Percutaneous

Endoscopic
Gastrostomy

By: Jose Byron Dadulla-

Evardone
 A percutaneous endoscopic gastrostomy
(PEG) is an endoscopic procedure for placing a
tube into the stomach through the abdominal wall
. PEG tubes may also be extended into the
small bowel.
 The procedure is performed in order to place a
gastric feeding tube as a long-term means of
providing nutrition to patients who cannot take
food orally. Many stroke patients, for example,
are at risk of aspiration pneumonia due to poor
control over the swallowing muscles; some will
benefit from a PEG performed to maintain
nutrition.
 PEGs may also be inserted to
decompress the stomach in cases of
gastric volvulus.
 Indications

 PEG should be considered for

pediatric and adult patients who
have an intact, functional
gastrointestinal tract but are unable
to consume sufficient calories to
meet metabolic needs. PEG is
inappropriate in patients with rapidly
progressive and incurable disease,
since nasoenteral feedings over a
short interval can provide the same
 The most common indications for
PEG are neurologic conditions
associated with impaired swallowing
and neoplasms of the oropharynx,
larynx and esophagus. Other
indications include facial trauma and
the need for supplemental feedings
in patients with miscellaneous
catabolic conditions.
 Inpatients with repeated aspiration
of nasogastric tube feedings or
requiring prolonged gastric
decompression, PEG can be modified
to percutaneous endoscopic
jejunostomy to provide both jejunal
feeding and gastric decompression.
 Contraindications

 An absolute contraindication to PEG

is the inability to bring the anterior
gastric wall in apposition to the
anterior abdominal wall. Therefore,
patients with prior subtotal
gastrectomy, ascites, or marked
hepatomegaly require careful
evaluation to be sure the stomach
and abdominal wall can be brought
together with gastric insufflation.
 Recognition of apposition may be
difficult in patients with severe
obesity. PEG should not be used for
nutritional support, when
gastrointestinal tract obstruction is
present. Relative contraindications to
PEG include proximal small bowel
fistula, neoplastic and infiltrative
diseases of the gastric wall, and
obstructing esophageal lesions.
Coagulation defects, if correctable,
are not a contraindication to PEG
 Technique

 The most widely used technique of PEG is the

"pull" method introduced by Gauderer and Ponsky
in 1980. Modifications of the original technique
have been reported. The gastrostomy tube can be
pushed rather than pulled into place by a "push"
method that has comparable results. In another
modification, the "introducer method," the
stomach is directly punctured and a Foley
Catheter placed over a guidewire. Finally,
percutaneous gastrostomy has also been
described without endoscopy using a nasogastric
tube or gastric insufflation, fluoroscopic
monitoring, and a direct percutaneous catheter
insertion technique.
 The basic elements common to all of
these techniques are: (1) gastric
insufflation to bring the stomach into
apposition to the abdominal wall;
 (2) percutaneous placement of a
tapered cannula into the stomach;
 (3) passage of a suture or guidewire
into the stomach;
 (4) placement of the gastostomy
tube; and verification of the proper
position
 Complications

 Reported complications include a

wound infection, peritonitis,
septicemia, peristomal leakage, tube
dislodgement, aspiration, bowel
perforation, and gastrocolic fistula.
Pneumoperitoneum is common after
PEG and of no significance, unless
accompanied by signs and symptoms
of peritonitis .
Position of PEG Tube
TOTAL PARENTERAL
NUTRITION
By: Jose Byron Dadulla-
Evardone
 Total parenteral nutrition (TPN),
is the practice of feeding a person
intravenously, bypassing the usual
process of eating and digestion. The
person receives nutritional formulas
containing salts, glucose,
amino acids, lipids and added
vitamins.
 TPN is normally used following surgery,
when feeding by mouth or using the gut is
not possible, when a person's digestive
system cannot absorb nutrients due to
chronic disease, or, alternatively, if a
person's nutrient requirement cannot be
met by enteral feeding (tube feeding) and
supplementation. It has been used for
comatose patients, although enteral
feeding is usually preferable, and less
prone to complications.
 Short-term TPN may be used if a
person's digestive system has shut
down (for instance by Peritonitis),
and they are at a low enough weight
to cause concerns about nutrition
during an extended hospital stay.
Long-term TPN is occasionally used
to treat people suffering the
extended consequences of an
accident or surgery.
 The preferred method of delivering TPN is
with a medical infusion pump. A sterile
bag of nutrient solution, between 500 mL
and 4 L is provided. The pump infuses a
small amount (0.1 to 10 mL/hr)
continuously in order to keep the vein
open. Feeding schedules vary, but one
common regimen ramps up the nutrition
over a few hours, levels off the rate for a
few hours, and then ramps it down over a
few more hours, in order to simulate a
normal set of meal times.
 The nutrient solution consists of water, glucose,
salts, amino acids, vitamins and (more
controversially) sometimes emulsified fats. Long
term TPN patients sometimes suffer from lack of
trace nutrients or electrolyte imbalances.
Because increased blood sugar commonly occurs
with TPN, insulin may also be added to the
infusion. Occasionally, other drugs are added as
well.
 Chronic TPN is performed through a Hickman line
or a Port-a-Cath (venous access systems). In
infants, sometimes the umbilical artery is used.
 Complications

 The most common complication of TPN use is

bacterial infection, usually due to the increased
infection risk from having an indwelling
central venous catheter. Liver failure may
sometimes occur; a recent study at Children's
Hospital Boston on the cause suggests it is due to
a large difference in omega-6 to omega-3 ratio.
When treated with a different fatty acid infusion
(which is not approved for use in the U.S.) two
patients were able to recover from their
condition.[1]
 Two related common complications of TPN are
venous thrombosis and priapism. Fat infusion
during TPN is assumed to contribute to both.[