Inserting a percutaneous endoscopic gastrostomy (PEG) tube

Inserting a percutaneous endoscopic gastrostomy (PEG) tube

Endoscopy Unit – Investigative procedure information leaflet

Inserting a percutaneous endoscopic gastrostomy (PEG) tube

Why is this leaflet important?

• We recommend that you read this leaflet carefully.
• It will explain some of the benefits and risks of the procedure.
• Your preparation details are included on page 4.
• If you have diabetes, specific information is included on pages 7 to 9.
• We want you to have all the information you need to make the right decision.
• You will need to record that you agree to have the procedure by signing a consent form and filling in the nursing assessment.
• You will be contacted by a Dietitian to assess if you need to use the PEG tube straight away or if the tube is for use in the future. Your Dietitian will discuss feeding options and management of the PEG tube prior to you coming in for the procedure.

Why do I need a PEG insertion?

It has been recommended for you to have a percutaneous endoscopic gastrostomy
(PEG) tube inserted. A PEG tube enables people who cannot eat or drink normally or
safely to take in enough liquid food (feed) and fluid to keep you strong and maintain
your weight. A PEG tube can be used for feed, fluid and medication to help keep you
at home

There are several reasons why you may not be able to eat normally at the present
time. There may be a narrowing at the back of your throat or in your gullet
(oesophagus) which is stopping food from going down normally. It may be that you
have had a stroke, and that this is causing problems with swallowing, or your gullet
may not be working properly for other reasons. If you do not receive enough food, your
recovery from illness may be delayed.

What is a percutaneous endoscopic gastrostomy?

• A percutaneous endoscopic gastrostomy (PEG) involves inserting a narrow plastic tube through your skin into your stomach.
• Once in place, the tube can be used to pass liquid food directly into your stomach. It is called percutaneous because it is done through the skin, and gastrostomy means making an opening into your stomach.

To perform the procedure, we will gently pass a gastroscope (camera) through
your mouth, over the back of your tongue, and into your stomach. The gastroscope
is a long flexible tube with a bright light and camera at the end, which is about the
thickness of your little finger. After the gastroscope has been inserted, we will wipe
the skin below your ribs with antiseptic and cover most of your abdomen (tummy)
with a sterile drape.

We will use the gastroscope to decide on the most suitable point for inserting the
feeding tube (this is usually below your left lower ribs). We will numb the skin in
this area with a local anaesthetic. This can sting a little to start with. We will then
pass a thin, hollow needle into your stomach. Once the needle is in your stomach,
a special thread will be passed through the needle into your stomach.

This thread is then grasped using special forceps and is pulled up and inside the gastroscope.
The gastroscope is then removed, and using the piece of thread, the feeding tube
is pulled down inside you and out through the incision (cut) in your tummy.

Attachments are then applied to the tube to keep it secure – a plastic triangle
against your skin, a clamp and a screw on end to prevent anything leaking out.

This is usually performed as an inpatient; however, some can be performed as an
outpatient procedure.

What do I need to do to prepare?

Eating/Drinking:
To allow us to see clearly inside your stomach, it must be completely empty of
food. If it is not, we may not be able to see certain areas of your stomach and we may
have to repeat the procedure.

As a result, you must not eat for six hours before the procedure. You may
take one or two sips of water up to two hours before the procedure.

Medication:
Please bring a list of any medications you are taking.
Continue to take your normal medicines up to and including the day of your
procedure.

Blood thinning medication:

If you are taking Warfarin, this will need to be reviewed in advance of you
coming to the endoscopy department. The Consultant you see in clinic or on
the ward will advise on what to do. You will need to stop taking this medication
before the procedure and may need blood thinning injections for a few days
before and after the procedure. If you have any concerns about this, please
contact the endoscopy unit.

If you are taking Clopidogrel, this will need to be stopped 7 days prior to the
procedure. If you are on the ward, they will arrange this. If you are an
outpatient the doctor, you see in clinic will advise you of this. If you have any
questions, please contact the endoscopy department.

If you are taking Phenindione, Rivaroxaban, Apixaban, Edoxaban,
Dabigatran, Prasugrel, Ticagrelor or any other blood thinning agents these
will need to be reviewed in advance of your appointment. The consultant you
see in clinic or on the ward will advise on what you need to do. It will be
necessary to stop the medication for a limited time, and you may need blood
thinning injections for a few days before and after. You will be advised of how
this should be done and whether any substitute medication is required. If you
have any concerns, please contact the endoscopy unit.

If we do not want you to take your normal medication, your consultant will
explain what you should do.

