Gastrostomy (PEG) feeding: Making the decision

PEG stands for Percutaneous Endoscopic Gastrostomy and is a small feeding tube which is inserted directly into the stomach.

Position of a PEG (please note that this is one type of PEG tube, there are many varieties so yours may not look like this)

Gastrostomy or PEG feeding allows you to have specially formulated liquid nutrition (prescribed by a dietitian), medications and water via a feeding tube, either instead of or as well as eating by mouth. A PEG tube also helps people who have difficulty swallowing and/or unsafe swallow.

It is designed for people who require tube feeding over a longer period of time (usually for more than 4 weeks) and can be removed if it is no longer required. It is hidden discretely under clothes and not visible when dressed.

A PEG insertion is a safe procedure and most complications are rare, but they can include:

• Skin infections
  You can develop infections around the PEG site. Every effort is made to minimise the risk of infection during the procedure. Training will be provided on keeping the PEG site clean after placement.
• Pain
  It is common to experience some pain after the procedure. The level of this is variable between individuals and will gradually reduce with time. The pain may persist on movement such as coughing. The doctors will be able to review this and provide pain relief where necessary.
• Bleeding
  Because a cut is made in the abdomen it is common to have some bleeding during a PEG insertion. This lasts for no more than a few seconds. A gauze dressing will be placed over the PEG site to help control this. Heavy internal bleeding is rare.
• Leaking
  It is common for small amounts of clear or straw-coloured liquid to seep from the PEG site after initial insertion. This will stop by itself. A leak from around the hole made in the stomach is rare but can cause an internal infection and pain.
• Sore throat
  Your throat may be sore for a day or two after the procedure. This is not serious and will get better.
• Pneumonia
  If you are very frail you can develop pneumonia after a PEG insertion. This is also a risk if you have very severe breathing problems such as COPD (bronchitis or emphysema) or cystic fibrosis. Your lung condition will need to be improved as much as possible before a PEG insertion.
• Reactions to the sedative
  The smallest dose of sedative possible will be provided to prevent you from experiencing any side-effects. If there are any reactions, medication shall be used to reverse the effects.
• Granulation
  There is a risk of the PEG site becoming overgranulated which is when skin/tissue grows over the stoma (the hole the tube is inserted in) due to friction between the skin and fixator plate. This can be minimised by good care of the site and securing the PEG with tape to minimise frequent movement (see page12 – ‘How will I care for the tube’).
• Peritonitis
  There is a very small risk of peritonitis, which is when the lining of the abdomen (peritoneum) can become infected due to making a hole into the stomach. Precautions will be taken to minimise the risk of this occurring.
• Bowel injury
  The stomach usually lies very close to the muscle and skin of the abdomen. However, there is a small risk of damage to the bowel if it lies between the stomach and the muscle. This bowel injury is rare but can be serious.

If you decide not to have the procedure it is very important that you inform the Endoscopy Unit as soon as possible and also the medical team who requested the test.

If you choose not to have the PEG, your alternative options will be discussed on an individual basis.

There are alternatives to having a PEG insertion. A naso-gastric tube (NG) is a tube leading to your stomach via your nostrils, but is designed for short-term use and can be more challenging to care for at home. A radiologically inserted gastrostomy (RIG) is another option, but these alternative procedures will be dependent on what is suitable for each individual.

Your stomach will need to be free of any food for the procedure, therefore you will not be allowed to eat or drink for six hours before the procedure.

You will be required to have a blood test in advance of the procedure.

If you take any blood thinning medications (e.g., Warfarin, Apixiban or Clopidogrel), you will be given individualised advice about stopping these before the procedure.

By law we must ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. The doctor will explain all the risks, benefits and alternatives before they ask you to sign the consent form. This is also an opportunity for you to ask the doctor any questions you may have regarding the procedure.

PEGs are placed in the endoscopy unit based at University College Hospital. You will be given a sedative during the procedure to help relax you. You will be monitored by nurses and doctors throughout to ensure you are comfortable.

The doctor will pass an endoscope (a type of flexible camera) through your mouth and into your stomach. A sedative (tablet that makes you sleepy but not unconscious) and a local anaesthetic (medication which numbs the area but does not put you to sleep) will be used when making a small cut in your skin to allow the feeding tube to be inserted. The doctors then use the camera on the tip of the endoscope to assist with guiding the feeding tube through. The whole process takes approximately 30 minutes to perform. This is usually painless, though you may feel some tugging as the tube is passed in.

