1. Percutaneous Endoscopic
Gastrostomy
and
Jejunostomy
By
Syeda lateefunnisa Sabiha Farheen
Msc,sem-1
Osmania university college for women

2. Tube feeding

3. Percutaneous endoscopic gastrostomy
• Percutaneous endoscopic gastrostomy (PEG)
is an endoscopic medical procedure in which a
tube (PEG tube) is passed into a patient's
stomach through the abdominal wall, most
commonly to provide a means of feeding
when oral intake is not adequate (for example,
because of dysphagia or sedation).

4. The PEG procedure is an alternative to open surgical
gastrostomy insertion, and does not require a general
anesthetic; mild sedation is typically used.
PEG administration of enteral feeds is the most commonly used
method of nutritional support for patients in the community
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

5. 1 Indications
2 Techniques
3 Contraindications
3.1 Absolute contraindications
3.2 Relative contraindications
3.3 In advanced dementia
4 Complications
5 Removal of PEG tubes
5.1 Indications
5.2 Techniques
6 History

6. Indications
Gastrostomy may be indicated in numerous situations, usually those in which
normal or nutrition (or nasogastric feeding is impossible. The causes for these
situations may be neurological (e.g. stroke), anatomical .
A gastrostomy can be placed to decompress the stomach contents in a patient
with a malignant bowel obstruction. This is referred to as a "venting PEG" and is
placed to prevent and manage nausea and vomiting.
A gastrostomy can also be used to treat volvulus of the stomach, where the
stomach twists along one of its axes. The tube (or multiple tubes) is used for
Gastropexy, or adhering the stomach to the abdominal wall, preventing twisting
of the stomach
A PEG tube can be used in providing gastric or post-surgical
drainage

7. Techniques
Two major techniques for placing PEGs have been described in the literature.
1,The Gauderer-Ponsky technique involves performing a gastroscopy to evaluate the
anatomy of the stomach. The anterior stomach wall is identified and techniques are used
to ensure that there is no organ between the wall and the skin:
A,Digital pressure is applied to the abdominal wall, which can be seen indenting the
anterior gastric wall by the endoscopist.
B,Transillumination (diaphanoscopy): the light emitted from the endoscope within the
stomach can be seen through the abdominal wall.
C, small (21G, 40mm) needle is passed into the stomach before the larger cannula is
passed.
2,An angiocath is used to puncture the abdominal wall through a small incision, and a soft
guidewire is inserted through this and pulled out of the mouth. The feeding tube is
attached to the guidewire and pulled through the mouth, esophagus, stomach, and out of
the incision.[2]
In the Russell introducer technique, the Seldinger technique is used to place a wire into
the stomach, and a series of dilators are used to increase the size of the gastrostomy. The
tube is then pushed in over the wire.

10. Contraindications
As with other types of feeding tubes, care must be made to place PEGs into an appropriate
population. The following are contraindications to PEG use
• Absolute contraindications
• Inability to perform an
esophagogastroduodenoscopy
• Uncorrected coagulopathy
• Peritonitis
• Untreatable (loculated)
massive ascites
• Bowel obstruction (unless the
PEG is sited to provide
drainage)
• Relative contraindications
• Massive ascites
• Gastric mucosal abnormalities: large gastric
varices, portal hypertensive gastropathy
• Previous abdominal surgery, including previous
partial gastrectomy: increased risk of organs
interposed between gastric wall and abdominal
wall
• Morbid obesity: difficulties in locating stomach
position by digital indentation of stomach and
transillumination
• Gastric wall neoplasm
• Abdominal wall infection: increased risk of
infection of PEG site
• Intra-abdmominal malignancy with peritoneal
involvement (tumor seeding into formed
channel with subsequent failure)

11. In advanced dementia
The American Medical Directors Association, the
American Geriatrics Society and the American Academy
of Hospice and Palliative Medicine recommend against
inserting percutaneous feeding tubes in individuals with
advanced dementia and, instead, recommend oral
assisted feedings. Artificial nutrition neither prolongs life
nor improves its quality in patients with advanced
dementia. It may increase the risk of the patient inhaling
food, it does not reduce suffering, it may cause fluid
overload, diarrhea, abdominal pain and local
complications, and can reduce the amount of human
interaction the patient experiences.

