Major Complications

Aspiration can occur during the procedure or later during gastric feeding. It occurs more commonly in neurologically impaired patients. The mortality related to aspiration can be as high as 60%. The best way to prevent these complications is to pay meticulous attention to procedural detail. The patient's stomach should be completely suctioned and overdistension should be avoided to prevent aspiration of gastric contents. Oversedation should also be avoided. The head of the bed should be elevated up 30° to 45° during feeding and continued for 1 hour after. Intermittent or continuous feeding is associated with less aspiration compared to rapid bolus feeding (McClave and Chang, 2003).

Peritonitis after PEG placement occurs in up to 1.2% of patients. Peritonitis can result from several factors such as premature removal or displacement of the tube before tract maturation, internal leakage around the exit stoma, and viscous perforation. Abdominal pain, fever, leukocytosis, and peritoneal findings on physical examination, may herald early peritonitis. If a leak into the peritoneal cavity can be documented on contrast study, early surgical intervention maybe required. In cases where the tube is pulled out prematurely and there is no sign of peritonitis, the patient can be managed conservatively with IV antibiotics and NG tube decompression.

Buried bumper syndrome occurs in about 22% of cases. In this condition, the internal bumper erodes through the stomach mucosa leading to ulceration. With time, this passage becomes re-epithelialized, covering the bumper, hence the name "buried bumper syndrome." The condition is due to excessive traction or pressure between the internal and external bolster of the tube leading to mucosal ischemia. By designing newer, softer, cup-shaped bumpers and decreasing excessive pressure between the bolster, the incidence has decreased. Typical findings include abdominal pain during feeding, swelling around the stoma, peritubal leaks, and difficulty advancing, pulling or rotating the feeding tube. This syndrome may also present as a local abscess or necrotizing tissue infection. Several techniques for management of this complication have been described. It is important to determine which will be less traumatic to the PEG site, pulling the tube through the abdominal wall, or back into the stomach (McClave and Chang, 2003).

Hemorrhage is a rare complication of PEG placement occurring in 0 to 2.5% of cases. It can result from direct puncture of the vessels in the gastric wall and can usually be managed by applying tamponade pressure to the internal bumper. Once the bleeding is controlled, the bumper should be loosened to avoid mucosal ischemia. Bleeding at time of procedure can also occur from mucosal tears in the esophagus or stomach.

Gastrocolocutaneous fistula is a widely described complication of PEG placement. This complication results either from inadvertent puncture of the intervening colon due to poor gastric insufflation or from migration and erosion of the tube through the colon. It may remain undetected for some time after the procedure. The patient usually presents with severe diarrhea or with stool seeping out around the PEG tube. It can also present in an earlier phase with signs of peritonitis if there is leakage into the peritoneal cavity. Occasionally, this problem may be discovered only when the old PEG tube is replaced with a new tube. In most cases, it can be managed conservatively by removing the gastrostomy tube and allowing the tract and fistula to close.

Necrotizing fasciitis is a rare but potentially lethal complication of PEG placement. Clinical features include localized abdominal pain, edema, erythema, and ecchymoses, with progression to bullae formation and eventually septic shock. Broad spectrum antibiotics with wide surgical debridement are necessary.

PEG site metastasis of head and neck tumors is a rare complication. So far nine cases have been reported. The median time for development of this complication is 8 months post-PEG placement. The exact mechanism of implantation is not known, although direct seeding of the tract by the tumor cells during the procedure is considered to a play major role. Some degree of hematogenous spread has also been speculated. Usually no specific treatment is necessary. Management by local radiation or wide excision have been described.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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