How to Check the Placement of a PEG Tube?

With a high technical success rate of 95% to 100% for insertion, percutaneous endoscopic gastrostomy (PEG) tubes are a safe and common method for long-term feeding. However, confirming the correct placement of a PEG tube after initial insertion or replacement is a critical safety step to prevent life-threatening complications such as aspiration pneumonia or peritonitis. This guide provides a comprehensive overview of the methods used to check PEG tube placement and emphasizes the importance of following established clinical protocols.

Quick Summary

Confirming proper PEG tube placement is crucial to prevent serious complications. This article details the gold standard radiological and endoscopic verification, as well as less reliable but useful bedside methods like visual assessment and pH testing. It compares these techniques and outlines necessary actions if misplacement is suspected.

Key Points

• Initial Placement: For new PEG tubes, radiographic contrast studies or endoscopic visualization are the most reliable methods for confirmation.

• Mature Tracts: After 4-6 weeks, bedside methods like aspirating gastric contents and checking pH can be used, but are less reliable than imaging.

• Unreliable 'Whoosh' Test: The air insufflation or 'whoosh' method is not recommended and should not be relied upon to confirm placement.

• Regular Monitoring: Daily inspection of the stoma site for infection and measuring the external tube length are essential routine care practices.

• Stop Feeding Immediately: If misplacement is suspected based on patient symptoms like pain or fever, feeding must be stopped and placement re-verified with imaging.

• Never Force Reinsertion: Blind attempts to re-insert a dislodged tube into an immature tract can cause serious injury and should be avoided.

Methods for Confirming PEG Tube Placement

Proper confirmation of a Percutaneous Endoscopic Gastrostomy (PEG) tube is essential for safe patient care. While different clinical settings and patient conditions may require different methods, the gold standard involves advanced imaging techniques. However, several other bedside assessment tools are commonly used, especially for routine checks.

The Gold Standard: Advanced Imaging

• Radiological Contrast Study: For initial placement confirmation or if misplacement is suspected, a water-soluble contrast examination through the replacement tube is considered the gold standard. In this procedure, contrast dye is injected into the tube, and an X-ray is taken to visualize the stomach, confirming the tube's position. This is the most accurate method for determining proper placement, especially after a new tube has been placed or replaced after a short period, when the tract is not yet mature.
• Endoscopic Visualization: During or immediately after placement, endoscopic visualization is used to confirm the position of the internal bolster or balloon within the stomach. An endoscope is reinserted into the stomach, and the physician visually inspects the tube's interior components to ensure correct positioning against the gastric wall.
• Computed Tomography (CT) Scan: A CT scan of the abdomen may be performed, particularly if misplacement into the peritoneal cavity is suspected, or for patients with complex anatomical features. This offers a high-resolution image of the tube's path.

Bedside Assessment Methods (For Established Tracts)

For PEG tubes in a mature tract (typically after 4 to 6 weeks), less invasive bedside checks can be performed. However, these are generally considered less reliable and should be used with caution, especially if the patient experiences pain or other symptoms of misplacement.

• Aspiration of Gastric Contents: Gently pulling back on a syringe attached to the tube can aspirate stomach contents. Gastric fluid is typically green, tan, or clear. The inability to aspirate fluid, however, does not definitively mean misplacement, as the tube might simply be against the stomach wall. Conversely, obtaining aspirate is not a guaranteed sign of correct placement.
• pH Testing: The pH of the aspirated fluid can be tested using litmus paper. Gastric fluid usually has a pH below 5.5, while respiratory fluid has a higher, more alkaline pH. This method can be unreliable if the patient is taking gastric acid-suppressing medication.
• Measuring External Length: Regularly measuring and documenting the length of the tube visible outside the body can help identify a dislodgement. A significant change in the external length indicates that the tube may have moved. This is not applicable to low-profile devices.
• Flushing with Sterile Water: Gently flushing the tube with a small amount of sterile water (30-50 ml for adults) should have no resistance and cause no pain. Resistance or pain can indicate a blockage or a misplaced tube. Leakage around the stoma during flushing also points to potential issues with the tube's position or the seal.

When to Suspect Misplacement

Prompt investigation is required if misplacement is suspected. Signs and symptoms may include:

• Abdominal pain or fever, especially after tube reinsertion.
• Signs of peritonitis.
• Leakage of gastric contents around the stoma.
• Resistance when flushing the tube.
• Vomiting or aspiration after feeding has resumed.

If any of these symptoms occur, feeding must be stopped immediately and a physician consulted for confirmation with imaging.

