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Medical Terminology - Percutaneous Endoscopic Gastronomy (PEG)*

A. INTRODUCTION

The tube your patient is using was placed in a procedure called a Percutaneous Endoscopic Gastronomy or PEG which simply means placing a tube into the stomach, through the abdominal wall, to the outside of the body under the visual guidance of an endoscope (a lighted instrument).  This tube (called a G-Tube) extends 12-15 inches from the skin with a cap or plug on the end of it.  To keep the tube in place, a short cross piece of tubing or bolster is placed near the skin level at the stoma (the tract from the outside skin to the stomach).

B. FEEDING THE PATIENT

The feeding tube should be checked before each feeding to be sure that it is in place, not clogged, and ready to accept the formula.
     Check the placement of the tube first:

1.	Measure the length of the tube from the stoma to the end of the tube.  If the measurement varies from previous measurements more than a pre-determined number of inches, check with the patient's doctor or health care provider.

     The doctor may or may not recommend the following two steps to check on tube placement and stomach contents prior to feeding:

2.

Draw 5-10 cc [3-5 for children] of air into the syringe.  Open the cap or plug on the tube.  Place a stethoscope on the left side of the abdomen just above the waist.  Place the syringe in the feeding tube and depress the plunger.  Listen for a bubbling or "gushing" sound with the stethoscope.  Try again if you do not hear it.  If you do not hear the sound, do not attempt to give the feeding.  Contact the doctor or health care provider and report the problem.

     If your doctor does not want you to check the stomach contents you may begin giving the formula.
     If your doctor does want you to check, follow these instructions:

3.

After you have heard the bubbling or "gushing" sound, gently draw back on the syringe plunger to withdraw the stomach contents or residual.  NOTE: You may not get any residual if the stomach is empty.  If the amount of the residual is less than the amount prescribed by you doctor, inject it back into the tube, draw up 30-50 cc [15-30 for children] of water into the syringe and rinse the tube by injecting the water into it.  If the residual is more than the doctor prescribes, inject the contents into the tube and wait 30-60 minutes.  Check the residual again.  If the residual is still high, do not attempt the feeding and report the problem to the doctor or health care provider.  Be sure to reinject the residual.

BOLUS METHOD:

1.	Insert the tip of the feeding container tube into the G-Tube.
2.	Open the clamp, allow it to drip in.  Adjust the flow of the formula (drops per minute) by opening or closing the clamp on the feeding container tube.  Check the instructions for the patient's flow rate and length of feeding.

When the formula in the container is almost finished, give the patient the amount of water prescribed for the feeding.  Do not let all of the formula run out before adding the water, or air will get into the patient's stomach causing gas.

1.	Place the amount of water prescribed in the feeding container.
2.	Open the clamp, allow it to drip in.
3.	When the water is almost gone, disconnect the feeding container and tubing.  Put the cap or plug on the tube.
4.	Rinse the feeding container well with hot water and allow it to air dry.  Store the container and tubing until the next feeding.  NOTE: Follow the doctor's instructions on how long the equipment (containers, tubing) should be used.

CONTINUOUS METHOD:

1.	Insert the tip of the pump set tube into the G-Tube.
2.	Check that the tubing is connected to the pump properly.  Open the clamp on the pump tubing.
3.	Follow the manufacturer's instructions to set the pump at the rate prescribed.
4.	Turn on the pump.

When the formula in the container is almost finished, give the patient the amount of water prescribed for the feeding.  Do not let all of the formula run out before adding the water, or air will get into the patient's stomach causing gas.

1.	Place the amount of water prescribed in the feeding container.
2.	Turn on the pump and pump the water in at the prescribed rate.
3.	When the water is almost gone, put new formula into the feeding container.  Pump the formula in at the prescribed rate.  NOTE: Follow the doctor's instructions on how long the equipment (containers, tubing) should be used.

The patient's doctor may or may not want you to decompress (let the air out of the stomach) before or after feedings.  To decompress the stomach, remove the cap or plug and allow the tube to drain into a collecting cup or drainage bag for the amount of time prescribed by the doctor.

D. GIVING MEDICATIONS
(IF PRESCRIBED)

Medications may be given through the feeding tube if the doctor allows.  Ask the doctor to order prescriptions in liquid form, if possible.

1.	If the medication is in tablet or capsule form, dissolve the prescribed amount in 30-50 cc [15-30 for children] of warm water or in small medication cup.  Or, pour the prescribed amount of liquid medication into the medication cup.
2.	Open the cap or plug on the tube.
3.	Draw up the medication with a syringe.
4.	Inject the medication into the tube.
5.	Flush the tube with 50 cc [30 for children] of warm water and replace the cap or plug.
6.	Keep the patient upright or at a 30° angle for 30 minutes after administering the medication.

E. CLEANING THE STOMA: 

The stoma should be cleaned daily with mild soap and warm water.  Use a cotton swab or small piece of gauze in a circular motion.  Be sure to rotate and clean under the bolster.  After cleansing, allow the site to air dry.  Always check for signs of redness, pain or soreness, swelling, or unusual drainage.  Report any signs of these symptoms to the doctor or health care provider.  There is no need to keep a dressing over the G-Tube.  In fact, heavy, taped dressings may promote skin problems.

F. PROBLEM SOLVING

1.	How do I unblock the tube? Rinsing tubes with water before and after feedings will prevent most blockages.  If the formula, water, or medication will not go in, first check that the tube is not kinked.  Occasionally, the tube will be blocked by residues from formula or medication.  To remove the blockage, place a syringe into the blocked tube.  Gently pull back on the plunger to remove the blockage.  If the blockage remains, use the syringe to instill water into the tube.  The tube may also be milked with the fingers.  Place one hand holding the tube securely at the stoma.  With the other hand run your thumb and forefinger down the tube to remove the blockage.  If both methods fail, call the patient's doctor or health care provider.
2.	What if the tube is pulled out? Confused patients may try to remove the tube.  If the patient repeatedly pulls at the tube, it may be covered with a small, light dressing.  Patients may also be outfitted with bulky mittens (or a one-piece outfit for infants) to prevent removal.  If the PEG is removed, however, do not panic.  Call the patient's doctor or health care provider.
3.	What if the stoma looks infected? Clean the area several times a day as prescribed.  If signs of skin irritation (redness, soreness, pain, swelling, unusual drainage) persist, call the patient's doctor or health care provider.
4.	What if there is leakage at the stoma? Leakage may occur because the tube has pulled away from the abdominal wall or because the stoma site is enlarged.  If the stoma site has enlarged, the doctor may need to replace the tube.  Report to the doctor or health care provider if the leakage does not stop.
5.	What if the feeding tube becomes disconnected? If the feeding tube becomes disconnected, estimate the amount of formula lost, reattach the feeding tube, and continue feeding, adding the estimated amount of lost formula.
6.	What if the tube is shorter or longer than usual? The length of the tube when originally placed is noted.  Ask the patient's doctor or health care provider about marking the tube where it should be located.  The tube should have a small amount of "play," but if the tube has become longer or shorter than the original length by more than the number of inches noted, it may be migrating (moving).  A shorter tube may be cause blocking or aspiration.  A longer tube may cause damage to the stomach lining.  Call the patient's doctor or health care provider if there is a significant change in the G-Tube's length.

This booklet has been prepared as a guide.  It is not meant to supercede any physician's or manufacturer's instructions.