Radiologically Inserted Gastrostomy (RIG) Procedure
A Radiologically Inserted Gastrostomy (RIG), also known as a Percutaneous Radiologic Gastrostomy (PRG), is a feeding tube placed directly into the stomach through the abdominal wall under imaging guidance.
It is commonly performed when a patient cannot meet nutritional needs orally, e.g. due to neurological disorders (stroke, MND, MS), head & neck cancers, or severe swallowing difficulties.
💡 Clinical pearl: In the UK, RIG is often chosen over PEG (endoscopic gastrostomy) in patients with unsafe sedation or difficult endoscopic access.
🛠️ Procedure Overview
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Preparation:
- Patient is usually sedated or given local anaesthesia to minimise discomfort.
- Radiologist uses fluoroscopy or ultrasound to identify the stomach and adjacent organs.
- Nasogastric tube may be inserted first to insufflate the stomach with air → improves visibility and safety.
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Insertion of the Tube:
- Small incision made in the abdominal wall.
- A needle punctures the stomach under radiological guidance → a guidewire is introduced.
- The gastrostomy tube is passed over the wire and positioned inside the stomach.
- The external end is secured with a fixation device to prevent dislodgement.
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Post-Procedure Care:
- Insertion site monitored closely for bleeding, leakage or infection.
- Feeding usually begins after 4–6 hours once placement is confirmed and patient stable.
- Care instructions given for cleaning, flushing, and troubleshooting tube blockage.
🌟 Benefits of RIG
- ✅ Minimally invasive compared to open gastrostomy.
- ✅ Imaging guidance ensures accurate and safe placement.
- ✅ Provides reliable long-term nutritional support in complex patients.
- ✅ Particularly useful when PEG insertion is unsafe or not possible.
⚠️ Risks and Complications
- 🦠 Infection at insertion site (cellulitis, peritonitis).
- 💉 Bleeding, haematoma, or injury to adjacent viscera (colon, liver, spleen).
- 🔄 Tube dislodgement, blockage, or leakage of gastric contents.
- ⚡ Aspiration during or after procedure.
- 📉 Rare: peritonitis from leakage, buried bumper syndrome.
💡 Clinical pearl: Always check for absolute contraindications (uncorrected coagulopathy, peritonitis, inability to access stomach) before proceeding. In ALS/MND, timing of RIG placement is crucial → early placement improves tolerance and reduces peri-procedural risk.
PEG vs RIG: Comparison
| Feature |
Percutaneous Endoscopic Gastrostomy (PEG) |
Radiologically Inserted Gastrostomy (RIG) |
| Approach |
Endoscopic visualisation of stomach via mouth → tube placed using pull/push technique. |
Radiological (fluoroscopy or ultrasound) guidance to puncture stomach directly. |
| Anaesthesia / Sedation |
Usually requires conscious sedation ± local anaesthetic. |
Often done under local anaesthetic alone (useful in high-risk patients). |
| Indications |
✅ First-line for long-term enteral feeding when safe to sedate and pass an endoscope. |
✅ Preferred in patients with poor airway protection, unsafe sedation (e.g. severe MND, frailty), or when endoscopy not feasible. |
| Contraindications |
Unsafe sedation, pharyngeal obstruction, severe coagulopathy, peritoneal sepsis. |
Massive ascites, severe coagulopathy, peritoneal sepsis (relative contraindications). |
| Benefits |
✅ Well-established technique, high success rate, widely available. |
✅ No need for sedation or endoscopic access; good for high-risk patients. |
| Limitations |
❌ Requires safe airway and sedation; risk of aspiration during procedure. |
❌ Tube may be smaller calibre → higher risk of blockage; fewer centres provide service compared to PEG. |
| Common Complications |
🦠 Infection, bleeding, aspiration pneumonia, buried bumper syndrome, peritonitis. |
🦠 Infection, bleeding, tube dislodgement/blockage, peritonitis (aspiration risk lower than PEG). |
| Clinical Pearl |
🩺 First choice when patient can tolerate endoscopy + sedation. |
🩺 Best option for frail patients, those with poor respiratory reserve, or upper GI obstruction. |
💡 Teaching Tip: In the UK, PEG is standard for long-term enteral feeding.
Use RIG if endoscopy is not possible or unsafe. Always discuss with MDT (gastroenterology, radiology, dietetics, speech therapy) before insertion.