Once the procedure is complete you will be kept in for observation to make sure there are no complications and that you are able to start using the PEG tube for fluid, nutrition or medications as required. If you are experiencing pain after the procedure, your pain relief will be reviewed by the doctors. You will then return to the ward where individual advice will be provided by your dietitian about using the PEG tube.

Typically, your stay will be anything from overnight to 5 days. It may be longer in some circumstances. You may need to come in the day before the procedure.

It is important not to move the triangle shaped fixator plate on the PEG for the first 10–14days post placement. After this it is important to rotate and advance the tube weekly to prevent the internal bumper from becoming buried. You will be taught how to do this by a nurse in the hospital or in the community and given the opportunity to practice.

The endoscopy unit will provide instructions about when the PEG tube can be used. This is usually a 60ml flush of water via the PEG 4 hours after insertion.

How can I use the PEG tube?

Via a pump – a bag or bottle of liquid feed is hung on a drip stand and given via a pump at a set rate and time as agreed with your dietitian. Depending on your needs, this could take place overnight to avoid disruptions during the day or daytime feeding can be done if suitable.

Via bolus feeding – liquid feed is given via the PEG using a large 60ml syringe at various intervals throughout the day. Each ‘feed’ should be given gradually to start with to prevent problems e.g. with reflux or nausea. The number and volume of feeds using the syringe will be agreed with your dietitian in order to achieve the number of calories that you need.

When you are feeding, it is important to make sure that you:

• Sit upright if you are feeding in the daytime
• Sleep at a 30–45 degree angle using pillows if you are feeding overnight or whilst in bed. This will help to prevent feed from being regurgitated.

Patient ‘bolus’ feeding through a PEG

What are the benefits to me?

Following PEG insertion, many people report that the good quality nutrition provided reduces fatigue and exhaustion. PEG feeding can also have additional benefits of helping manage symptoms e.g. constipation, diarrhoea and dehydration. A PEG can also aid the tolerance to treatments, for example, radiotherapy, and aid in recovery afterwards.

Difficulty with swallowing or not having the ability or appetite to eat can be upsetting for you, your family and carers. The PEG can help remove the anxiety and pressures of these feelings by providing all the nutrition you need from a specially prepared liquid feed.

Some people are at a higher risk of developing a chest infection which can occur when food or drink accidentally passes into the airways or lungs during swallowing. PEG feeding can also help reduce the risk of chest infections as feed is passed directly into the stomach.

Will I be able to take anything by mouth?

Yes, you can eat and drink as long as there are no concerns with your ability, and safety with taking an oral diet.

Having a PEG fitted does not necessarily mean that you have to stop eating and drinking. This will depend on your condition and treatment. Your Speech and Language Therapist will advise whether this is safe for you, and what types of food and drinks are suitable.

Will I gain or lose weight?

If you have lost weight your dietitian will take this into consideration when designing your feeding plan with the aim to regain some of the weight you have lost. If you don’t need to gain weight the dietitian will aim to ensure that your weight is kept stable and will monitor this closely.

If I am not eating anymore, do I still have to look after my mouth?

Your mouth must be looked after even if you are not eating. Plaque can build up very quickly so it is essential to brush your teeth at least twice daily where possible. A saline mouthwash is usually recommended for good mouth health.

What about sexual relationships?

Having a PEG should not interrupt personal and sexual relationships. You can still share your bed with your partner and it shouldn’t interfere with sex or get damaged, and can be secured with dressing tape.

How will I care for the tube?

You will be asked to clean the stoma site daily with water, and dry thoroughly. The external fixator will need to be kept 2-5mm from the skin and as discussed in the tube aftercare section, you will need to advance and rotate the tube weekly 10-14 days after the PEG has been inserted.

The tube should be flushed with at least 30mls of freshly run tap water or cooled boiled water if you have been told you are immunocompromised, before and after the feed or medicine administration to prevent tube blockage. You should only use the tube to administer the prescribed feed, water and liquid medication.

If you are not using your PEG, it is still essential to flush the tube daily with water to keep the tube working.

How will I take my medication?

