Gastrostomy Tube: PEG Feeding, Care & Complications

What Is a Gastrostomy Tube?

A gastrostomy tube is a feeding tube that passes through the skin of the abdomen directly into the stomach, allowing liquid nutrition, fluids, and medications to be delivered when a person cannot eat adequately by mouth. Common types include PEG tubes (Percutaneous Endoscopic Gastrostomy) and gastrostomy buttons.

A gastrostomy creates a direct pathway from outside the body into the stomach through a small opening called a stoma. This opening is made through the abdominal wall, and a tube or button device is placed to keep the pathway open. The device is secured both inside the stomach (with an internal bumper or balloon) and outside on the skin (with an external fixation device).

The term gastrostomy comes from the Greek words "gaster" (stomach) and "stoma" (mouth or opening). When the procedure is performed using an endoscope passed through the mouth to guide placement, it is called Percutaneous Endoscopic Gastrostomy or PEG. This minimally invasive technique was first described in 1980 and has become the most common method for placing feeding tubes.

Gastrostomy tubes serve as a lifeline for individuals who cannot meet their nutritional needs through oral intake alone. They allow the delivery of specially formulated liquid nutrition, water for hydration, and crushed or liquid medications directly into the stomach, where normal digestion can occur. This approach maintains the physiological process of digestion and absorption through the gastrointestinal tract, which is preferable to intravenous nutrition whenever possible.

Types of Gastrostomy Devices

There are several types of gastrostomy devices available, each with specific advantages depending on the patient's needs, lifestyle, and the expected duration of use. Understanding the differences helps patients and caregivers make informed decisions about which device may be most appropriate.

PEG tubes are the most commonly placed gastrostomy devices. They consist of a flexible tube that extends from outside the body into the stomach. The external portion can be capped when not in use and connected to feeding equipment when nutrition is administered. PEG tubes are typically the first device placed and are appropriate for both short-term and long-term use.

Gastrostomy buttons (also called low-profile devices or MIC-KEY buttons) sit flush against the skin surface, making them less visible and more comfortable for active individuals. They require an extension set to be connected for feedings and medication administration. Buttons are often placed after an initial PEG tube once the stoma tract is well-established, usually after 6-8 weeks.

Balloon gastrostomy tubes have an internal balloon filled with water that holds the tube in place within the stomach. These tubes need regular balloon checks and typically require replacement every 3-6 months. They can be changed at home or in outpatient settings once the tract is mature.

Who Needs a Gastrostomy?

Gastrostomy tubes are recommended for individuals who cannot consume adequate nutrition by mouth over an extended period, typically when oral feeding difficulties are expected to last more than 2-4 weeks. The decision to place a gastrostomy involves careful consideration of the underlying condition, nutritional status, life expectancy, quality of life goals, and patient preferences.

• Neurological conditions: Stroke, dementia, Parkinson's disease, motor neuron disease (ALS), multiple sclerosis, and traumatic brain injury can all affect swallowing function
• Head and neck cancers: Tumors or their treatment (surgery, radiation) may temporarily or permanently impair swallowing
• Congenital conditions in children: Cerebral palsy, genetic syndromes, and developmental disorders may affect feeding ability
• Severe dysphagia: Difficulty swallowing from various causes that leads to aspiration risk or inadequate intake
• Facial trauma: Injuries that prevent normal oral feeding during recovery
• Failure to thrive: When a person cannot maintain adequate nutrition despite efforts to improve oral intake

How Do I Prepare for Gastrostomy Placement?

Preparation for gastrostomy placement typically involves fasting for 6-8 hours before the procedure, stopping certain medications (especially blood thinners) as directed by your doctor, and having blood tests to check your clotting function. You will receive detailed instructions from the facility performing the procedure.

The preparation process begins well before the day of the procedure. Your healthcare team will conduct a thorough assessment to ensure you are a suitable candidate for gastrostomy placement. This typically includes a review of your medical history, current medications, allergies, and any previous abdominal surgeries that might complicate the procedure.

