A Percutaneous Endoscopic Gastrostomy (PEG) is a feeding tube inserted directly into the stomach through the abdominal wall using an endoscope. It is indicated when a patient cannot maintain adequate oral intake due to conditions such as stroke with dysphagia, oesophageal/head & neck cancers, neurodegenerative disorders (MND, MS, Parkinson’s) or severe trauma. 💡 Clinical pearl: In the UK, PEG is the standard method for long-term enteral feeding when endoscopic access is possible and sedation is safe.

🛠️ Procedure Overview

Preparation:
- Patient is sedated or given local anaesthetic with conscious sedation.
- An endoscope is introduced through the mouth into the stomach to allow direct visualisation.
- Stomach is insufflated with air → helps appose the gastric wall to the abdominal wall.
Insertion of the Tube:
- A small abdominal incision is made at the transillumination point.
- A hollow needle punctures the stomach, and a wire or thread is passed through the endoscope.
- The feeding tube is pulled into position via the “pull” or “push” technique.
- The internal bumper secures the tube inside the stomach, and an external flange fixes it to the skin.
Post-Procedure Care:
- Insertion site is cleaned and dressed.
- Monitor for infection, bleeding, leakage or dislodgement.
- Feeding can usually start within 12–24 hours once placement is confirmed.

🌟 Benefits of PEG

✅ Minimally invasive with relatively quick recovery.
✅ Provides long-term nutritional support.
✅ Can improve quality of life in chronic neurological or malignant conditions.
✅ Usually better tolerated than nasogastric tubes for prolonged use.

⚠️ Risks and Complications

🦠 Infection at the insertion site (commonest complication).
💉 Bleeding, injury to abdominal viscera (rare but serious).
🔄 Tube blockage, leakage, or dislodgement.
⚡ Aspiration pneumonia during sedation or early use.
📉 Peritonitis if gastric contents leak into peritoneum.
⚠️ Rare: buried bumper syndrome (internal fixation eroding into stomach wall).

💡 Clinical pearl: Always assess for suitability of sedation and endoscopic access. PEG is preferred when feasible, but RIG is an alternative if endoscopy or sedation is unsafe (e.g. advanced MND with poor respiratory reserve).

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.

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Percutaneous Endoscopic Gastrostomy (PEG) procedure:

🛠️ Procedure Overview

🌟 Benefits of PEG

⚠️ Risks and Complications

PEG vs RIG: Comparison

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