed tomography (CT)/ultrasound-guided imaging may enhance safety of this technique.²⁰ Recently, endoscopic ultrasound-guided PEG tube placement was described as a safe technique when adequate transillumination and finger indentation is not possible.²¹

Gastrocolocutaneous fistula may develop when the PEG tube is placed directly through the bowel into the stomach.^22,23 Oftentimes, patients are asymptomatic; transient fever and ileus may be the only features. It may be discovered upon manipulation of the tube or while placing the replacement tube, which is placed into the colon. Diarrhea develops once feeding is started. Diagnosis is confirmed with contrast-enhanced radiography. Intraperitoneal leak is rare. Removal of the PEG tube allows spontaneous closure of the fistulae, but surgery may be needed in presence of peritonitis or abscess formation. Preventive measures include those described above for prevention of colonic injury.²⁴

The small bowel is protected by the greater omentum, which separates it from the upper abdomen. Postoperative adhesions can significantly alter anatomy and can transfix the bowel in the upper abdomen.²⁴ Omentectomy further increases this risk. Patients present with signs of peritonitis, and broad-spectrum antibiotics and surgery are usually required.

Splenic injury is extremely rare, with only one case of fatal retroperitoneal hemorrhage reported so far that involved laceration of splenic vein.²⁵ Similarly, injury to the liver during PEG placement is rare. Usually, close clinical observation is sufficient in most cases. However, intraperitoneal bleeding has been reported due to liver laceration during PEG placement.²⁶ Confirmatory techniques described above are useful to avoid such complications.

Abdominal wall bleeding can occur and is often caused by the puncturing of an abdominal wall blood vessel. Tightening the external bumper against the skin can effectively control bleeding from the track of the PEG tube.²⁴

Post-Procedure Complications
Peristomal pain. Adequate analgesia during and after the procedure should be given to reduce pain or discomfort. Onset of pain after the procedure in the presence of analgesia may indicate onset of clinical infection at the ostomy site. Excessive tension of the external bumper against the skin should be avoided, as it causes pain and impairs healing of the underlying gastric mucosa.²⁴

Aspiration. Aspiration is one of the most common complications of feeding through a PEG tube and frequently leads to death due to aspiration pneumonia. Advanced age, gastro-esophageal reflux disease, gastroparesis, high-osmolality feeds, impaired consciousness, poor oral hygiene, and sedatives are contributing factors. Elevation of the head end of the bed to at least 30-45 degrees, intermittent feeding, prokinetic agents, and good dental care can minimize aspiration.

PEG site infection. Infection at the PEG tube site is the most common complication of PEG placement. Peristomal wound infection is seen in up to 30% of cases.²⁷ Fortunately, less than 2% require aggressive medical or surgical therapy.28 PEG site infection presents as pain at the ostomy site, erythema, induration, discharge of pus, foul smell, and in severe cases, a fluctuant mass (Figure 1). Advanced age, poor nutritional status, uncontrolled diabetes, obesity, and chronic corticosteroids/immunosuppressants increase risk of infection. Excessive pressure between the external and internal bumper is associated with a higher rate of infection. The administration of prophylactic antibiotics prior to PEG tube placement significantly reduces risk of infection. A single dose of a first-generation cephalosporin 30 minutes prior to the procedure is sufficient.^28-30 Patients already receiving antibiotics do not require additional prophylaxis. When diagnosis is established early, 5-7 days of broad-spectrum antibiotics via enteral route is appropriate.²⁷ Systemic infections require intravenous antibiotics. Rarely, necrotizing fasciitis develops, which can be life-threatening if not treated early. Patients with diabetes, chronic renal failure, pulmonary tuberculosis, and alcoholism are at higher risk. Treatment includes broad-spectrum intravenous antibiotics and surgical debridement.²⁷ Clinical trials are currently being conducted involving use of enteral rather than intravenous antibiotics for prophylaxis for infection after PEG tube placement.

