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home - Oesophagus - Dysphagia - PEG Written by Dr Sebastian Zeki
Knowledge


Knows the various causes of dysphagia and their clinical
presentations

Understands the methods of assessment and investigation including
the use of manometric assessment where appropriate

Knows the range of therapeutic options including the potential for
endoscopic treatment, and how to select appropriate treatment

Non-Cardiac Chest Pain:
Understands the potential role of the oesophagus in patients
presenting with chest pain in whom a cardiac cause has been
excluded and its role in the genesis of functional symptoms.

Knows the range of appropriate investigation of such patients and the
various avenues of management

Carcinoma of the Oesophagus:
Knows the predisposing factors, presentation, diagnostic work-up and
staging

Knows the range of potential therapies (including palliative care), and
understand how the appropriate selection is made

Skills
Can make a thorough clinical assessment, select investigations
appropriately and plan therapy.

Behaviours
Manages patients with oesophageal disease with care and
compassion.

Also....

PEG

PEGIncidence of Complications—Complications are more likely to occur in elderly patients with comorbid illnesses, especially with infection or history of aspiration.Early vs delayed feeding after PEGEarly feeding (≤4 hours after PEG placement) may be as safe as later feedingMost places start with water and medications through the PEG 4 hours post procedure with tube feedings are initiated the following day. Minor Complications These occur in 14 %.Pneumoperitoneum is common and of no consequence.Ileus can occur.Bleeding usually resolves by tightening the external bumper against the abdominal wall, then release within 48hrs. Usually works. Major complicationsThese occur in 3%.Gastric and esophageal perforation- this is rare. Outcomes1m mortality is 15%, at 1 yr is 63% .The overall in-hospital mortality rate is 15 %.There is no improvement in functional status, subjective health status, or nutritional status in 70%.50% have reported improved quality of life.Regarding long-term facilities PEG is successful at either maintaining or improving body weight in most.Late mortality and healing of pressure ulcers is improved in patients who received a PEG in comparison to those who didn’t.Quality of life is improved in 68%.For cancer there is no proof this improves overall cancer outcomes or helps quality of life in terminally ill.Regarding stroke, brain injury and neurodegenerative disease PEGs are useful in neurological dysphagia.PEGs should be deferred until 2-3weeks after dysphagic CVA to see if patients spontaneously recover.Regarding dementia there are no overall guidelines but medical treatments should focus on preserving and maximizing preservation of a patient's physical function and should be done with the family. Wound infection Reduce with antibiotic prophylaxis/ nasal decontamination if have MRSA Peristomal leakage — Consider healing factors (eg nutrition) rather than larger PEG.Can remove PEG for 24-48 hours to allow slight site closure/ may have to resite completely Clogging —Avoid by dissolving medications and flushing with water after all meds and feedIf clogged, flush 60cc warm water (better than coca-cola)Otherwise need special declogging brushTube dysfunction — Cna be caused by yeast implantation into tube wall often with silicone rather than polyurethane tubes Can flush the tube daily with 3 to 5 cc of ethanol in an attempt to "sterilize" the tube lumen. Ulceration —Responds to loosening of the external bolster. If rigid internal bolster change for a flexible one Inadvertent PEG tube removal — Inadvertent PEG tube removal is a common complication usually occurring in combative or confused patients who pull on the tube. Many PEG tubes today are designed to be externally removed with 10 to 14 pounds of external pull pressure.PEG tubes that are inadvertently removed within the first four weeks of PEG tube placement should not be replaced blindly at the bedside as tract won’t have matured. Should be replaced endoscopically Colocutaneous fistula — Rare. Due to interposition of bowel (esp. splenic flexure) between the ant. abdominal wall and gastric wall. The PEG tube is placed directly through the bowel into the stomach.Usually only discovered when PEG replaced. The replacement doesnt go back into the stomach and when feeding starts, diarrhoea developsPrevent by placing PEG under transillumina-tion and finger pressing Buried bumper syndrome — Due to tight apposition of internal bumper to stomachTreatment:Collapsible internal bolster: Remove by simple external traction.Non-collapsible internal bolster: Remove by PEG wound tract cut-down or the push-pull T-technique (cutting PEG externally and pulling PEG through endoscopically at same time as external pushing. Necrotizing fasciitis: RareDue to excess external bolster traction Avoid by making 1cm incision/ allowing bolster to free float/ clean and dress skin over external bolsterWound care is important following PEG tube placement but no guidance Special PEG situations:Prior abdominal surgery- care with interpositioned bowel.Obesity Consider making a larger incision and spreading fat tissue until anterior rectus fascia is reached, after which standard PEG tube can be placed using conventional technique. The external wound should be closed with sutures or clips.Pregnancy Can be used as late as 26 weeks but need anaesthetic consulatation.Ascites Paracentesis befor and after PEG has been done with broad spectrum antibiotics. If v obese (BMI >40 kg/m2) and can palpate but not transilluminate, can use wire down a spinal needle. Indications for PEG:Intact mental status and dysphagia.Patients who require gastric decompression.Patients being treated for head and neck cancer. Consider PEG on case by case basis:With anorexia or hypermetabolism and weight loss (such as patients with cancer) so long as it is understood by the patient, caregiver, and family that the goal is not simply to improve nutritional status, which is unrealistic.With an altered mental status and dysphagia (including patients with dementia) after discussion with the family and caregivers has established realistic goals (such as the provision of hydration or the use of nutrition or medications for comfort care). It is unrealistic to expect improvement in functional status or survival.In a persistent vegetative state if the goals of the family, or the wishes of the patient, were to provide comfort care (eg nutrition, hydration, and/or medications.) Other intra-abdominal complications Small bowel obstruction from a small bowel wall hematoma following PEG placement Intrahepatic placement of a PEG tube Herniation of the stomach through a PEG tube fistula sitePeritonitis with intact PEG tube and correct placement: Possibly with tangiential penetration of stomachPEG tract tumor seeding — Patients with proximal GI tract cancers, such as head and neck and esophageal cancers are. Try to use an overtubePEG vs surgical gastrostomy —No difference in mortality/ morbidity but PEG is cheaper Written by Dr Sebastian Zeki

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