Percutaneous Endoscopic Gastrostomy (PEG) – Information and Care guidelines for patients and carers

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This booklet aims to provide you with information about your PEG tube. It explains what the procedure is, how it is performed, and gives aftercare advice. If you have additional questions please contact your Nurse or Dietitian who will be able to help you.

What is a Percutaneous Endoscopic Gastrostomy? (PEG)
• Percutaneous – meaning something is inserted through the skin
• Endoscopic – the instrument used to place the PEG tube is called an endoscope
• Gastrostomy – means an opening into the stomach

A PEG is a small tube that is inserted through the skin directly in to the stomach so that you can receive feed, fluid and medication without swallowing.

Why do I need a PEG?
You are unable to take enough food and fluid by mouth to meet all of your nutritional and
hydration needs. The PEG can help to meet these requirements as the feed and fluid can
be given directly into the stomach.
How long will the tube last?
The PEG tube is made from polyurethane and if it is well cared for it can last for several
years. Depending on the reason that you are having the PEG, you may only need it for a
short period and then it can be removed.
Can I still eat and drink?
You may be able to eat and drink, but this depends on the reason why you are having the
PEG tube inserted in the first place.
If you are having swallowing difficulties the Doctor may refer you to a Speech and
Language Therapist who will be able to advise you on what you can safely eat and drink.

What does the PEG tube look like?

Freka ®PEG

How do I prepare?
• If you are diabetic it is important that you contact your diabetic specialist nurse or assessment nurse prior to any of these preparations so that they can instruct you on what you need to do.
• If you are taking any medicines e.g. Warfarin, Aspirin or Clopidogrel these may need to be altered or stopped before your procedure. You may also need to have blood tests. Please speak to your GP, the assessment nurse or the hospital doctor for advice.
• Before the procedure it is important that your stomach is empty. Please do not eat or drink anything for at least six hours (preferably overnight) before the procedure.
• If you have a nasogastric tube as a method of feeding you should not have any feed down it for at least six hours (preferably overnight) before the procedure.

What to bring with you?
• Your appointment letter and the health questionnaire. Please complete the health questionnaire.
• A dressing gown and a pair of slippers.

When you arrive at the Endoscopy department:
• A nurse will welcome you and admit you to the unit for the procedure.
• The nurse will also take details on whether you have any allergies to any medicines, any medical conditions and anything which would require you to be given any further antibiotics before the procedure (for example an artificial heart valve or if you suffer from valvular heart disease).
• They will ask you for details of any medicines you are currently taking, e.g. Warfarin, Aspirin and Clopidogrel. It is important that the doctor in the Endoscopy department is aware of these and any other conditions before the procedure is started.
• You will be asked to put on a hospital gown. If you wear spectacles or dentures you will be asked to remove them.
• Before you go to the endoscopy room, the Doctor or Nurse placing the PEG will discuss the procedure, explaining any risks and give you the opportunity to ask questions. Then you will be asked to sign a consent form. This will be completed before you go to the endoscopy room.
• In the endoscopy room you will be asked to lie on your back. A small plastic intravenous cannula will be placed in a vein in your right hand or arm. You will be administered sedation (this is usually a sedative called Midazolam).
• Your throat may be made numb by using a local anaesthetic spray and then a flexible tube (endoscope) will be passed through your mouth into the stomach. This will allow the doctor to inspect your stomach and identify the correct position for the PEG.
• The procedure will take approximately 30 minutes.
• Most patients remain overnight in hospital after this procedure.
• Your throat may be slightly sore for a day or so after the procedure.
• You should not drive, operate machinery or drink alcohol for about 24 hours after the procedure, nor should you make any important decisions.
• Your GP and Community Dietitian will be sent a letter informing them of the procedure you have had.

Are there any significant risks?
PEG placement is generally a safe and well tolerated procedure. However, the following are potential risks:
• Reactions to the medication given (sedative)
• Pain.
• Infection at the insertion site.
• Bleeding from the incision site.
• Perforation, which is a little tear in the wall of the bowel. This is rare and would require a hospital stay for antibiotics and possibly a surgical repair.

