PEG Tube Placement
What the Examiner Expects
Percutaneous endoscopic gastrostomy — placement of a feeding tube directly into the stomach through the abdominal wall under endoscopic guidance. The examiner expects you to know the indications (need for enteral nutrition > 4 weeks, such as stroke with dysphagia, head and neck cancer, or neurodegenerative disease), contraindications, and the pull technique: endoscope identifies safe puncture site using transillumination and finger indentation, a needle is inserted percutaneously into the stomach, a guidewire is passed, grasped endoscopically, pulled out through the mouth, and the PEG tube is pulled through the mouth, esophagus, and stomach, exiting through the abdominal wall.
Key Examiner Focus Points
- Indications: enteral access for patients unable to take oral nutrition > 4 weeks
- Pull technique most common; transillumination and finger indentation confirm position
- Contraindications: ascites, coagulopathy, interposed colon (Chilaiditi), peritoneal dialysis
- Buried bumper syndrome: internal bumper migrates into gastric wall
- If PEG cannot be placed, consider surgical or laparoscopic gastrostomy
Common Curveballs
Patient has a large hiatal hernia — can you place the PEG?
Proceed with caution. The hernia may alter gastric position. Ensure adequate transillumination and finger indentation at the puncture site. If you cannot achieve safe positioning, consider a surgical or laparoscopic gastrostomy instead.
3 weeks after PEG placement, there is erythema and purulent drainage at the site
PEG site infection. Local wound care and oral antibiotics (covering skin flora). If there is a peristomal abscess, consider removal of the PEG and placement at a new site after the infection resolves.
The PEG tube is accidentally pulled out 10 days after placement — the tract is immature
An immature tract (< 2–4 weeks) will not hold a blind replacement. The tube may enter the peritoneal cavity. Place a Foley catheter to maintain the stoma if possible, obtain a water-soluble contrast study through the Foley to confirm intragastric position. If tract is lost, may need surgical or repeat endoscopic placement.