Percutaneous Endoscopic Gastrostomy Placement-What to Expect

 

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Judy J. Davis, M.D., F.A.A.P.

1095 E Warner Ave #102

Fresno, CA 93710

(559) 412-8184 Fax (559) 4381174



PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PLACEMENT


A percutaneous endoscopic gastrostomy placement is a procedure done in order to feed directly into the stomach through the abdominal wall. This is done when a child is unable or unwilling to take enough nutrition by mouth in order to sustain normal growth and nutritional status. The tube that is placed through the abdominal wall into the stomach will remain there for a minimum of three months and then it can be withdrawn in the clinic and a button or a low profile device, which is almost even with the skin, will be put in its place if desired. The tube is placed during an endoscopic procedure where a flexible tube, attached to a powerful light source, is passed through the mouth and guided through the esophagus into the stomach and duodenum for direct observation of the lining of these areas. The endoscopist is a specially trained physician who uses esophagogastroduodenoscopy (EGD) to help diagnose and treat certain disorders of the upper gastrointestinal tract as well as place gastrostomy tubes. After the percutaneous endoscopic gastrostomy tube (PEG) is placed, the child will be admitted to the hospital and observed overnight for any complications.


PREPARATION FOR PEG:


Preparation for your child's procedure is individually based on age. Your child will receive a preparation specific for him or her. Please read the instructions at least two days before the procedure.


WHAT HAPPENS DURING THE PEG


*An IV will be started in your child's arm or hand. Cream will be placed on the skin to decrease the amount of pain associated with IV insertion. The child will most likely have the hand and arm placed on a board to help prevent dislodgment of the IV. If general anesthesia is used, the IV will be placed after your child has been put to sleep with gas.              

*Your child will be put in a gown and vital signs will be taken. Questions will be asked about the health of your child recently and whether or not the preparation for endoscopy could be followed. Medications will be given through the IV to make your child sleepy and less anxious and also so that your child will not remember anything about the procedure. An antibiotic will also be given through the IV in order to decrease the risk of infection after placement of the PEG.

*         Your child will then be taken from the room that you are in into the procedure room and the PEG will be done. The scope is inserted by the physician into the mouth and advanced through the esophagus, stomach and duodenum. If there are biopsies to be taken because of abnormal findings on the endoscopy, they will be done at this time. Following this a medication will be injected in the skin in the left upper part of your child's abdomen In order to numb that area. Then a 1/2-inch incision is made in that area of the abdomen and a catheter is placed through the incision.  Then a guidewire is placed through the

catheter into the stomach, which can be seen by the physician. The endoscope is then used to grab that wire and pull it out of your child's mouth. The gastrostomy tube is then attached to the wire and advanced through the mouth, esophagus, and stomach and out of the abdominal wall. The feeding devices are then placed on the exterior part of the gastrostomy tube. There is a bolster on the inside of your child's stomach that will prevent dislodgment of the gastrostomy tube unless considerable force is applied to it. No stitches are needed for this procedure.

*When the procedure is finished your child will go to the recovery room and rest until the sedation wears off. Your child's pulse, respiration, blood pressure and oxygen saturation will be monitored during and after the PEG. You can be with your child once the procedure is over and your child is stable. As soon as he or she is alert enough, your child will be transferred to the hospital room that has been assigned to him or her for overnight observation for any complications related to the procedure. Your child will not be able to take anything by mouth until the next morning. IV fluids will be given throughout the night and in the morning feedings will begin through the gastrostomy tube.

*You will be taught how to care for the gastrostomy tube and how to feed through the gastrostomy tube during your stay in the hospital. The tube should be turned 90 degrees three times a day after cleaning with half strength hydrogen peroxide for the first two weeks. After two weeks, you can use mild soap and water to clean the gastrostomy site and it is only necessary to turn the tube once a day. It is important to note where the retainer ring is on the tube and keep it at the same site that your doctor has told you it should remain. This keeps the tube from migrating into your child's stomach and also makes sure that the apparatus next to your child's skin isn't squeezing the skin too tightly. It is also very important that you flush the tube after every medication is given and after every feed is given and at least every four hours during continuous feeds. This helps prevent blockage of the tube with formula or medication. The procedure is extremely well tolerated with some discomfort related to the incision which may require some intravenous pain medication overnight, but by the next day usually Tylenol or ibuprofen satisfactorily treats the discomfort.