Important Notice:
If you are discharged within 72 hours of having your PEG placed and you notice any of the following symptoms, DO NOT PUT anything through the PEG and contact Ward 8 on 01908 996395/996394 or the Endoscopy unit on 01908 996460 URGENTLY:

• Leakage of fluid around the PEG tube.
• Pain on feeding (stop the feed).
• Prolonged or severe pain with possible abdominal bloating.
• New bleeding from the PEG site.

National patient Safety Agency (2010) Rapid Response Report: Early detection of complications after gastrostomy.

Care of the PEG tube and the insertion site:
o Always wash your hand thoroughly before touching the PEG and the insertion site.
o The PEG will not be used for the first 6 hours after the procedure. You will also have to remain nil by mouth for 6 hours after the procedure.
o Intravenous fluids will be given to prevent you from becoming dehydrated.
o After 6 hours the tube will be flushed with 50mls of sterile water. If your PEG is required for feed or medication, these can be given via the PEG the following morning but not before.
o Leave the original dressing intact for 24 hours. After which, the dressing may be removed and the PEG insertion site cleaned with sterile gauze and sterile water. Leave the site exposed. Remove and re-dress sooner if there is excessive bleeding.
o The tube should remain under moderate tension for 24 hours to promote good adaptation of the stomach wall to the abdominal wall. (Fresenius insertion guideline)
o After 24 hours the triangular fixation plate can be loosened. It should be kept 0.5-1cm from the abdominal wall. Do not keep the fixation plate too tight or a pressure sore may develop.
o Clean around the PEG tube site once daily for the first 10 days with sterile water and sterile gauze. After this time clean with mild soapy water and dry well.
o If the insertion site is painful or red the nurse or the GP will take a swab to check for infection.
o Leave the feeding line clamp open when the PEG is not being used for feeding, as this will prevent flattening of the tube.
o The feeding tube should be flushed with at least 30mls of water before and after feed or medicine administration. This will prevent the tube from blocking.
o If the PEG tube becomes blocked, warm water may be used to un-block it. Use a purple 60ml syringe and connect it onto the PEG tube. Use a continuous ‘pushpull’ action to slowly dislodge the blockage. This may take some time. You can also contact your Abbott Nutrition Nurse on 07824483335 for support.
o If the PEG falls out it is very important that you act quickly before the tract closes. Go to A&E immediately and they will contact the appropriate team.

Rotating and advancing the PEG:
To prevent the internal bumper of the PEG from becoming buried it is very important that the PEG is advanced and rotated daily. This should start 10 days after placement and not before.

Advance and rotate procedure:
1. Wash hands thoroughly with soap and water.
2. Open the fixation clip (see Fig 1).
3. Detach tube from groove in fixation plate (see Fig 2).
4. Move plate away from skin (see Fig 3).
5. Advance the PEG tube into the stomach by 6-7cm and rotate 360 degrees, then gently pull back the tube to feel resistance.
6. Place the fixation plate back to its original position (0.5-1cm away from the skin). Reinsert tube in the groove (see Fig 4) and close the fixation clip (see Fig 5).
7. Your fixation plate should not be too tight or too loose.

Courtesy of Fresenius kabi: Gastrostomy Feeding Care Guidelines for patients and carers

Before discharge from hospital:
• You and/or your family or carer will be given training and information on setting up feeds, PEG care and who to contact if you need advice.
• Your Abbott Nutrition Nurse will be advised of your discharge from hospital and will arrange to visit you at home.
• You will be discharged home with a 14-day supply of all the required equipment for your PEG and if required, feed.
• Your community dietitian will arrange further deliveries of feed and other equipment once you are at home.

PEG Replacement and Removal:
If your PEG needs replacing, your GP may refer you to the hospital to be seen by the Gastroenterologist and the Nutrition Nurse. They will review the PEG and decide if it needs changing. If you no longer need your PEG your GP will refer you to the Gastroenterologist to remove it.

Useful Contacts:
Community Dietitian: 01908 995416
Abbott Nutrition Nurse: 07824483335
District Nurse:
Hospital Nutrition Nurse: Jane Radice 01908 660033 Bleep 1722