Blood tests are usually performed several days before the procedure to check your blood counts, clotting function, and kidney function. If you take blood-thinning medications such as warfarin, aspirin, clopidogrel, or newer anticoagulants, you will receive specific instructions about when to stop these medications to reduce bleeding risk. The timing of stopping anticoagulants varies depending on the specific medication and your individual risk factors.

On the day of the procedure, you will need to fast - this means no food or liquids for at least 6-8 hours beforehand. This fasting period is crucial because an empty stomach reduces the risk of complications during the procedure and makes it easier for the doctor to place the tube correctly. If you take essential medications, you may be advised to take them with a small sip of water, but always confirm this with your healthcare team.

What to Expect When You Arrive

When you arrive at the hospital or endoscopy unit, you will be checked in and taken to a preparation area. A nurse will verify your identity, confirm you have fasted appropriately, and review your allergies and medications. You will change into a hospital gown and have your vital signs measured.

An intravenous (IV) catheter will be placed in your hand or arm. This IV line serves multiple purposes: it allows administration of sedation medications during the procedure, provides fluids to keep you hydrated, and gives access for any medications that might be needed. The IV placement involves a brief needle stick and is usually mildly uncomfortable but not painful once in place.

You will also receive prophylactic antibiotics through the IV line before the procedure begins. Studies have shown that a single dose of antibiotics given before PEG placement significantly reduces the risk of infection at the insertion site. This is now standard practice at most institutions.

How Is a Gastrostomy Tube Placed?

Gastrostomy tubes are most commonly placed using the PEG (Percutaneous Endoscopic Gastrostomy) technique, which involves passing an endoscope through the mouth to guide tube insertion through the abdominal wall. The procedure typically takes 15-30 minutes and is performed under sedation with local anesthesia.

The most widely used technique for gastrostomy placement is the Percutaneous Endoscopic Gastrostomy (PEG) procedure. This approach combines endoscopy (using a camera inserted through the mouth) with a small incision in the abdomen, allowing the tube to be placed with direct visualization and minimal invasiveness. The PEG technique has largely replaced open surgical gastrostomy due to its safety, efficiency, and faster recovery time.

Before the procedure begins, you will receive sedation through your IV line. Most PEG procedures are performed under conscious sedation (also called moderate sedation), which means you will be relaxed and drowsy but not completely unconscious. You may receive medications like midazolam and fentanyl, which provide relaxation and pain relief while allowing you to breathe on your own. Some patients may require general anesthesia, particularly if they have significant respiratory issues or cannot tolerate the endoscope while awake.

A throat spray or gel containing local anesthetic may be applied to numb your throat and suppress the gag reflex, making it more comfortable when the endoscope is passed. The endoscope is a thin, flexible tube with a light and camera at its tip. It is gently guided through your mouth, down your esophagus, and into your stomach. The camera transmits images to a monitor, allowing the doctor to see inside your stomach clearly.

The Pull Technique

The most common method for PEG tube placement is called the "pull" technique (also known as the Ponsky-Gauderer technique). Once the endoscope is in position inside the stomach, the room lights are dimmed. The doctor then shines the light from the endoscope against the stomach wall, and this light can be seen through the skin of the abdomen - this is called transillumination. The site where the light is brightest indicates where the stomach is closest to the abdominal wall, which becomes the insertion point.

The insertion site on the abdomen (usually in the left upper quadrant) is cleaned with antiseptic solution and draped with sterile towels. Local anesthetic is injected into the skin, underlying fat, and muscle layers to numb the area. A small incision (approximately 1 centimeter) is made through the skin. A needle with a sheath is then inserted through this incision, through the abdominal wall, and into the stomach - the doctor watches this on the monitor to ensure correct positioning.

A guidewire or suture is passed through the needle into the stomach and grasped with a special instrument passed through the endoscope. This wire or suture is then pulled up through the esophagus and out of the mouth. The PEG tube is attached to this wire and pulled down through the mouth, esophagus, stomach, and out through the abdominal wall. The internal bumper of the tube lodges against the inside of the stomach wall, while an external fixation device secures the tube against the skin.

