Skip to content

Percutaneous Endoscopic Gastrostomy (PEG) Tube

I. Background

Percutaneous endoscopic gastrostomy (PEG) is a commonly performed procedure that provides durable enteral access for feeding and medications. This document outlines patient selection and perioperative considerations for PEG tube placement.

II. Guideline

A. Patient Selection / Preoperative Care

  • Contraindications to PEG Placement

    • Anatomic inability to place PEG (e.g., Roux-en-Y anatomy, mesh overlying site, esophageal stricture)
    • Uncontrolled agitation (requiring restraints/sitter in prior 48 hrs)
    • Ascites
    • Severe dementia
    • Anorexia nervosa

  • Special Situations

    • Esophageal cancer: Discuss with Thoracic Surgery if esophagectomy planned
    • Failure to thrive: Proceed only if medically reversible
    • Palliative decompression: OK in unresectable malignancy
    • Peritoneal dialysis: Must be on HD x6 weeks before PEG; wait ≥4 weeks to resume PD
    • VP shunt: Separate PEG and VP shunt placement by ≥7 days
    • ALS (without trach): Prefer IR-placed gastrostomy due to anesthesia risk
    • Active chemotherapy:
      • Delay PEG during severe leukopenia (WBC <2.5 or ANC <0.5) or platelets <50k
      • Risk/benefit discussion required
    • Immunosuppressants / Corticosteroids:
      • Delay PEG during induction therapy
      • If planning to stop, wait until discontinued
      • If long-term use, wait until on stable maintenance dose

  • Anticoagulation Management

    • Heparin drip: Hold 4 hours pre- and post-procedure
    • Prophylactic heparin/enoxaparin: Do not hold
    • Therapeutic enoxaparin: Hold AM dose; resume PM if no bleeding
    • DOACs: Hold 24 hrs prior; resume PM if no bleeding
    • Aspirin: Continue
    • Clopidogrel/Ticagrelor/Effient (alone): Continue
    • Dual antiplatelet therapy (DAPT):
      • Preferred: Continue aspirin, hold second agent 5 days before procedure
      • If unable: Risk/benefit discussion on delaying PEG vs. performing while on DAPT

  • Preoperative Tube Feeds & Diet

    • Bedside PEG (ICU)
      • Protected airway: Hold feeds for ≥1 hour
      • Unprotected airway: Hold solids/tube feeds ≥6 hrs, clear liquids ≥2 hrs
    • OR PEG
      • NPO after midnight
      • High-risk nutrition: solids/tube feeds ≥6 hrs, clear liquids ≥2 hrs

B. Procedural Care

  • Follow bedside surgery protocol: sterile prep, timeout, sedation, consent
  • Antibiotic prophylaxis: Weight-based Cefazolin within 1 hr of incision
  • T-fastener Indications:
    • Corticosteroids
    • Chemotherapy
    • Immunosuppressants
    • At attending discretion
  • Equipment: See Appendix A

C. Postoperative Care

  • Immediate PEG Care

    • PEG to gravity drainage (foley bag) x 4 hrs
    • Start tube feeds and meds ≥4 hrs post-procedure
    • Document PEG depth post-op and POD1
    • Continue postop checks for high-risk or complicated patients
    • Remove T-fasteners at 2–3 weeks unless causing necrosis
    • Schedule follow-up at 4 weeks
    • If PEG becomes dislodged → Urgent EGS evaluation

  • Dislodged PEG Tube

    • If <30 days from placement → emergent EGS consult
    • Concerning findings: peritonitis, free air/fluid, infection → consider exploration
    • If stable, attempt balloon gastrostomy tube placement with imaging confirmation (X-ray or CT with IV + per-tube contrast)
    • Consider repeat PEG in stable patients

  • PEG Removal

    • Minimum of 4 weeks post-placement
    • Criteria to remove:
      • Resolved indication (e.g., cleared by SLP)
      • 2 weeks of full PO intake
      • Weight stability
      • Tolerance of food textures
      • No planned surgery or radiation
    • Consider high-dose PPI to support tract closure

III. References

  1. Abraham NS, et al. J Can Assoc Gastroenterol. 2022;5(2):100–101.
  2. Bischoff SC, et al. Clin Nutr. 2022;41(2):468–488.
  3. Boullata JI, et al. JPEN J Parenter Enteral Nutr. 2017;41(1):15–103.
  4. ASGE Standards of Practice Committee, et al. Gastrointest Endosc. 2016;83(1):3–16.
  5. ASGE Standards of Practice Committee, et al. Gastrointest Endosc. 2015;81(1):81–89.
  6. Davies N, et al. Cochrane Database Syst Rev. 2021;8(8):CD013503.
  7. de Sousa Magalhaes R, et al. Scand J Gastroenterol. 2020;55(4):485–491.
  8. Gangwani MK, et al. Dig Dis Sci. 2023;68(5):1966–1974.
  9. Keung EZ, et al. J Am Coll Surg. 2012;215(6):777–786.
  10. Lipp A, Lusardi G. Cochrane Database Syst Rev. 2013;2013(11):CD005571.
  11. Lucendo AJ, et al. Rev Esp Enferm Dig. 2015;107(3):128–136.
  12. Meenaghan N, et al. J Gastrointest Surg. 2009;13(2):236–238.
  13. Oterdoom LH, et al. J Neurosurg. 2017;127(4):899–904.
  14. Rosenberger LH, et al. Surg Endosc. 2011;25(10):3307–3311.

IV. Authors

  • Elizabeth D. Krebs, MD
  • Nina E. Collins, APRN
  • Christian J. Carpenter, RN
  • Michael C. Smith, MD

Appendix A: Procedural Equipment

  1. Trauma procedure cart
  2. Sterile towels
  3. Bite block
  4. Sterile gown and gloves
  5. Eye protection
  6. Endoscopy scope
    • Pediatric colonoscope for PEG-J
    • Pediatric XP scope for esophageal narrowing
  7. 1-liter bottle normal saline
  8. Endoscopy connector set
  9. Suction tubing and canister
  10. Chlorhexidine skin prep
  11. PEG or PEG-J kit
    • If PEG-J: T-fasteners are required

Appendix B: Bedside Gastrostomy Care

  • Tube site monitoring

    • Record external length every shift
    • Clean site each shift with NS-moistened gauze
      • If skin breakdown: Triple Care EPC + dry gauze
      • If intact skin: Triple Care Ointment or Ilex Cream + dry gauze
    • Change gauze PRN

  • Tube care

    • Flush with 30 mL water every 8 hrs and PRN
    • Secure tube to prevent pulling or dislodgement
    • Use abdominal binder or appropriate tape

  • Feeding Instructions

    • Follow attending or nutrition orders
    • If tube is dislodged or depth changes → stop feeds and notify EGS