Editing PEG insertion (section)

== '''Complications''' ==

* Leakage
** True significant leakage due to a technical error tends to present in first few days
** Can present as either asymptomatic leakage of gastric fluid around the tube to skin, or leakage to peritoneum causing overwhelming peritonitis and sepsis
** Causes:
*** Inadequate fixation of the stomach against the inner abdominal wall
*** Separation of the two (due to ischaemia and necrosis of the gastric wall from an over-tight seal)
*** Tube migration
*** Distal obstruction
*** Balloon deflation/rupture
*** Incorrectly-sized device
*** DGE
*** Constipation
*** Increased intra-abdominal pressure
** Diagnosis - minor pneumoperitoneum is not diagnostic, because it can be present for 1-2 weeks normally. However, large-volume pneumoperitoneum is highly suggestive of leak. If in doubt, do a contrast study down the PEG.
** Management of 
*** If no intra-peritoneal leakage on contrast study, 'rest' the tube for a week and give IV Abx, to allow it to seal. Then repeat the contrast study before feeding. 
*** If there is obvious peritoneal leakage, manage based on clinical scenario - operate if there is peritonitis or sepsis. Can be done laparoscopically.
**** If everything looks healthy at operation, can do a purse-string around the tube and re-fix to the abdo wall
**** If stomach looks 'bad', remove the tube and staple/suture off the defect, and consider replacing the tube in a healthy location
*** Late leaks - generally behave like a controlled gastro-cutaneous fistula, but can become uncontrolled and cause peritoneal sepsis
* Buried bumper
** When the internal fixator erodes past the stomach wall, and instead sits within the stomal tract
** Risk factors - frequent and inadvertent device traction, rapid weight gain, lapses in exit site care
** Presentation - leakage, blockage, infection/inflammation at exit, pain, inability to advance device within tract
* Bleeding
** Immediate post-procedural bleeding can be controlled with gentle traction on tube
* Minor irritation to skin - close attention to cleansing
* Fungal infection - antifungal powders/creams
* Infection may reflect abscess - can incise to look for pus, and give antibiotics
** Always consider and exclude a necrotising infection
* Migration is generally related to excessive traction and subsequent necrosis
* Gastrocolic fistula - if colon is pierced at insertion
** Frequently patient has diarrhoea
** Free leaks/abscesses must be controlled, but fistulas 
** PEG-associated gastrocolic fistulas may subside when the tube is pulled out, but not necessarily
* Abdominal sepsis following PEG
** Stop feeds, get a tubogram
* PEG pulled out
** Gastrostomy:
*** If early (within four weeks), before a tract has formed, give Abx and NGT, and rebook procedure for 5-7 days
**** Can also attempt to reinsert if it seems like there is a decent tract and no peritonitis or sepsis, but also put in an NGT and 'rest' the stomach for a week on Abx
*** 4-6 weeks - bedside replacement with similar-sized tube, then confirm no leak with tubogram before using again
*** >6 weeks: put in a Foley 20Fr as a temporising measure and then replace it with a feeding tube when available, safe to use straight away if flushing well and pH of aspirate <=5
* Delirious patient pulling PEG out - try an abdominal binder
* Pain
** Consider poor tube positioning - too close to costal margin
* Blocked tube
** See separate topic under 'nutrition'