Percutaneous Endoscopic Gastrostomy

By: Jose Byron DadullaEvardone

A percutaneous endoscopic gastrostomy (PEG) is an endoscopic procedure for placing a tube into the stomach through the abdominal wall . PEG tubes may also be extended into the small bowel. The procedure is performed in order to place a gastric feeding tube as a long-term means of providing nutrition to patients who cannot take food orally. Many stroke patients, for example, are at risk of aspiration pneumonia due to poor control over the swallowing muscles; some will benefit from a PEG performed to maintain nutrition.

 PEGs

may also be inserted to decompress the stomach in cases of gastric volvulus.

Indications
 PEG

should be considered for pediatric and adult patients who have an intact, functional gastrointestinal tract but are unable to consume sufficient calories to meet metabolic needs. PEG is inappropriate in patients with rapidly progressive and incurable disease, since nasoenteral feedings over a short interval can provide the same

 The

most common indications for PEG are neurologic conditions associated with impaired swallowing and neoplasms of the oropharynx, larynx and esophagus. Other indications include facial trauma and the need for supplemental feedings in patients with miscellaneous catabolic conditions.

 In

patients with repeated aspiration of nasogastric tube feedings or requiring prolonged gastric decompression, PEG can be modified to percutaneous endoscopic jejunostomy to provide both jejunal feeding and gastric decompression.

Contraindications
 An

absolute contraindication to PEG is the inability to bring the anterior gastric wall in apposition to the anterior abdominal wall. Therefore, patients with prior subtotal gastrectomy, ascites, or marked hepatomegaly require careful evaluation to be sure the stomach and abdominal wall can be brought together with gastric insufflation.

 Recognition

of apposition may be difficult in patients with severe obesity. PEG should not be used for nutritional support, when gastrointestinal tract obstruction is present. Relative contraindications to PEG include proximal small bowel fistula, neoplastic and infiltrative diseases of the gastric wall, and obstructing esophageal lesions. Coagulation defects, if correctable, are not a contraindication to PEG

Technique

The most widely used technique of PEG is the "pull" method introduced by Gauderer and Ponsky in 1980. Modifications of the original technique have been reported. The gastrostomy tube can be pushed rather than pulled into place by a "push" method that has comparable results. In another modification, the "introducer method," the stomach is directly punctured and a Foley Catheter placed over a guidewire. Finally, percutaneous gastrostomy has also been described without endoscopy using a nasogastric tube or gastric insufflation, fluoroscopic monitoring, and a direct percutaneous catheter insertion technique.

 The

basic elements common to all of these techniques are: (1) gastric insufflation to bring the stomach into apposition to the abdominal wall;  (2) percutaneous placement of a tapered cannula into the stomach;  (3) passage of a suture or guidewire into the stomach;  (4) placement of the gastostomy tube; and verification of the proper position

Complications
 Reported

complications include a wound infection, peritonitis, septicemia, peristomal leakage, tube dislodgement, aspiration, bowel perforation, and gastrocolic fistula. Pneumoperitoneum is common after PEG and of no significance, unless accompanied by signs and symptoms of peritonitis .

Position of PEG Tube

TOTAL PARENTERAL NUTRITION
By: Jose Byron DadullaEvardone

 Total

parenteral nutrition (TPN), is the practice of feeding a person intravenously, bypassing the usual process of eating and digestion. The person receives nutritional formulas containing salts, glucose, amino acids, lipids and added vitamins.

TPN is normally used following surgery, when feeding by mouth or using the gut is not possible, when a person's digestive system cannot absorb nutrients due to chronic disease, or, alternatively, if a person's nutrient requirement cannot be met by enteral feeding (tube feeding) and supplementation. It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications.

 Short-term

TPN may be used if a person's digestive system has shut down (for instance by Peritonitis), and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. Long-term TPN is occasionally used to treat people suffering the extended consequences of an accident or surgery.

The preferred method of delivering TPN is with a medical infusion pump. A sterile bag of nutrient solution, between 500 mL and 4 L is provided. The pump infuses a small amount (0.1 to 10 mL/hr) continuously in order to keep the vein open. Feeding schedules vary, but one common regimen ramps up the nutrition over a few hours, levels off the rate for a few hours, and then ramps it down over a few more hours, in order to simulate a normal set of meal times.

The nutrient solution consists of water, glucose, salts, amino acids, vitamins and (more controversially) sometimes emulsified fats. Long term TPN patients sometimes suffer from lack of trace nutrients or electrolyte imbalances. Because increased blood sugar commonly occurs with TPN, insulin may also be added to the infusion. Occasionally, other drugs are added as well. Chronic TPN is performed through a Hickman line or a Port-a-Cath (venous access systems). In infants, sometimes the umbilical artery is used.

Complications

The most common complication of TPN use is bacterial infection, usually due to the increased infection risk from having an indwelling central venous catheter. Liver failure may sometimes occur; a recent study at Children's Hospital Boston on the cause suggests it is due to a large difference in omega-6 to omega-3 ratio. When treated with a different fatty acid infusion (which is not approved for use in the U.S.) two patients were able to recover from their condition.[1] Two related common complications of TPN are venous thrombosis and priapism. Fat infusion during TPN is assumed to contribute to both.[

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