by Maria Adams, MS, MPH, RD
Anatomy and Physiology
Digestion of food begins in the mouth. When you swallow, food is pushed down into the esophagus, a muscular tube that carries food to the stomach where it is digested. From the stomach, food travels to the small intestines, where digestion continues and nutrients are absorbed into the bloodstream.
Eating food provides you with nutrients that are necessary for your body to function, grow, and repair itself. We need to consume six types of nutrients to sustain life: carbohydrates, protein and fat, which all provide energy, but in different forms, vitamins and minerals, which help the body use the energy provided by food, and water, which dissolves the other nutrients, and is necessary for lubrication, transportation, and regulation of body temperature. The abdominal wall, which protects the stomach, intestines, and other abdominal organs, consists of layers of skin, fat, muscle, fascia, and membranes. The fascia is a layer of fibrous tissue beneath the skin and fat.
Reasons for Procedure
Adequate nutrient intake is essential to support life and maintain health. Under certain circumstances, it may not be possible to take in enough, or even any, nutrients through the mouth. In these situations, an alternative form of feeding becomes necessary.
Examples of conditions or circumstances that may make alternative feeding necessary include the inability to: consume food through the mouth due to cancer of the esophagus, oral surgery, or swallowing difficulties following a stroke, meet nutritional requirements fully with normal foods due to major surgery, trauma, burns, or anorexia, digest food on account of inflammation of the pancreas, adequately absorb food on account of radiation therapy or inflammatory bowel disease affecting the small intestine.
If the digestive tract is still functioning, food can be provided in the form of a thick liquid through a tube that leads into the stomach or small intestine. This is referred to as tube feeding. If the intestine is not functioning, or needs rest, nutrition may be provided as a clear liquid solution directly into the bloodstream via an IV. This is referred to as parenteral nutrition.
There are many different types of tube feedings. The least invasive method is the placement of a nasogastric tube through the nose and into the stomach or small intestines. This method is not ideal for longer durations since it's positioning through the nose is cumbersome, uncomfortable, and may cause breathing difficulties, such as aspiration.
Another common method of tube feeding is the percutaneous endoscopic gastrostomy, or PEG, which involves the insertion of a feeding tube directly into the stomach through a small incision in the abdominal wall. This method is a less invasive alternative to the placement of a feeding tube into the stomach via a larger incision, known as an open laparotomy.
A third method is endoscopic percutaneous jejunostomy, which is like a PEG, except that the tube is inserted into the middle portion of the small intestine, known as the jejunum, instead of the stomach. This method is beneficial for individuals with gastric reflux disease who risk aspirating stomach contents into their lungs if it rises up into the throat.
A PEG is usually performed as an inpatient procedure when it becomes clear that a patient will be unable to take food by mouth for an extended period of time. If your PEG placement is scheduled as an outpatient procedure, your doctor will advise you on the steps you should take at home to prepare for the surgery.
A PEG procedure takes an average of 30 minutes. To begin the procedure, you will receive a sedative through an IV to help you relax. He or she will also apply a local anesthetic at the site in your abdomen where the PEG tube is to be placed.
The most commonly used PEG placement procedure is the "pull method." In this procedure, your doctor will insert a lighted endoscope through your mouth and thread it down your esophagus and into your stomach. A camera attached to the endoscope will produce images of the inside of your stomach displayed on a video monitor.
Next your doctor will insert a needle into the stomach at the spot where the PEG tube is to be inserted. While doing this, he or she will use the endoscope to locate the end of the needle inside the stomach and encircle it with a wire snare.
Your doctor will then pass a thin wire through this needle until it reaches the stomach, attach the endoscope to the wire, and pull both the endoscope and wire out through the mouth. At this point there will be a thin wire entering the front of the abdomen into the stomach, and continuing upward and out of the mouth.
Your doctor will attach the PEG feeding tube to the wire outside of your mouth. By gently tugging on the other end of the wire, he or she will pull the tube back through the mouth and esophagus and into the stomach.
Your doctor will continue to pull until the tip of the tube comes out of the incision in the stomach and abdomen. A soft, round "bumper" attached to the portion of the tube that remains inside the stomach secures it in place. The outer portion of the tube will be secured with a bumper as well and sterile gauze will be placed around the incision site.
In the alternative "push" method, your doctor will begin in the same fashion by using an endoscope to guide a wire though the abdominal wall and into the stomach. But instead of pulling the PEG tube through the mouth, he or she will push it directly into the stomach over the wire.
Risks and Benefits
Complications associated with a PEG placement are relatively rare, but can include: infection, PEG tube dislodgment, malfunction, or leakage at the insertion site, a hernia in the wall of the abdomen, an abnormal connection, or fistula, between the stomach and colon, aspiration, peritonitis, septicemia, abdominal bloating, nausea, regurgitation, vomiting, and/or diarrhea.
Potential benefits of a PEG tube placement include: ensuring adequate intake of essential nutrients and water, maintaining the function of the digestive tract, avoiding prolonged use of nasogastric tube or parenteral nutrition.
In a PEG placement, or any procedure, you and your doctor must carefully weigh the risks against the benefits to determine if it's the most appropriate treatment option for you.
After the Procedure
After your procedure: You will continue to receive fluids through an IV for a day or two. Once there is evidence that your digestive tract is functioning, you will receive clear liquids through the PEG tube; if tolerated, this will be followed by a tube feeding formula. A nurse or dietitian will teach you how to use and care for your PEG tube, and how to choose an appropriate formula.
If your procedure is done on an outpatient visit, you will most likely go home the same day. After your PEG placement: remain upright for 30-60 minutes after feedings, get out of bed often, change the sterile gauze pads around the incision site regularly, tape the tube site to help prevent dislodging when not in use, avoid smoking, resume normal activities as quickly as possible to promote healing.
Call your doctor promptly if you experience: signs of infection, such as fever or chills, redness, swelling, increasing pain, excessive bleeding, or discharge at the incision site, interruption in the flow of tube feedings, abdominal pain and/or bloating, nausea, regurgitation, or vomiting, and/or constipation or diarrhea.
- Feeding tube placement. The Cleveland Clinic Health Information Center. Available at: http://www.clevelandclinic.org/health/health-info/docs/2800/2825.asp?index=10348. Accessed October 21, 2004.
- Medical encyclopedia: feeding tube insertion - gastrostomy. MedlinePlus. National Institute of Health website. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/002937.htm. Accessed October 21, 2004.
- Role of percutaneous endoscopic gastrostomy. The Society of American Gastrointestinal Surgeons website. Available at: http://www.sages.org/sg_asgepub1017.html#sectionII. Accessed October 25, 2004.
- Your feeding tube placement. WFSM Division of Radiologic Sciences. Available at: http://www.rad.wfubmc.edu/patienteduc/feed_tube_placemnt.htm. Accessed October 21, 2004.
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