Alternative Placement Methods

While the endoscopic technique is most common, there are situations where alternative approaches may be necessary. Radiologically-inserted gastrostomy (RIG) uses X-ray guidance (fluoroscopy) instead of endoscopy to place the tube. This method may be preferred when endoscopy is not possible due to obstruction in the throat or esophagus, or when a patient cannot safely have an endoscope passed.

Surgical gastrostomy may be performed as an open procedure or laparoscopically (using small incisions and a camera). Surgical placement is sometimes chosen when a patient is already undergoing abdominal surgery for another reason, when endoscopic or radiological approaches have failed, or in complex anatomical situations.

What Should I Expect After the Procedure?

After gastrostomy placement, you will typically stay in the hospital overnight for monitoring. You may feel drowsy from sedation and experience mild discomfort at the insertion site. Tube feeding usually begins the same day or the next day, starting with small amounts and gradually increasing.

Immediately after the procedure, you will be taken to a recovery area where nurses will monitor your vital signs as the sedation wears off. You may feel drowsy, and your throat might be slightly sore from the endoscope. Some people experience mild nausea as the sedation clears, but this usually resolves quickly. You will not be able to eat or drink anything by mouth until your healthcare team confirms it is safe, which is typically after you are fully awake.

The insertion site may be sore and tender for several days after the procedure. This discomfort is usually well-controlled with over-the-counter pain relievers like acetaminophen (paracetamol). Your doctor may also prescribe stronger pain medication for the first few days if needed. Some bruising around the site is normal and will resolve over 1-2 weeks.

Most patients stay in the hospital overnight after gastrostomy placement. During this time, the nursing staff will monitor you for any signs of complications, teach you and your caregivers how to care for the tube, and initiate feeding through the gastrostomy. Some patients with straightforward procedures and good support at home may be discharged the same day, while others with complex medical conditions may stay longer.

Starting Tube Feeding

Feeding through the new gastrostomy tube typically begins within 4-24 hours after placement, depending on your institution's protocol and your individual circumstances. Research has shown that early feeding (within 4 hours) is safe and may even reduce the risk of certain complications. Your healthcare team will determine the appropriate timing based on your specific situation.

Initial feedings are started slowly and gradually increased. You might begin with small amounts of water to ensure the tube is functioning properly, followed by diluted formula. Over the following days, the volume and concentration of feedings are increased until you reach your target nutritional goals. This gradual approach helps your digestive system adjust and reduces the risk of nausea, bloating, and diarrhea.

There are different methods for delivering nutrition through a gastrostomy tube. Continuous feeding uses a pump to deliver formula slowly over many hours (often overnight), which may be preferred for patients who do not tolerate larger volumes at once. Bolus feeding involves giving larger amounts of formula over a shorter period (typically 30-60 minutes), similar to eating a meal. Intermittent feeding uses a pump to deliver moderate amounts over 2-4 hours several times per day. Your dietitian and medical team will recommend the method that best suits your needs.

Before Leaving the Hospital

Before discharge, you and your caregivers will receive comprehensive education about gastrostomy care and feeding. This training typically covers cleaning and caring for the stoma site, operating feeding equipment (pumps, syringes, extension sets), preparing and storing formula, flushing the tube to prevent blockages, recognizing signs of complications, troubleshooting common problems, and emergency contact information.

You will receive prescriptions for any necessary supplies and medications, along with instructions for obtaining ongoing supplies. Many patients work with a home health nursing service in the first few weeks after placement, which provides additional support and education in the home environment. Follow-up appointments will be scheduled with your gastroenterologist, surgeon, or primary care provider to check on the stoma site and address any concerns.

How Do I Care for My Gastrostomy at Home?

Daily gastrostomy care includes cleaning around the stoma site with soap and water, gently rotating the tube to prevent skin adhesion, flushing with water before and after feedings, and inspecting for signs of infection. Proper care prevents most complications and keeps the tube functioning well.

Caring for a gastrostomy at home becomes routine with practice, and most patients and caregivers become comfortable with the daily tasks within the first few weeks. Consistent, proper care is essential for preventing complications such as infection, skin breakdown, and tube blockage. While the specific instructions may vary slightly based on your type of device and healthcare provider's preferences, the fundamental principles of care are similar.

