PEG

Contraindictions
Acites: can leak and cause peritonitis
Inability to transilluminate (can cutdowm to fascia to facilitate or can use bedside US)

Several different techniques: push, pull or Seldinger

Proc
Give Abx
Thorough endoscopy
Insufflate until rugal folds disapear
Transilluminate skin and bounce finger
Infiltrate with LA, bigger skin incision than PEG to allow infection to drain
Introduce needle 45 deg cephalad
Pass wire and grasp with endosnare
Push or pull PEG
Visualise with endoscope, button should rotate freely to avoid gastric wall necrosis


Complications
15% total
10 infection rate if antibiotics used
Leak is usually caused by too much tension causing gastric necrosis
Confirm with fluoroscopy or CT
If confirmed, pull PEG and place NG
Pneumoperitoneum may persist for several weeks
Progressive enlargement of stoma is usually due to excess movement of PEG. Need to correct movement rather than placing bigger PEG
Gastrocolic fistula is rare. Be suspicious if patient develops perifeeding diarrhoea several weeks after placement
Fuoroscopy is diagnostic
Rx is removal of PEG