Buried bumper syndrome. This is an uncommon complication that occurs in 0.3-2.4% of patients with PEG tubes.^5,6,31 PEG tube placement creates a gastrocutaneous fistula, and the bumper may migrate through the gastric wall and may lodge anywhere between the gastric wall and the skin along the PEG tube track. It can occur as a result of excessive tension between external and internal bumpers of the PEG tube that facilitates such a migration. Onset of symptoms is described in the literature as early as within 2 months and as late as after 7 years. Partial or complete epithelialization of gastric mucosa over the internal bumper may result in complete closure of the internal orifice. Patients usually present with peritubal leak, infection, immobile PEG tube, abdominal pain, and resistance to feeding. Mortality and significant gastrointestinal (GI) bleeding have been reported due to this complication. The buried bumper may be confirmed endoscopically or radiographically. Buried bumper can be removed endoscopically with minimal trauma to the PEG track. If the epithelialization over the bumper is complete, electrosurgical incision with a needle-knife is required to remove the bumper endoscopically.³²

GI ulceration. Pressure ulceration occurs around the PEG tube site due to pressure necrosis of the gastric mucosa because of an internal bumper. Appropriate tension between internal and external bumpers may help reduce this complication. Esophagitis, gastric erosions, and gastritis are other common findings in patients with PEG tubes. Peptic ulcer disease and esophagitis respond to antisecretory therapy with proton pump inhibitors.²⁷

Peg site leak/irritation. Leakage of gastric contents and/or feeding is a common and significant management problem. This complication occurs in 1-2% of patients.²⁴ Hypersecretion of gastric acid, buried bumper syndrome, large ostomy site with small PEG tube, and absence of an external bumper to stabilize the PEG tube are risk factors for leakage/irritation. Local ostomy care with mild soap and water, acid suppression with proton pump inhibitors, treatment of infection, and supportive devices to stabilize PEG tubes may help in reducing leakage.²⁴ A PEG tube with a low-profile button device may help in reducing side torsion of the tube and resulting ulcer formation.⁵ In some refractory cases, removal of the PEG tube is required to promote healing. Addition of prokinetic agents, proton pump inhibitors, and parenteral nutrition may facilitate healing. Once healed, a new PEG tube may be placed at a different site.²⁴ Conservative measures fail in cases of persistently leaking gastrocutaneous fistula, whereas endoscopic electrochemical cauterization and clip placement has achieved superior results33 (Figures 2A-2C).

Gastric outlet obstruction. Gastric outlet obstruction develops when the internal bumper of the PEG tube gets lodged in the pylorus or duodenum, causing partial or complete obstruction (Figure 3). Patients may present with vomiting, aspiration pneumonia, and crampy abdominal pain. CT scan or upper GI series will confirm diagnosis. Endoscopic retrieval of the internal bumper or deflating the balloon and pulling back the tube may provide relief from symptoms. Gastric and bowel volvulus are rare and mainly associated with placement of the PEG tube through the posterior wall of the stomach.^34-37 Treatment is surgical. Placement of the PEG tube on the anterior wall of the stomach prevents this complication.

PEG tube dislodgement. Accidental dislodgement of the PEG tube occurs in 1.6-4.4% of cases.²⁷ Patients with confusion or those who are combative are at higher risk. Maturation of the PEG tube track occurs in 7-10 days, but in the presence of poor wound healing, malnutrition, ascites, and corticosteroid treatment, it may be delayed up to 4 weeks. If recognized early, a dislodged PEG tube should be replaced endoscopically, as the track may be immature and the anterior abdominal wall and the stomach may separate, causing free perforation. In cases where an ostomy is closing, management is directed at avoiding enteral feeding, broad-spectrum antibiotics, and repeat PEG tube placement in 7-10 days.^38,39 Traction/pulling on a newly placed PEG tube can displace it into the peritoneal cavity or subcutaneous tissue, as a fistula is not well developed (Figure 4). Patients present with fever and abdominal pain, which requires surgical exploration and debridement.