Every time you handle the gastrostomy tube or perform any care, begin by washing your hands thoroughly with soap and water for at least 20 seconds. This simple step is one of the most important things you can do to prevent infection. If you are away from a sink, alcohol-based hand sanitizer can be used, but handwashing with soap and water is preferred, especially before preparing formula or handling feeding equipment.

Stoma Site Care

The skin around the gastrostomy tube requires daily cleaning to remove any drainage, crusting, or formula residue. For most patients, cleaning with mild soap and warm water is all that is needed. Use a clean washcloth or gauze to gently clean around the tube, then rinse thoroughly and pat dry. Avoid using harsh soaps, hydrogen peroxide, or alcohol on the site, as these can irritate the skin and delay healing.

After cleaning, inspect the site carefully for any signs of problems. Look for redness, swelling, warmth, unusual discharge (especially if it is yellow, green, or foul-smelling), and pain or tenderness beyond the normal mild discomfort. Some clear or slightly yellow drainage is normal in the first few weeks after placement, but persistent or worsening drainage should be reported to your healthcare provider.

Once daily, gently rotate the tube 360 degrees (one full turn). This rotation prevents the skin from growing onto the tube and helps ensure the tube moves freely. Do not force rotation if there is resistance - if the tube seems stuck, contact your healthcare provider. After rotating, gently push the tube in slightly and then let it return to its natural position. There should be about 3-5mm of movement (the width of a small pencil eraser).

Flushing the Tube

Regular flushing keeps the gastrostomy tube clear and prevents blockages, which are one of the most common tube-related problems. Use clean, room-temperature tap water for flushing unless you have been instructed to use sterile water (usually only necessary for immunocompromised patients or specific medical conditions).

• Before feedings: Flush with 30-60ml of water to ensure the tube is patent
• After feedings: Flush with 30-60ml of water to clear residual formula
• After medications: Flush with 30-60ml of water (flush between different medications if giving more than one)
• When not feeding: Flush at least every 8 hours if the tube is not being used for continuous feeds

Use a catheter-tip or ENFit syringe to deliver water flushes. Apply gentle, steady pressure - never force water through a blocked tube, as this can damage the tube or cause injury. If you encounter resistance, try gently pushing and pulling on the syringe plunger (a technique called "push-pull" or "milking") to loosen any blockage.

Bathing and Activity

You can shower starting the day after your gastrostomy placement, letting water run over the site without directing high-pressure water at it. Do not submerge the site in water for the first 3 weeks after placement - this means no baths, swimming pools, hot tubs, or natural bodies of water. After 3 weeks, once the stoma tract is well-established, most patients can resume these activities, but check with your healthcare provider first.

Most daily activities can be resumed as you feel comfortable, though you should avoid strenuous exercise and heavy lifting for at least 2 weeks after placement. The external part of the tube can be secured to your abdomen with tape or a tube holder to prevent pulling and discomfort during movement. If you have an active lifestyle, a low-profile button device may eventually be more suitable once your tract is mature.

What Complications Can Occur With Gastrostomy?

Most gastrostomy complications are minor and manageable. Common issues include infection at the stoma site, leakage around the tube, granulation tissue formation, and tube blockage. Serious complications like tube dislodgement within the first 3 weeks require emergency attention as the tract can close rapidly.

While gastrostomy is generally a safe procedure with high success rates, complications can occur. Understanding potential problems helps patients and caregivers recognize issues early and seek appropriate care. Most complications are minor and can be managed without hospitalization, but some situations require urgent medical attention.

Complications can be categorized as early (occurring within the first 30 days after placement) or late (occurring after 30 days). They can also be classified by severity as minor (manageable with local care or outpatient treatment) or major (requiring hospitalization or surgical intervention). Studies report overall complication rates of approximately 10-15%, with major complications occurring in less than 3% of patients.

