Percutaneous Gastrostomy tubes: Trouble-shooting a blocked Percutaneous Endoscopic Gastrostomy (PEG) / Radiologically Inserted Gastrostomy (RIG)

This information does not replace clinical judgement. Refer to Conditions of use and copyright for further T&Cs.

Early and appropriate management of a blocked PEG/RIG concordant with the resident’s goals of care may avoid preventable suffering.

Flowchart

The flowchart shows all of the information at one time. Health professionals should always remain within their scope of practice; these pathways should never replace clinical judgement.

Click the link below to view the full flowchart.

Practice points

The practice points are a systemised documentation of expanded relevant information - use only in conjunction with the flowchart - note, you can access each relevant point from the flowchart link.

  • Recognising a blocked percutaneous gastrostomy tube early may assist in successful management.

    Suspect a blocked tube if there are any of the following:

    1. Tube is difficult or impossible to flush; a requirement for increasing pressure to flush the tube should raise concern for a partial blockage.
    2. Recurrent high-pressure or occlusion alarm on feeding pump.
    3. Where gravity feed is used, the feed stops dripping.

    Note: if the above signs are accompanied by severe pain on attempting to flush the PEG /RIG then this may be a sign of tube dislodgement or buried bumper syndrome - see Percutaneous gastrostomy tubes: Trouble-shooting a leaking Percutaneous Endoscopic Gastrostomy (PEG) / Radiologically Inserted Gastrostomy (RIG).

    • Don appropriate personal protective equipment (gloves, eye protection and plastic apron)
    • Use an ENFit enteral syringe at least 20 mL in size (do not use smaller syringes as these may rupture the tube) and half-fill with clean, warm water
    • Close the clamp (if present)
    • Open the cap on the feeding port and connect the syringe - if there are 2 feed ports, ensure the 2nd port is held closed throughout the procedure to avoid splash risk
    • Open the clamp (if present)
    • Aspirate (“pull”) from the tube
    • "Push” water gently (avoid excessive force) into the tube and then allow the plunger to return to its original position
    • Keep repeating the “push and pull” back and forth in a pulsating manner until the water cools down, the water becomes cloudy or the tube unblocks - this may take 20 to 30 minutes
    • Do not use carbonated beverages such as cola or acidic juices as these can worsen blockages through precipitation of crystals

  • Quality management of a percutaneous gastrostomy tube / radiologically inserted gastrostomy may prevent tube blockages. The following should be considered in development of a resident’s gastrostomy management plan:

    Domain Contributors to tube blockagePrevention
    Enteral feeding Failure to adequately flush enteral feeding tube before and after each feed
    • The resident’s enteral feeding regimen should include routine flushing before and after each feed with an appropriate volume of clean water
    • Continuous enteral feeds via a pump over many hours require a minimum of 4-hourly flushes of the gastrostomy tube to reduce risk of tube blockage
    • Consult a dietitian and GP to determine an appropriate volume of flush in residents on fluid restrictions
    Medication administration Enteral administration of medications that are not well crushed or not suitable to be crushed
    • Check Don’t rush to crush prior to crushing or seek pharmacist advice
    • Use liquid form of medication
    • Give each medication individually and flush before and after each medication using clean water (note do not use saline to flush the tube as this can cause crystallisation and increase risk of tube obstruction)
    Venting and gastric aspiration Frequent aspiration or siphoning of gastric fluid into the tube may increase risk of precipitation of feed or medications in the tube
    • Whilst some residents require intermittent or regular
      gastric venting for medical reasons, it is important that the gastrostomy tube is flushed immediately after venting, using enough water to clear the tube of residual gastric fluid
    • Use a clamp on the device to avoid back-flow of gastric fluid into the tube
    • If back-flow of gastric fluid occurs during the course of using the gastrostomy tube when administering feeds / medication / flushes, it is important that the tube is flushed again prior to completing use of the tube, to ensure that it is clear of any gastric fluid / debris
    Daily cares Failure to adequately flush enteral feeding tube
    • Flushing should occur before and after each bolus feed (or every 4 hours if continuous / pump feeds), before and after each medication and routinely before bedtime
    Material fatigue or deterioration Material fatigue due to expected deterioration over time or unexpected deterioration due to mishandling; silicone PEGs are more susceptible to blockage than polyurethane PEGs
    • Ensure gentle handling of enteral feeding tube
    • Avoid use of syringes smaller in volume than 20 mL to avoid excess pressure on tube
    • Ensure regular scheduled tube exchange in keeping with manufacturer recommendations
    • Monitor tube for evidence of warping or change in contour
    • Inspect tube for discolouration of tubing - black, brown or creamy patches may indicate colonisation of the tube with fungi which increases risk of tube blockage
    • Avoid over-tightening of fittings: when attaching syringes and feed giving sets to the gastrostomy tube, turn until you feel a little resistance
    • Clean the gastrostomy tube fittings of all feed and medication debris daily. Build-up on these fittings will lead to sticking and eventual breakage