If you are unable to swallow your medication by mouth, it can be taken via the PEG instead. Medication will be prescribed in a liquid form wherever possible and administered down the PEG tube using a syringe. Pharmacy will be able to advise you on the safest way to administer you medication via PEG.

The tube must always be flushed with water before and after administration of drugs to prevent the tube blocking.

Will a PEG affect my bowels?

People in general can have trouble with their bowels, in particular constipation. There can be numerous reasons for this including weakened muscles, poor fibre intake or poor fluid intake. PEG insertion can help with these problems. There are a variety of different feeds available and your dietitian may advise on the use of a high fibre feed if constipation remains a problem. If you have problems with persistent diarrhoea your dietitian will also take this in to consideration when deciding on which feed to use.

Will I be able to take a bath and shower?

You will need to wait until the site is fully healed before you can bathe or shower as normal (this will take a few weeks). After that period it is safe to have a bath and shower, making sure the tube end is closed and the clamp applied. Dry the area thoroughly but gently afterwards.

Can I go swimming or do exercise?

Yes. However, we would advise you avoid vigorous/strenuous exercise for at least 2 weeks after your PEG has been inserted, and the site has healed. Light exercise such as walking should be fine.

It is advisable to cover the site with a waterproof dressing when swimming in public pools. Make sure the tube end is closed and the clamp applied. The district nurse will be able to advise on the appropriate dressings where necessary.

How long will I need to stay in hospital if I have a PEG fitted?

The stay will be affected by a variety of factors. This may include whether you will use your PEG straight away, your tolerance to the feed and if there are any concerns with the PEG post insertion and ensuring you and your family members or carers are able to manage the PEG. Typically your stay will be anything from overnight to 5 days. It may be longer in some circumstances.

How long do the tubes last?

In general the gastrostomy tubes usually last for about 1–2 years but can last longer than this, especially if they have been well cared for. They can be replaced in hospital if necessary. There are also low profile devices that can be arranged if you require a feeding tube long term.

Can a PEG fall out?

The PEG is fixed by an internal disc within the stomach so it cannot easily fall out. Externally, it can also be secured to the skin by using a hypoallergenic tape to prevent it from getting pulled. Taping the tube can also minimise the risk of developing overgranulation tissue on the skin around the tube.

Some types of gastrostomy tubes are held in place with an internal balloon, and the management of this will be discussed with you.

Is it reversible?

If the PEG is no longer being used or necessary then yes it can be reversed or removed. Your hospital team, community dietitian, district nurse or G.P can help arrange this. You normally need to return to the endoscopy suite at your local hospital, where it is removed and this will heal quickly.

Does it hurt?

After the procedure you will likely feel a small amount of pain around the PEG site which will usually pass after a few days. Your doctors will be able to give you some pain relief.

What if I can’t manage a PEG?

Some people might find it difficult to use their PEGs by themselves, especially if they have poor hand function. If you do not have family members that can help you, your dietitian can liaise with the district nurses in your area to see if support can be provided.

Is it my decision whether I have a PEG?

YES. The decision is yours.

However we recommend that you talk to your family and to all the people involved in your care to ensure you are fully informed before making the decision (e.g. Hospital Consultant, GP, Dietitian, Speech and Language therapist, Specialist nurse).

Will having a PEG change my life at home?

Having a PEG should not affect or restrict your normal activity. Your dietitian will agree with you a suitable feeding plan which will meet the needs of your daily routine.

Where would I get the pump?

If you decide to feed with a pump, this will either be loaned to you on the ward or delivered to your home. This pump will be on long term loan from a feeding company and will need to be returned after you have finished using it.

What feed will I receive?

Your dietitian will recommend the most suitable liquid feed for you, which contains all the energy, protein, vitamins and minerals you need in a day. This feed has to be prescribed by your GP. You may also require extra water via your tube and the dietitian will advise you on this. The PEG should only be used for prescribed feed, medications and water.

For further information your dietitian can be contacted.

Department of Nutrition & Dietetics
3rd Floor East
University College London Hospital
NW1 2PG

Direct line: 0203 447 9289
Fax: 020 7380 9811

Head & Neck Dietitians
Ground Floor Central
University College London Hospital
NW1 2PG

Direct line: 0203 447 9755

Neuroscience Dietitians
Box 91, The National Hospital of Neurology & Neurosurgery
Queen Square
WC1N 3BG

Direct line: 020 3448 3109

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