A Percutaneous Endoscopic Gastrostomy (PEG) tube is a feeding device placed through the abdominal wall directly into the stomach, providing long-term nutritional support for individuals unable to safely swallow or consume enough calories by mouth. The procedure is generally considered safe and less invasive than a surgical gastrostomy, making it the preferred method for enteral feeding extending beyond four weeks. While the PEG tube delivers nutrition, hydration, and medication, its use is associated with potential complications. Understanding these risks, which occur in an estimated 4% to 24% of cases, is important for patient safety.
Acute Risks Associated with Placement
The immediate risks associated with PEG tube placement occur during the procedure or within the first 48 hours and often involve severe internal injury. One serious acute complication is hemorrhage, resulting from the accidental puncture of an abdominal wall vessel or a deeper artery. This bleeding is rare but can lead to a rectus sheath hematoma or significant intra-abdominal bleeding, sometimes requiring urgent surgical intervention.
Another life-threatening risk is the perforation of an internal organ, occurring when the needle or trocar passes through a structure other than the stomach during insertion. The colon is the most commonly injured organ, which can lead to peritonitis if gastric contents leak into the area. While pneumoperitoneum (air in the abdomen) is common and usually benign, a true perforation requires immediate recognition and often surgical repair.
The procedure also carries risks related to the sedation or general anesthesia required for the endoscopy. These include adverse cardiopulmonary events such as hypoxia (low oxygen levels) and hypotension (low blood pressure). Patients are also at risk for aspiration of stomach contents into the lungs during sedation, which can rapidly progress to aspiration pneumonia. These complications necessitate a short hospital stay following insertion.
Localized Stoma and Skin Complications
Complications affecting the stoma (the external opening where the tube exits the skin) are the most frequently encountered long-term issues. Stoma site infection, or cellulitis, is the most common minor complication, potentially affecting up to 30% of patients, presenting as redness, pain, pus discharge, or a foul odor. Risk factors include poor hygiene, diabetes, malnutrition, and excessive pressure from the external fixation device.
Leakage of stomach contents or formula (peristomal leakage) is another common problem that significantly impacts skin health. Gastric acid and digestive enzymes irritate the skin, causing redness, inflammation, and eventual skin breakdown (dermatitis or maceration). Managing this involves applying barrier creams or powders and ensuring the tube is properly seated to minimize the gap between the skin and the external bolster.
The constant irritation and moisture can also stimulate hypergranulation tissue, an overgrowth of pink, moist tissue around the stoma site. This tissue is highly vascular and bleeds easily, worsening leakage and hygiene issues. Treatment often involves applying a caustic agent like silver nitrate or topical steroid creams to reduce the tissue overgrowth.
Mechanical Hazards of the Tube
Mechanical issues relate to the physical failure or improper positioning of the tube, creating maintenance challenges. Tube blockage, or clogging, is a frequent hazard, often occurring when formulas or medications are not adequately flushed with water after each use. A clogged tube prevents the delivery of necessary nutrition and medication, often requiring specialized declogging tools or device replacement.
Accidental dislodgement or removal of the tube is a concerning complication, especially in agitated or confused patients. If the tube is pulled out within the first four weeks before the tract has fully matured, it is a serious medical emergency, allowing stomach contents to leak into the abdomen and cause peritonitis. Even after the tract has matured, the stoma can close within hours, requiring immediate reinsertion.
A specific long-term mechanical hazard is the “buried bumper syndrome.” This occurs when the internal retention device migrates and becomes embedded in the gastric wall tissue. This migration is caused by applying excessive tension between the internal and external bolsters, slowly pulling the device into the stomach lining. This syndrome can lead to feeding intolerance, pain, and inability to insert the tube, often requiring endoscopic or surgical removal.
Systemic and Feeding-Related Concerns
The process of enteral feeding introduces systemic concerns that extend beyond the stoma site or the tube’s mechanics. Aspiration pneumonia is a life-threatening complication that occurs when gastric contents, formula, or oral secretions are breathed into the lungs. This risk is elevated in patients with a poor gag reflex, impaired consciousness, or a high volume of residual stomach contents, and it is a leading cause of death in tube-fed patients.
Metabolic complications, particularly refeeding syndrome, can occur if nutritional support is initiated too quickly in malnourished patients. The sudden influx of carbohydrates stimulates insulin release, causing a rapid shift of electrolytes (like phosphate, potassium, and magnesium) from the bloodstream into the cells. This rapid depletion of serum electrolytes can lead to severe consequences, including cardiac arrhythmias, respiratory failure, and neurological dysfunction.
Common gastrointestinal issues are frequently reported, including diarrhea, constipation, and nausea. These are often related to the formula composition, the rate of infusion, or the patient’s underlying disease. Diarrhea is a common side effect, which can be exacerbated by certain medications or by the high osmolality of the liquid feed. Managing these issues requires careful adjustment of the feeding protocol, formula selection, and close monitoring of laboratory values.