POSSIBLE COMPLICATIONS OF PEG: 


*The PEG procedure is a safe procedure and is associated with very little risk. However, complications can occur.

*One possible complication is perforation, which is a tear through the wall of the gastrointestinal tract that  may allow leakage of fluid and bacteria from the gastrointestinal tract into the chest or abdominal cavity, which can cause infection and pain. Perforation of the esophagus can also cause air to leak into the chest and breathing difficulties (i.e., pneumothorax). The complication of perforation usually requires surgery, but sometimes can be managed by antibiotics and intravenous fluids and sometimes a chest tube is necessary. Perforation can occur through the colon and then into the stomach during this procedure. This can result in a fistula, or a tract between the anterior abdominal wall, colon and the stomach. This requires surgical intervention.



*Bleeding can occur from the site of any biopsies that may be taken or from the site of the gastrostomy tube placement. Bleeding is usually minor and stops on its own, but occasionally repeat esophago-gastroduodenoscopy needs to be done and cauterization (application of an electric current) or injection of a specialized fluid may be necessary to stop the bleeding. Rarely, transfusion or surgery is required. Bright red blood in the child's emesis is fairly common in the first 24 hours of the procedure. Also coffee ground material can be seen if the child throws up in the first 24 hours.

* Local irritation of the vein may occur at the site of the medication injection, but it usually subsides in two to three days. Elevating the extremity and using hot compresses on the affected area will be helpful. Tylenol or ibuprofen is often helpful for the discomfort.

*Other risks include drug reaction, i.e., slowing of the heart rate or respiratory rate or possible allergic reaction to the medications. Blood pressure depression can also occur, secondary to the medications given.

*Abdominal bloating or crampy abdominal pain due to the air injected into the gastrointestinal tract can occur and this subsides by the next morning. Again, use of Tylenol or ibuprofen is good measures to alleviate the discomfort.

*Infection at the site of the gastrostomy placement can occur and this is usually treated with antibiotics via the gastrostomy tube. This is usually a late complication, meaning it occurs after the child is discharged from the hospital. It is important to watch this gastrostomy site for signs of redness or tenderness. Fever is also an important sign to watch for in your child as this may signal an infection. Death is extremely rare but remains a remote possibility.


TELL YOUR DOCTOR IF


*Your child is allergic to medications.

*Your child takes any medications.

*Your child has any lung problems or a loose tooth.

*Your child is pregnant.


HOW LONG DOES THE PROCEDURE TAKE?


*PEG placement takes up to 3060 minutes.

*You need to arrive at least one hour prior to the scheduled procedure in order to have the IV placed and your child sedated in time for the procedure.

*Recovery time after the procedure is between 1 and 2 hours. The recovery room nurse will notify you after your child is ready to go to his or her room when he or she is alert enough.


SPECIAL NOTES


*Please advise your doctor if your child becomes ill before the procedure, as it might need to be canceled for the safety of your child.

*Sometimes medications that are given for sedation can cause vomiting and nausea for the first 24 hours after the procedure.



RESULTS


*You will be given the results of any biopsies that may have been taken during the endoscopy and PEG procedure    within one week of the procedure.

*Your child will be discharged the day following the procedure if he or she is stable.

*A return visit appointment to the clinic will be made in approximately two weeks following the procedure. If you have any questions regarding the procedure, please don't hesitate to call (559) 4388400.






Judy J. Davis, M.D., F.A.A.P.

Fellow American Academy of Pediatrics

Fellow SubBoard American Academy of Pediatric Gastroenterology

American Board of Nutrition

Clinical Professor, Department of Pediatrics, University of California, San Francisco

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