Site Infection (Peristomal Infection)

Infection at the gastrostomy site is one of the most common complications, occurring in approximately 5-30% of patients depending on how strictly infection is defined. Signs of infection include increasing redness, warmth, swelling, and tenderness around the stoma, along with purulent (pus-like) discharge that may be yellow or green and have an unpleasant odor. You might also develop a fever.

Mild infections can often be treated with improved local wound care and oral antibiotics. More severe infections may require IV antibiotics and, rarely, removal of the tube. Prevention strategies include proper hand hygiene, daily site care, keeping the external fixation device appropriately positioned (not too tight against the skin), and completing the prophylactic antibiotic given at the time of placement.

Tube Dislodgement

Accidental removal or dislodgement of the gastrostomy tube can occur if the tube is pulled (either accidentally or intentionally) or if the internal balloon deflates or the internal bumper slips through an enlarged stoma. The urgency of this situation depends on how long you have had the gastrostomy.

After 3 weeks to 3 months, the tract is usually mature enough that the tube can be replaced in an outpatient setting, but you should still contact your healthcare provider promptly. For mature stomas (more than 3 months old), many patients are trained to replace their own tubes at home if they have a balloon-type device.

Leakage Around the Tube

Some leakage of gastric contents around the tube (called peristomal leakage) is common and can range from a minor nuisance to a significant problem that causes skin breakdown. Causes include a stoma tract that has enlarged, a tube that is too small for the tract, excessive movement of the tube, high gastric acid production, or improper tube positioning.

Management strategies include ensuring the external fixation device is positioned correctly, using barrier creams or zinc oxide to protect the skin, considering a larger-diameter tube or different device type, addressing causes of increased gastric pressure (such as constipation), and sometimes using medications to reduce stomach acid production.

Granulation Tissue

Granulation tissue is overgrowth of wound-healing tissue at the stoma site, appearing as red, moist, raised tissue around the tube. It is common (affecting up to 50% of patients) and usually occurs when there is chronic irritation, moisture, or movement at the site. While not dangerous, granulation tissue can bleed easily and cause discomfort.

Treatment options include silver nitrate application by your healthcare provider, topical steroid creams, keeping the site dry, and ensuring the tube is properly secured to minimize movement. Severe cases may require cauterization or surgical removal.

Tube Blockage

Blockages occur when formula, medication residue, or stomach contents accumulate inside the tube. They are more common when tubes are not flushed adequately, when medications are not properly crushed and dissolved, or when thick formulas are used. Prevention through regular flushing is key.

If a blockage occurs, try flushing with warm water using gentle push-pull motions with the syringe. If this fails, a carbonated beverage (like cola) or an enzyme-based unclogging solution may help. Never use excessive force, and contact your healthcare provider if simple measures do not clear the blockage.

How Is Nutrition Delivered Through a Gastrostomy?

Nutrition is delivered through a gastrostomy using specially formulated liquid formulas. Feeding can be continuous (using a pump over many hours), bolus (larger amounts given over 30-60 minutes like a meal), or intermittent. Your dietitian will calculate your nutritional needs and recommend the best feeding regimen.

Enteral nutrition through a gastrostomy tube provides complete nutrition directly to the stomach, maintaining the normal process of digestion. This approach preserves gut function, supports immune health, and is associated with fewer complications than intravenous (parenteral) nutrition. The specific formula, amount, and schedule are individualized based on your nutritional needs, tolerance, lifestyle, and underlying condition.

A registered dietitian is a key member of your healthcare team and will assess your nutritional requirements based on factors including your weight, height, activity level, medical conditions, and nutritional goals. They will recommend a formula type, calculate the volume and calorie target, and work with you to establish a feeding schedule that fits your lifestyle.

Types of Enteral Formulas

Enteral formulas are specialized liquid nutrition products designed to provide complete nutrition when delivered to the gastrointestinal tract. They come in several categories based on their composition and intended use.

Standard polymeric formulas contain intact proteins, carbohydrates, and fats in forms similar to regular food. They are suitable for most patients with normal digestive function and are available in various calorie densities (typically 1.0-2.0 calories per milliliter). Higher-calorie formulas are useful when fluid restriction is needed or when higher energy needs cannot be met with standard formulas.