We will need to know if you don’t feel well and have a cough, a cold or any
other illness when you are due to come into hospital for your procedure.
Depending on your illness and how urgent your procedure is, your procedure
may need to be delayed.

If you have diabetes, please read pages 7 to 9 carefully.

What will happen on the day of my procedure?

Before the procedure you will be welcomed and assessed by an Endoscopy Nurse.
Bring your medicines or prescription and the patient health questionnaire. We will need
to know if you suffer from any other medical conditions, allergies or past operations
etc. The nurse will discuss the procedure with you, take your pulse, blood pressure
and confirm that you wish to go ahead with the procedure. Your appointment time
takes into account the time required to admit you to the unit by the nurse. You should
expect to be with us for around 3-4 hours including waiting and recovery time.
You will be given antibiotics intravenously prior to the procedure to reduce risk of any
infection.

Sedation:
We usually give you a sedative drug by injection through a small tube (venflon) in the
back of your hand, to help make sure that you are relaxed and comfortable during the
procedure. We also give a strong painkiller called Fentanyl.

This is NOT a general anaesthetic, the sedative will not put you to sleep but helps to
relax you; it is known as conscious sedation and as such you should be able to
respond to verbal commands.

Please be aware you cannot have sedation unless you have a responsible adult who
will accompany you home and care for you for a minimum of 12 hours. You must not
drive yourself for 24 hours. If you fail to make appropriate arrangements for someone
to accompany you home, we may have to cancel your procedure.

What will happen during my percutaneous endoscopic gastrostomy insertion?

• In the Endoscopy room you will be made to feel comfortable on a trolley, resting on your back. A nurse will stay with you throughout the procedure.
• A nurse will attach a blood pressure machine and a small device to your finger to monitor your pulse rate and oxygen saturation in your blood. We will then give you a sedative injection and oxygen throughout the procedure.
• To keep your mouth in a comfortable position, we will insert a plastic mouthpiece between your teeth and gums.
• When the gastroscope has been gently passed over the back of the throat, down into your stomach, air will be passed through it to expand your stomach to give a clear view of the lining. This may make you feel bloated and may make you want to belch.
• The PEG tube will then be inserted as described earlier in this leaflet
• The test generally takes between 15 -20 minutes to complete.

What will happen after my percutaneous endoscopic gastrostomy?

• You will return to the ward (if an inpatient) or endoscopy recovery area (if an outpatient) where the nurses will carry out routine observations. If you feel any discomfort you will be given medication to help with this.
• You may feel a little bloated with wind pains but these usually settle quite quickly.
• You will not be allowed to eat or drink after the procedure. After 4 hours’ water will be given through the PEG tube and you can then begin to eat and drink again.
• Your Dietitian will advise you about a feeding regimen if you need to use the PEG tube straight away and will also arrange training for you to look after the PEG.

Leaving the hospital:

• Do not apply a dressing to the wound.
• Once you get home, it is important to rest quietly for the rest of the day. This is very important if you have been sedated, sedation lasts longer than you think.
• You should not be left alone during the 12 hours immediately after the procedure.
• You must be accompanied home from the hospital by a responsible adult.

For 24 hours after the procedure, you should not:

• Drive a car
• Sign any legally binding documents
• Take sleeping tablets
• Work at heights – including ladders
• Use machinery
• Drink alcohol

The effects of the test and injection should wear off within 24 hours, when most
patients are able to carry out normal activities again. If you work, we do advise you to
have the following day off.

Risks of the procedure:

Everything we do in life has risks. A percutaneous endoscopic gastrostomy is
considered to be a safe procedure, but occasionally there can be side effects and
complications. These include the following:

• Wound Infection;
• reactions to the drugs given;
• your oesophagus puncturing during the procedure;
• Pneumonia
• Peritonitis
• Injury to other abdominal organs
• Seeding of tumour to PEG site if being inserted for head and neck cancer
• stomach fluid leaking around the tube (this can lead to the skin around the tube
  becoming very red and sore and it may become necessary to remove the tube to
  allow the skin to heal); and
• a blood vessel can be pierced accidentally when passing the needle into the
  stomach. This can result in bleeding. This will usually stop by itself, or if not, you
  may need a blood transfusion.
• Sometimes we are unable to safely insert the tube into your stomach. If this
  happens you may need to have the feeding tube placed in the radiology
  department (using X rays to find the stomach) or an operation to place the tube
  surgically.
• Hospital acquired infection with COVID 19 (Coronavirus)
  If there are complications, surgery is occasionally needed to put right these types of
  complications.
  You will be cared for by a skilled team of doctors, nurses and other healthcare workers
  who are involved in this type of procedure every day. If problems arise, we will be able
  to assess them and deal with them appropriately.