12. Complications
Major complications are not common but can occur after PEG tube insertion. mortality after
PEG is very rare and is usually due to underlying co-morbidities
Cellulitis (infection of the skin) around the gastrostomy
site
Hemorrhage
Gastric ulcer either at the site of the button or on the
opposite wall of the stomach ("kissing ulcer")
Perforation of bowel (most commonly transverse
colon) leading to peritonitis
Puncture of the left lobe of the liver leading to liver
capsule pain
Gastrocolic fistula: this may be suspected if diarrhea
appears a short time after feeding. In this case, the
feed goes direct from stomach to colon (usually
transverse colon)
Gastric separation
"Buried bumper syndrome" (the gastric part of the
tube migrates into the gastric wall)

13. POST-INSERTION CARE
After PEG tube insertion adequate pain relief should be
administered. Many patients report abdominal discomfort after
PEG insertion due to inflation of the stomach during the
procedure. Traditionally, feeding was delayed until the next day
due to the fear of peritoneal leakage risk after feeding. Many
studies investigated the safety of early feeding from 1 h to 6 h
after PEG insertion, including a meta-analysis which found that
feeding initiated as early as 4 h after PEG placement is safe.
The stoma should be examined (for signs such as pain,
discoloration, swelling, exudation, pus and leakage around the
stoma) and cleaned daily. The tube should be rotated about 180
degrees and moved up and down about 1-2 cm in the stoma
site on a daily basis after the stoma has completely healed

14. Removal of PEG tubes
Indications
PEG tube no longer required (recovery of swallowafterstroke or
surgery for head and neckcancer, or frombraintrauma)
Persistent infectionof PEG site
Failure, breakage or deteriorationof PEG tube (a new tube canbe
sited along the existing track)
"Buried bumper syndrome"

15. Technique
s
PEG tubes with rigid, fixed "bumpers" are removed
endoscopically. The PEG tube is pushed into the stomach
so that part of the tube is visible behind the bumper. An
endoscopy snare is then passed through the endoscope,
and passed over the bumper so that the tube adjacent to
the bumper is grasped. The external part of the tube is
then cut, and the tube is withdrawn into the stomach, and
then pulled up into the esophagus and removed through
the mouth. The PEG site heals without intervention.
PEG tubes with a collapsible or deflatable bumper can be
removed using traction (simply by pulling the PEG tube
out through the abdominal wall).

17. History
The first percutaneous endoscopic gastrostomy
performed on a child was on June 12, 1979 at the
Rainbow Babies & Children's Hospital, University
Hospitals of Cleveland. Dr. Michael W.L. Gauderer,
pediatric surgeon, Dr. Jeffrey Ponsky, endoscopist,
and Dr. James Bekeny, surgical resident, performed
the procedure on a 4 1⁄2-month-old child with
inadequate oral intake.[12] The authors of the
technique, Dr. Michael W.L. Gauderer and Dr. Jeffrey
Ponsky, first published the technique in 1980.[12] In
2001, the details of the development of the
procedure were published, the first author being the
originator of the technique itself.

18. CONCLUSION
Since its introduction in 1980, PEG has gained world-
wide acceptance as a safe technique for providing
enteral feeding in patients with poor oral intake who
have a functional GI system. PEG tube placement
has many indications, and is the recommended tube
type if not contraindicated. PEG tubes can result in
minor or even major complications, but most
patients do well with them. The pull technique is the
most commonly used method, but other techniques
are possible or even necessary in certain situations.
Knowing when and how to place PEG tubes, as well
as how to manage and even remove them, is an
important part of the management of many
patients. Quality and safe care of PEG tubes begin at
pre-insertion screening and throughout post-
insertion aftercare. Prevention of and proper
management of complications are critical to
ensuring successful outcome.

19. Jejunostomy
Jejunostomy is the surgical creation of an opening (fistula) through the skin at the front
of the abdomen and the wall of the jejunum (part of the small intestine). It can be
performed either endoscopically, or with formal surgery
A jejunostomy may be formed following bowel resection in cases where there is a need
for bypassing the distal small bowel and/or colon due to a bowel leak or perforation.
Depending on the length of jejunum resected or bypassed the patient may have
resultant short bowel syndrome and require parenteral nutrition.
A jejunostomy is different from a jejunal feeding tube which is an alternative to a
gastrostomy feeding tube commonly used when gastric enteral feeding is
contraindicated or carries significant risks. The advantage over a gastrostomy is its low
risk of aspiration due to its distal placement. Disadvantages include small bowel
obstruction, ischemia, and requirement for continuous feeding

20. Techniques
TheWitzeljejunostomyisthemostcommonmethodof jejunostomycreation.Itis an
opentechniquewherethejejunosotomyissited30 cm distalto theLigamentof Treitz
on theantimesentericborder,withthecathetertunneledina seromusculargroove.
Thereare severaltechniquesfor placement,includinga directsurgicalor endoscopic
technique,or a more complicatedRoux-en-Yprocedure.The J-tubemayuse a long,
catheter-like tube or a button.Depending on the placement type,the tube may be changed
at home,or mayneed to be changedat a hospital.A J-tube is helpfulfor individualswith
poorgastricmotility,chronicvomiting,or at highriskfor aspirationand in those in whom
gastrostomytubesare contraindicated

22. https://en.wikipedia.org/wiki/Percutane
ous_endoscopic_gastrostomy
http://emedicine.medscape.com/article/
149665-overview#a3
https://en.wikipedia.org/wiki/Jejunosto
my
References