Percutaneous Endoscopic Gastrostomy (PEG) Tube Insertion Patient Information Ninewells Hospital Endoscopy Unit Telephone: 01382 660111, extension: 40078 or bleep 4470 Perth Royal Infirmary Endoscopy Unit Telephone: 01738 473824 The aim of this leaflet is to give you some information about the insertion of your PEG tube. What is a PEG tube? A Percutaneous Endoscopic Gastrostomy (PEG) is a feeding tube which is placed through the wall of your abdomen into your stomach. The tube is used to give liquid feeds directly into your stomach and is usually required if you are unable to swallow food normally or unable to take adequate quantities of food and fluid. Example of a PEG Tube: (Photograph courtesy of Merck Biomaterial, Hampshire). This tube is held in place inside your stomach by a plastic disc and on the outside by a plastic bar. Why do I need it? The doctors and nurses looking after you have referred you for a PEG tube because you have difficulty eating and drinking or they anticipate that you may have problems in the near future. Page 1 of 6
Why not use a nasogastric tube? Nasogastric tubes (NG tubes) are thin tubes placed through your nostril and down your throat into the stomach. They are often used to give liquid feeds in the short term; however they may make you feel uncomfortable when used for a long time. Also NG tubes can come out easily requiring replacement. PEG tubes are more discreet because they can be concealed under clothes when not being used and are more pleasant when feeding is needed for longer periods of time. How is a PEG tube placed? PEG tubes are placed with an endoscope in the Endoscopy Unit. A gastroscopy (also known as endoscopy) allows direct inspection of the gullet (oesophagus), the stomach and the first part of the small intestine (duodenum). You will be given a sedative injection to make you very drowsy and the doctor will pass a slim flexible tube (an endoscope) through your mouth to the stomach. The nurse will give you a local anaesthetic and insert a fine needle through the skin into your stomach. The PEG tube is then placed into your stomach. How long does the PEG insertion take? The procedure takes between 15 and 20 minutes. However, you may be in the Endoscopy Unit for 1 to 2 hours. Please ask your doctor or nurse any further questions you may have. Do I need to make any changes to my medications for this procedure? If you are taking any blood thinning tablets such as Warfarin, Clopidogrel, Rivaroxaban, Dibigatran or Apixaban, please contact your specialist nurse or doctor, as you will need to stop taking these for a specific period of time before the procedure. What happens on the day of your appointment? You must not eat any food (including tea, coffee, etc. with milk) for at least 6 hours before the test. You can drink water until 2 hours before the test. You will be given any prescribed medication with a little water at the usual times (except medicines for diabetes). Please sign the consent form in the middle of this booklet unless you need further information or wish to discuss any issues before you sign it. Do not wear nail varnish or false nails as this will interfere with the monitor we use. What happens when I arrive at the unit? A nurse will discuss the procedure with you. If you have any questions, please ask: if you are anxious, let us know. The nurse will confirm that you have understood your consent form and agree to go ahead with the procedure. You may keep your spectacles on or dentures in until immediately before the procedure. Page 2 of 6
After you have spoken with the endoscopist, these will be removed and kept in your trolley. What happens during the procedure? In the procedure room you will meet the endoscopist, nurse specialist and other staff who will remain with you during the procedure. You will be told if students are present, and if you prefer you can ask them to leave. The endoscopist/nurse specialist will explain the procedure and you can ask any questions you may have. A monitor will be placed on your finger to measure your pulse and breathing. You may be given oxygen through a small tube in your nose. You will lie down on your back or side. A plastic guard will be placed between your teeth. The sedation will be given into the fine plastic needle in your hand or arm. You will also receive painkillers through this needle. Sedation is not a general anaesthetic. You may be slightly awake and aware of the procedure. Sedation may make you forgetful, so you may not remember details of the test. The effects of sedation last in your system for 24 hours. You may experience some discomfort as the endoscope touches the back of your throat and you may gag briefly at this point. You may be asked to swallow to help the tube go down. The tube will not interfere with your breathing. The test is not painful but you may feel discomfort and bloating from air passed down the tube. What happens after the procedure? You will be taken to the recovery area where your breathing, pulse and blood pressure will be recorded until you recover from the initial effects of the sedation. You will then be taken back to your ward. What are the risks/complications of gastroscopy? A gastroscopy is classified as an invasive investigation and because of that it has the possibility of associated complications. These occur extremely infrequently. We need to draw your attention to them so you can make your decision. The doctor who has requested the test will have considered this. The risks may be compared to the benefit of having the procedure carried out. The risks can be associated with the procedure itself and with administration of sedation. Risks of the gastroscopy examination: The main risks are of mechanical damage to teeth or bridgework; perforation or tear of the lining of the stomach or oesophagus (risk approximately 1 in 2000 cases) and bleeding. Certain cases may be treated with antibiotics and intravenous fluids. Perforation may require surgery to repair the hole. Risks of sedation: Sedation can occasionally cause problems with breathing, heart rate and blood pressure. If any of these problems do occur, they are normally short lived. Page 3 of 6
