Percutaneous Gastrostomy tubes: Trouble-shooting a leaking 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 leaking 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.
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Recognising a leaking percutaneous gastrostomy tube early may assist in successful management.
Suspect a leaking tube if there are any of the following:
- Fluid secretions are seen to leak around the gastrostomy: test with a pH strip to determine if acidic (suggests gastric fluid - note if the resident is on a proton pump inhibitor such as pantoprazole or omeprazole gastric fluid may not be acidic on pH testing).
- Skin around the gastrostomy is excoriated, red, irritated and / or oozing.
Source: NSW Agency for Clinical Innovation and the Gastroenterological Nurses College of Australia. A Clinician’s Guide: Caring for people with gastrostomy tubes and devices from pre- insertion to ongoing care and removal. Sydney: ACI; 2015. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0017/251063/ACI-Clinicians-guide-caring-people-gastrostomy-tubes-devices.pdf
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If any of the following red flags are identified in residents who have a leaking percutaneous gastrostomy tube, review the resident’s advance care plan, consult resident or substitute health decision maker (or nominated decision support person) and refer to Management of residents with unstable vital signs pathway.
The following are considered red flags in the resident with a leaking percutaneous gastrostomy:
- Vital signs in the red or danger zone - refer to Recognition of the deteriorating resident
- Severe abdominal pain on attempting to flush gastrostomy tube or on administration of feeds (ensure that feed administration is ceased)
- Suspected bowel obstruction: abdominal distension, vomiting, lack of passage of flatus and bowel motions
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First screen for red flags as above. Where there are no red flags, any of the following may prompt escalation to HHS RaSS (at GP discretion) or to the HHS Gastrostomy Support Service:
- Red flags in a resident who has conservative goals of care and does not wish to be transferred to hospital.
- Tube appears damaged.
- Suspected balloon rupture.
- Progressively increasing volumes of peristomal leakage.
- Breakdown of skin at site.
- Bleeding at PEG / RIG site.
- Recurrent peristomal infections.
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Percutaneous gastrostomy tube management plan should encompass the following actions to prevent tube leak and complications of a leak:
- Implement daily gastrostomy care:
- Clean site with mild soap and water thoroughly twice a day - dry after cleaning, with care to dry around the tube and under the bolster plate / external flange
- Flush the tube a minimum of twice daily, before and after bolus feeds or every 4 hours if continuous feeds and before and after each medication
- Rotate tube gently through 360 degrees (unless otherwise advised by the HHS Gastrostomy service)
- Confirm tube position against gastrostomy care plan prior to use
- Monitor for evidence of site leak / signs of infection
- Protect peristomal skin with a barrier wipe such as Cavilon No-sting barrier film
- Weekly checking of retention balloon volume as recommended by manufacturer instructions - balloon should be checked by those with an appropriate scope of practice and training.
- Adequate stabilisation of the device and avoiding traction / pulling on the device.
- Fit of the bolster plate / external flange, with 3 to 5 mm between the skin and the plate when gentle traction is applied: check fit with resident lying and sitting. The bolster plate / external flange should only be adjusted by those with an appropriate scope of practice and training.
- Optimise the Resident’s bowel assessment and management to prevent constipation as this is a frequent cause of leaking gastrostomy tubes.
- Implement daily gastrostomy care:
References
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- 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.
- 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.
- PEG and PEG-J insertion and ongoing management. Princess Alexandra Hospital, Metro South Health; 2020.
- 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.
- Boeykens K, Duysburgh I, Verlinden W. Prevention and management of minor complications in percutaneous endoscopic gastrostomy. BMJ Open Gastroenterol. 2022;9(1).
- Dandeles LM, Lodolce AE. Efficacy of agents to prevent and treat enteral feeding tube clogs. Ann Pharmacother. 2011;45(5):676-80.
- 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.
- Sealock RJ, Munot K. Common Gastrostomy Feeding Tube Complications and Troubleshooting. Clin Gastroenterol Hepatol. 2018;16(12):1864-9.
- 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-caringpeople-gastrostomy-tubes-devices.pdf accessed 2/2024. - Ghevariya VP, V.; Momeni, M.; Krishnaiah, M.; Anand, S. Complications associated with percutaneous endoscopic gastrostomy tubes. Annals of Long-term care. 2009.
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Pathway Percutaneous Gastrostomy tubes: Trouble-shooting a leaking Percutaneous Endoscopic Gastrostomy (PEG) / Radiologically Inserted Gastrostomy (RIG) Document ID CEQ-HIU-FRAIL-00026 Version no. 3.0.0 Approval date 12/04/2024 Executive sponsor Executive 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 Supersedes PEG tube: trouble shooting a leaking 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 Keywords PEG tube complications, RIG tube complications, Leaking PEG, Leaking RIG, percutaneous endoscopic gastrostomy tube leakage 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