If you have diabetes:
If you monitor your blood glucose, please monitor your blood glucoses every 2 hours
on the day of your procedure.

If your diabetes is treated with lifestyle measures only (diet and exercise), you don’t
need to take special precautions.

Instructions for on the day of your percutaneous endoscopic gastrostomy
(PEG) tube

Basal-Bolus regimens (Injections 3 or more times a day)

Before the procedure
For those taking long-acting insulin (e.g. Lantus®, Levemir®) in the morning, reduce
dose by 20%.

For those taking a rapid acting insulin (e.g. Novorapid®, Humalog®) with breakfast,
the rapid acting insulin should be omitted.

Capillary blood glucose should be checked at least every two hours until the end of the
procedure.

If on an afternoon list, and therefore able to eat breakfast, give usual dose of rapid
acting insulin with breakfast, but omit the lunchtime dose.

After the procedure
Usual insulin treatment should be resumed.

 Twice daily regimens
Mixed insulin injections twice a day (e.g. Novomix 30®, Humalog Mix 25® or 50®)

Before the procedure
Half the usual morning dose of insulin should be given. Capillary blood glucose should
be checked at least every two hours until the end of the procedure.

After the procedure
Usual insulin treatment should be resumed.

 Once daily regimens
Injections once a day (e.g. Insulatard®, Humulin I®)

If taken in the morning, half the usual dose of insulin should be given. If taken in the
evening, the usual dose of insulin should be given. Capillary blood glucose should be
checked at least every two hours until the end of the procedure.

If there is any doubt or concern, the local diabetes specialist nurse or consultant
should be contacted for advice.
If more than one meal is to be missed, or there are two consecutive blood glucose
levels above 15mmol/l, consider commencing CVRIII.

Patients with Diabetes Treated With Tablets and/or GLP-1 Agonists

Instructions for on the day of the procedure.
Omit the morning dose of the diabetes drug. Take the usual dose of the diabetes drug
when able to eat after the procedure. It is recommended that capillary blood glucose is
checked every 2 hours from waking until the test.

If there is any doubt or concern, the local diabetes specialist nurse or consultant
should be contacted for advice.

Contact Details:
If you have any specific concerns about your procedure, that you feel have not been
answered and need explaining, please contact the following:

Alexandra Hospital, Redditch
Booking Office – 01527 512013 / 01527 505751
Endoscopy Nursing Staff – 01527 512014

Kidderminster Hospital
Booking Office – 01562 826328
Endoscopy Nursing Staff – 01562 513249

Worcestershire Royal Hospital
Booking Office – 01905 760856
Endoscopy Nursing Staff – 01905 733085

If you need to contact a Dietician please contact,
Nutrition and Dietetics
Redditch – 01527 512043
Worcester – 01905 760136

Nutrition Nurse – 07784 920931

Please note you will need to leave a message with your contact number and you will
be contacted.

Other information:
The following internet websites contain information that you may find useful.
www.worcestershirehealth.nhs.uk/Acute_Trust
Information about Worcestershire Acute Hospitals NHS Trust

www.patient.co.uk
Information fact sheets on health and disease

www.nhsdirect.nhs.uk
On-line health encyclopaedia and best treatments website

If your symptoms or condition worsens, or if you are concerned about anything,
please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you
and your loved ones. If you have any questions or concerns, please do speak with a
member of staff on the ward or in the relevant department who will do their best to
answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well
and where improvements can be made. There are lots of ways you can share your
experience with us including completing our Friends and Family Test – cards are
available and can be posted on all wards, departments and clinics at our hospitals. We
value your comments and feedback and thank you for taking the time to share this with
us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the
nurse in charge or the department manager in the first instance as they are best
placed to answer any questions or resolve concerns quickly. If the relevant member of
staff is unable to help resolve your concern, you can contact the PALS Team. We offer
informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf,
if you feel unable to do so, to resolve your problems and where appropriate refer to
outside help.

If you are still unhappy you can contact the Complaints Department, who can
investigate your concerns. You can make a complaint orally, electronically or in writing
and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Thursday from 8.30am to 4.30pm and
Friday: 8.30am to 4.00pm. Please be aware that a voicemail service is in use at busy
times, but messages will be returned as quickly as possible.

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If you are unable to understand this leaflet, please communicate with a member of
staff.

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