Careful monitoring by a fully trained endoscopy nurse ensures that any potential problems can be identified and treated rapidly. Older patients and those who have significant health problems, for example, people with significant breathing difficulties due to a bad chest may be assessed by a doctor before being treated. Risk of PEG: There is a small risk of bleeding when the needle is passed into the stomach and a small risk of leakage of air or fluid from the stomach into the abdominal cavity (perforation). If this occurs then antibiotics are given and occasionally an operation is needed. The risk of these things happening is about 1% (1 in every 100 patients). There is also a small risk of developing an infection after PEG insertion. To reduce this risk we give an antibiotic immediately after the procedure. Occasionally it is impossible to place the tube safely in the stomach and then other methods of feeding will need to be used. Some patients are too unwell to have the gastroscopy performed, perhaps because of chest or breathing problems, and if this is the case the procedure is postponed. Are there any risks after the PEG has been put in? In general the PEG tube is well tolerated after insertion. Occasionally the skin around your tube can become inflamed and uncomfortable. The risk of this can be reduced by keeping the area clean and dry. If the PEG tube is pulled violently in the first few days and removed, peritonitis may occur if fluid escapes from the hole into the abdominal cavity. This is very serious, but occurs very rarely because the PEG is held in place in the stomach by a small disc. After the first few days, a track forms around the tube, and if it breaks or comes out later, there is no risk at all, as the hole into the stomach seals over naturally within 24 hours. Can the PEG be removed? If the PEG is no longer needed, then it can be removed fairly simply. The hole into the stomach heals over within 24 hours and stitches are not required. On very rare occasions we must take special precautions with endoscopes if there is a possibility you have been at risk of variant CJD. We therefore ask all patients undergoing any endoscopy procedure if they have been told that they are at increased risk of CJD. This helps prevent the spread of CJD to the wider public. A positive answer will not stop your procedure taking place, but enables us to plan the procedure to minimise any risk of transmission to other patients. Produced by Nurse Practitioner, Gastroenterology and Tayside Dietitians Clinical Network HEN Group Reviewed: 06/2017 Review: 06/2019 LN0409 Page 4 of 6
Name of procedure(s): Gastroscopy with Insertion of Percutaneous Endoscopic Gastrostomy (PEG) Tube Inspection of the upper gastrointestinal tract with a flexible endoscope (with or without biopsy and photography/video) and insertion of Percutaneous Endoscopic Gastrostomy (PEG) Tube Biopsy specimens will be retained. Statement of patient You have the right to change your mind at any time, including after you have signed this form. I have read and understood the information in the attached booklet including the benefits and any risks. I agree to the procedure described in this booklet and on the form. I understand: That any procedure in addition to those described above will only be carried out if it is necessary to save my life or to prevent serious harm to my health. That you cannot give me a guarantee that a particular person will perform the procedure. The person will however, have appropriate experience. Information, including digital information (video and/or photographic material) may be stored as part of the patients medical records and may be stored on computer databases. The University of Dundee is very active in medical research: donations of excess body tissues and agreement to the use of images are a valuable resource for researchers and clinical scientists. Please tick () the appropriate box if you agree to: Excess body tissue not required for diagnosis or future treatment being used for medical research Digital images (for example such as described above) being used for research, education and teaching in presentations (for example conferences or websites) and in publications. Whenever relevant, such images will be anonymised to protect patient privacy. (If consent is withdrawn at a later date, it may not be possible to withdraw images that are already in the public domain.) NB: Medical staff you must complete the appropriate clinical photography forms. Have you ever been notified that you are at increased risk of CJD or vcjd for public health purposes? (Please tick) Yes No Patient Signature:.. Date: Name (print in capitals): Page 5 of 6
If you would like to ask further questions please do not sign the form now. Bring it with you and you can sign it after you have talked to the healthcare professional. Please remember to bring this booklet and form with you when attending for your appointment. Confirmation of consent (To be completed by a health professional when the patient is admitted for the procedure). I have confirmed that the patient/parent understands what the procedure involves including the benefits and any risks. I have confirmed that the patient/parent has no further questions and wishes the procedure to go ahead. Signed: Date: Name (print in capitals): Job title: Additional discussions with patient Endoscopist signature: Date: Page 6 of 6