Comparison of PEG Tube Placement Confirmation Methods

Method	Reliability	Best Use Case	Key Considerations
Radiological Contrast Study	High	Initial placement and suspected misplacement	Gold standard, but requires radiology resources
Endoscopic Visualization	High	Initial placement confirmation	Requires endoscopy equipment and trained personnel
CT Scan	High	Suspected intraperitoneal placement, complex anatomy	Involves radiation and is used for specific concerns
Aspiration of Contents	Low to Moderate	Routine checks of established tracts	Not definitive; may not always retrieve aspirate
pH Testing of Aspirate	Low to Moderate	Routine checks of established tracts	Unreliable if patient is on acid-suppressing drugs
External Length Measurement	Low to Moderate	Routine monitoring	Not applicable for low-profile tubes; only tracks significant movement
Gentle Water Flush	Low to Moderate	Routine checks of established tracts	Resistance or pain are red flags; not for definitive confirmation
Air Insufflation ('Whoosh')	Very Low	Should not be used	Unreliable and dangerous; lacks specificity

Nursing Role in Routine PEG Tube Care

Nurses and caregivers play a crucial role in the daily monitoring and maintenance of PEG tubes. Following established protocols is key to preventing complications.

Daily Care and Monitoring

• Site Inspection: The insertion site, or stoma, should be inspected daily for any signs of infection, such as redness, swelling, increased drainage, or odor.
• Tube Movement: For tubes with external bumpers, the tube should be rotated daily and moved in and out by 1-2 cm after the initial healing period to prevent the bumper from becoming buried in the stomach wall. The external bumper should not be pulled tightly against the skin.
• Flushing: The tube should be flushed with water before and after every feed or medication administration to prevent clogging.
• Patient Education: Caregivers and patients, where applicable, must be educated on how to perform simple checks and recognize potential problems.

Conclusion

Ensuring correct PEG tube placement is a non-negotiable aspect of patient safety. While advanced imaging techniques like radiological contrast studies remain the most reliable for initial confirmation and troubleshooting suspected misplacement, routine bedside checks are vital for daily monitoring in patients with established gastrostomy tracts. Methods such as aspirating gastric contents and measuring pH can offer helpful, though not definitive, confirmation, while others like air insufflation are considered dangerous and should be avoided entirely. Strict adherence to protocols, daily site inspections, and prompt action when misplacement is suspected are essential practices for preventing serious and potentially fatal complications related to tube feeding.

How to check the placement of a PEG tube: A summary

1. Stop Feeding if in Doubt: If you suspect the tube is misplaced or experience patient discomfort, stop all feeding immediately.
2. Use Reliable Imaging: For initial checks or suspected misplacement, confirm with a radiological contrast study or CT scan.
3. Perform Bedside Checks for Established Tracts: For daily checks on mature tracts, use methods like aspirating gastric contents, pH testing, and measuring external tube length.
4. Avoid Unreliable Methods: The auscultatory or 'whoosh' test is not a reliable indicator and should not be used for confirmation.
5. Inspect Site Daily: Routinely check the stoma for signs of infection, including redness, swelling, and leakage.
6. Rotate and Move Tube: Once the tract is mature, rotate and move the tube daily to prevent the internal bumper from becoming embedded.
7. Know the Red Flags: Be aware of signs like abdominal pain, fever, peritonitis, or resistance during flushing, and seek immediate medical help.

Remember

• Radiological Confirmation: Always the most reliable for initial placement or reinsertion after dislodgement.
• Bedside Checks Are Not Foolproof: Relying on aspiration or pH alone can lead to dangerous feeding errors.
• Never Force a Tube: If resistance is met during reinsertion, stop and consult a specialist.

Following these steps ensures vigilance and promotes patient safety in managing PEG tubes.

Frequently Asked Questions

What is the most reliable method to confirm a PEG tube is in the correct position?

The gold standard for confirming PEG tube placement is a radiological contrast study (X-ray with contrast dye) or endoscopic visualization, particularly for new tubes or if misplacement is suspected.

Can I rely on the 'whoosh test' (air insufflation) to check placement?

No, the 'whoosh test' is unreliable and should not be used to confirm PEG tube placement. Studies have shown it is not specific enough to accurately determine if the tube is in the stomach.

What should I do if a PEG tube is dislodged?

If a PEG tube is dislodged, especially within the first few weeks of insertion, you should not attempt to re-insert it blindly. The tract may not be mature, and misplacement could cause peritonitis. Seek immediate medical assistance and confirm placement with imaging after reinsertion.

How do you perform a pH test to check placement?

To perform a pH test, aspirate a small amount of fluid from the tube and place a drop on pH paper. Gastric contents typically have a pH of less than 5.5. However, this method is unreliable if the patient is on acid-reducing medication.

What are the signs that a PEG tube might be misplaced?

Signs of misplacement include severe abdominal pain, fever, leakage around the stoma, significant changes in the external tube length, or resistance when flushing the tube. If these symptoms occur, stop feeding and consult a healthcare provider.

How often should I check PEG tube placement?

For routine care, placement should be assessed before each use, particularly before administering medications or feeds. For new tubes or if misplacement is suspected, placement must be confirmed with imaging. Daily site checks are also critical for monitoring.

What is a 'buried bumper syndrome' and how can I prevent it?

Buried bumper syndrome occurs when the internal bumper of the PEG tube erodes into the gastric wall. It can be prevented by ensuring the tube is not secured too tightly and by rotating the tube daily once the stoma is healed.