Once the ostomy is well developed, in case of dislodgement, a balloon replacement tube can be placed at the bedside. Alternatively, a nonballoon–type replacement with a soft internal dome can be used.²⁷ Aspiration of bile from the replacement tube confirms correct placement. When in doubt, it should be confirmed radiographically or endoscopically. In patients prone to pulling at tubes, a short outer segment of the tube, an abdominal binder, or a low-profile, button-type tube should be considered.²⁷

Fungal colonization of tube. Colonization of the PEG tube with fungus may lead to degradation of the tube. It is a long-term complication that is reported to cause up to 70% failure by 450 days.²⁷ Cracking, puncture, and brittleness of the tube are attributed to fungal infection. Newer polyurethane devices appear to be more resistant to fungal infection.

PEG tube blockage. Thick enteral nutrition feeding, medications, and other things can clog the PEG tube. This complication occurs in up to 45% of patients.⁴⁰ A narrow-caliber PEG tube is more prone to this situation. Prevention is the key to avoiding this problem. Medications should be crushed and dissolved completely in water before administrating through the PEG tube. The PEG tube should be flushed with 30-60 mL of free water using a large syringe after medication administration and every 4 hours. Use of saline to irrigate can cause crystallization and promote clogging. Infusion of warm water to unclog the PEG tube is superior to other agents. Carbonated beverages can be used to unclog the PEG tube. Pancreatic enzymes with bicarbonate solution can be left in the PEG tube for several hours before flushing with water. A special “declogging” plastic brush can help with cleaning the tube. Although practiced commonly, use of wire to clean the tube has a small risk of perforation.²⁴

Post-PEG diarrhea. Diarrhea occurs in 10-20% of patients after PEG placement.⁴¹ Dietary changes, infection, malnutrition, and medications are potential causes. Rate of feeding should be tailored to the patient’s nutritional needs and tolerance to prevent both aspiration and diarrhea. Hyperosmolar solutions, lactase deficiency, and fat malabsorption due to pancreatic insufficiency should be considered as causes of diarrhea. Antibiotics and magnesium antacids are common culprits. Consultation with nutritionists and pharmacists can be helpful in finding the cause.⁴¹ When above causes are excluded, placement of the PEG tube into the jejunum or colon should be suspected, which can be confirmed by injecting contrast into the tube and obtaining an x-ray or CT scan.^42,43

Tumor implantation. Metastases or implantation of a tumor at a PEG site is a rare complication. The mechanism of implantation is believed to be direct seeding of the tumor during the procedure.⁴⁴ This complication has been reported mainly in patients with head and neck cancer. It is manifested by unexplained skin changes or development of a growth at the PEG site. Although no treatment is required, palliative radiotherapy and surgical block resection at the PEG site has been described.^45,46 Instead of routine push/pull techniques, Russell introducer-type placement, in which the tube is passed directly through the abdominal wall, should be considered to avoid this potential complication.⁵

Miscellaneous Complications
Several complications, including PEG site herniation,²⁴ aortogastric fistula,⁵ subcutaneous emphysema,⁵ subcostal neuralgia,⁵ and bronchoesophageal fistula,⁵ have been described in the literature.

Psychological Effects of PEG Placement
A significant level of depression and stress was found in patients whose lifestyle had changed, in part due to having to use a PEG tube and in part due to underlying disease.⁴⁷ Similar results were found among the relatives of these patients. However, it has also been reported that patients and caregivers feel that PEG tubes helped in feeding and in prolonging survival.⁴⁸ It is difficult to obtain accurate information from patients, as many of them have advanced dementia, inability to comprehend, read, or write, and altered mental status. Further studies are needed to accurately evaluate post-PEG placement psychological effects.

Conclusion

PEG tubes have become the modality of choice for providing enteral access to patients who need long-term nutrition and medications. They are very safe and well tolerated but not without complications. Thorough evaluation of indications, contraindications, and complications; utilizing optimal technique during placement; and appropriate post-placement care are vital in order to minimize complications. Early recognition and prompt, aggressive treatment are essential to optimizing outcomes in cases where complications develop.