Semi-elemental and elemental formulas contain proteins that are partially or fully broken down into smaller peptides or amino acids. These formulas are easier to absorb and may be used for patients with digestive disorders, malabsorption, or certain allergies.

Disease-specific formulas are designed for particular medical conditions. For example, diabetes-specific formulas have modified carbohydrate content to help with blood sugar control, renal formulas are lower in certain electrolytes for kidney disease patients, and pulmonary formulas have adjusted fat and carbohydrate ratios for respiratory conditions.

Feeding Methods

Continuous feeding delivers formula at a slow, steady rate over many hours, typically using an enteral feeding pump. This method may run for 12-24 hours daily and is often used initially after tube placement, for patients who do not tolerate larger volumes, or when administered overnight to allow freedom during the day. The slow delivery reduces the risk of nausea, bloating, and diarrhea.

Bolus feeding mimics normal meal patterns by delivering larger volumes (typically 240-500ml) over 30-60 minutes, several times per day. Formula can be delivered using a syringe (gravity bolus) or a pump set to a higher rate. This method offers more flexibility and freedom between feedings but may cause discomfort if given too quickly or in excessive volumes.

Intermittent feeding is a middle ground, using a pump to deliver moderate volumes over 2-4 hours, several times per day. This method provides some of the tolerance benefits of continuous feeding while allowing breaks between feeding sessions.

Medications Through the Gastrostomy

Many oral medications can be given through a gastrostomy tube, but proper preparation is essential to prevent tube blockage and ensure the medication works correctly. Always consult your pharmacist or healthcare provider before giving medications through the tube.

• Liquid medications are preferred when available, as they flow easily through the tube
• Tablets must be crushed into a fine powder and dissolved in water (check that the medication can be crushed - some cannot)
• Capsules may need to be opened and the contents dissolved (again, check with your pharmacist first)
• Enteric-coated and extended-release medications should NOT be crushed, as this destroys their special properties
• Flush the tube with 30ml of water before giving medications, between different medications, and after all medications are given

Can a Gastrostomy Tube Be Removed?

Yes, a gastrostomy tube can be removed when it is no longer needed, such as when swallowing function improves. The removal procedure is usually straightforward and can often be done in an outpatient setting. After removal, the stoma typically closes on its own within a few days to weeks.

Gastrostomy tubes are not necessarily permanent. For many patients, tube feeding is a temporary measure while recovering from surgery, illness, or treatment. When the underlying condition improves and adequate oral intake is restored, the gastrostomy can be removed. The decision to remove the tube is made collaboratively between you, your family, and your healthcare team.

Before removal is considered, your healthcare team will assess whether you can safely meet your nutritional and hydration needs through oral intake alone. This evaluation often involves a swallowing assessment by a speech-language pathologist, monitoring of oral intake over several days or weeks, and assessment of your nutritional status and weight stability.

The Removal Procedure

The method of removal depends on the type of device you have. Balloon gastrostomy tubes and buttons can usually be removed simply by deflating the balloon and gently pulling the tube out. This can often be done in a clinic setting and takes only a few minutes. You may feel brief discomfort or a "pop" sensation as the tube comes out.

PEG tubes with internal bumpers may require endoscopy for removal, as the bumper must be retrieved from the stomach. Alternatively, some tubes have bumpers designed to collapse and pass through the GI tract after being cut at skin level (the "cut and push" method). Your gastroenterologist will determine the safest removal approach based on your specific tube type.

After Tube Removal

Once the tube is removed, the stoma site will begin to close. For most patients, the opening closes spontaneously within several days to 2 weeks. During this time, you will need to keep the site clean and covered with a dressing. There may be some leakage of gastric contents until the tract closes completely.

In some cases, particularly when the tube has been in place for many years, the stoma may not close completely on its own. This is called a persistent gastrocutaneous fistula and may require surgical closure if it does not heal with conservative management.

After removal, you should monitor your weight, nutritional intake, and overall health closely. Some patients find that their swallowing or appetite changes over time, and in rare cases, a gastrostomy may need to be placed again in the future.

Frequently Asked Questions