References

    1. Pironi L, Boeykens K, Bozzetti F, Joly F, Klek S, Lal S, et al. ESPEN guideline on home parenteral nutrition. Clin Nutr. 2020;39(6):1645-66.
    2. Boullata JI, Carrera AL, Harvey L, Escuro AA, Hudson L, Mays A, et al. ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103.
    3. PEG and PEG-J insertion and ongoing management. Princess Alexandra Hospital, Metro South Health; 2020.
    4. Roveron G, Antonini M, Barbierato M, Calandrino V, Canese G, Chiurazzi LF, et al. Clinical Practice Guidelines for the Nursing Management of Percutaneous Endoscopic Gastrostomy and Jejunostomy (PEG/PEJ) in Adult Patients: An Executive Summary. J Wound Ostomy Continence Nurs. 2018;45(4):326-34.
    5. Boeykens K, Duysburgh I, Verlinden W. Prevention and management of minor complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol. 2022;9(1).
    6. Dandeles LM, Lodolce AE. Efficacy of agents to prevent and treat enteral feeding tube clogs. Ann Pharmacother. 2011;45(5):676-80.
    7. Ley D, Saha S. Everything that You Always Wanted to Know About the Management of Percutaneous Endoscopic Gastrostomy (PEG) Tubes (but Were Afraid to Ask). Dig Dis Sci. 2023;68(6):2221-5.
    8. Sealock RJ, Munot K. Common Gastrostomy Feeding Tube Complications and Troubleshooting. Clin Gastroenterol Hepatol. 2018;16(12):1864-9.
    9. NSW Agency for Clinical Innovation and Gastroenterological Nurses College of Australia. A Clinicians Guide: caring for people with gastrostomy tubes and devices from pre-insertion to ongoing care and removal. 2015. https://aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/ACI-Clinicians-guide-caring-people-gastrostomy-tubes-devices.pdf accessed 2/2024.
    10. Ghevariya VP, V.; Momeni, M.; Krishnaiah, M.; Anand, S. Complications associated with percutaneous endoscopic gastrostomy tubes. Annals of Long-term care. 2009.
    11. Blacka J, Donoghue J, Sutherland M, Martincich I, Mitten-Lewis S, Morris P, et al. Dwell time and functional failure in percutaneous endoscopic gastrostomy tubes: a prospective randomized-controlled comparison between silicon polymer and polyurethane percutaneous endoscopic gastrostomy tubes. Aliment Pharmacol Ther. 2004;20(8):875-82.
  • Pathway Percutaneous Gastrostomy tubes: Trouble-shooting a blocked Percutaneous Endoscopic Gastrostomy (PEG) / Radiologically Inserted Gastrostomy (RIG)
    Document ID CEQ-HIU-FRAIL-00025
    Version no.3.0.0
    Approval date08/04/2024
    Executive sponsorExecutive Director, Healthcare Improvement Unit
    Author Improving the quality and choice of care setting for residents of aged care facilities with acute healthcare needs steering committee
    Custodian Queensland Dementia Ageing and Frailty Network
    SupersedesPEG tube: trouble shooting a blocked tube v2.0.0
    Applicable to Residential aged care facility registered nurses and General Practitioners in Queensland RACFs, serviced by a RACF acute care support service (RaSS)
    Document source Internal (QHEPS) and external
    Authorisation Executive Director, Healthcare Improvement Unit
    KeywordsPEG tube complications, RIG tube complications, Blocked PEG, Blocked RIG, percutaneous endoscopic gastrostomy tube blockage
    Relevant standards Aged Care Quality Standards:
    Standard 2: ongoing assessments and planning with consumers
    Standard 3: personal care and clinical care, particularly 3(3)
    Standard 8: organisational governance

Last updated: 6 December 2024