Gastrostomy X-ray

Under X-ray, a tube is placed through a percutaneous puncture into the stomach or surgically inserted into the stomach, known as a gastrostomy. The tube is used primarily to administer food for nutrition and, if necessary, to extract stomach contents for examination or to relieve your bloating and discomfort.

Gastrostomy tubes can also be placed under X-ray guidance. Numerous clinical studies have shown this method to be comparable to endoscopic-guided placement. Optimal indications include malignant or benign strictures of the esophagus and when percutaneous endoscopic gastrostomy cannot be performed because of the inability to precisely locate a safe puncture site. Although this method of placement is also very effective, it is prone to blockage because the fistula tube used in this method is often a small diameter catheter. Replacement of the fistula can also be tricky The PEG was originally designed as a long-term enteral nutritional route for patients who have normal gastrointestinal function but are unable to ingest food by mouth. All patients who are expected to be unable to consume nutrients for more than 2 weeks or more should be on nutritional support. Nasogastric or nasoenteric tubes may be placed for nutritional support if the patient has normal gastrointestinal function and

the expected duration of enteral nutritional support is less than 30 days. If the expected duration of enteral nutrition is greater than 30 days, a gastrostomy or jejunostomy should be considered. These patients may have severe neurologic or developmental disabilities, traumatic or neoplastic oropharyngeal obstruction, or critically ill patients who require prolonged tracheal intubation.

As the safety and efficacy of PEG have been well established, the range of indications for PEG has been expanded, and PEG has been used to facilitate the administration of enteral hyperthermic cardiac nutritional support in patients with burns (even through the skin at the burn site). PEG has also been used in patients receiving adjuvant therapy for esophageal, head and neck cancer. Patients with severe maxillofacial trauma can similarly benefit from PEG. Non-nutritional applications of PEG include gastric emptying disorders, irreversible obstruction, tumor metastasis, and gastric decompression after Nissen fundoplication; it can also be used for medication administration in children and bile retrieval in patients with cholangiocarpal fistulae; and simultaneous placement of multiple PEGs as a method of gastric immobilization in patients with gastric hernias and gastric torsion. Numerous retrospective clinical studies have shown that at least one complication occurs after PEG in 10-16% of adult and pediatric patients. The overall mortality rate is 1%, the incidence of major complications is 3%, and the incidence of lesser complications is 13%. Up to 30% of minor complications were due to wound infections, caused by a variety of microorganisms, but the most common were S aureus and beta-hemolytic streptococci.

Jain et al showed that a single application of a prophylactic dose of cefazolin, whose antimicrobial spectrum covers 72% of the pathogenic organisms in PEG infections, reduced the incidence of postoperative infectious complications after PEG from 28.6% to 7.4%, and that cefoxitin was effective only against the causative organisms in 33% of PEG infections. In the presence of a significant infection the local manifestations are erythema of the skin around the orifice, localized tenderness, and the patient's systemic manifestations are low-grade fever and leukocytosis. Early recognition of infection and prompt local incision and drainage usually eliminate the infection. Otherwise, it can lead to infected necrosis of the abdominal wall or even death. Necrosis of the abdominal wall tissue between the catheter head and the soft cushion plays an important role in the development of infection. The cushion is locally hemostatic, but too much pressure can lead to ischemia of the subcutaneous tissue, so it should be tightened appropriately. If a dressing is required, it should be placed on top of the cushion and not underneath, for the same reason, to prevent ischemia from occurring as a result of too much pressure. Infections should be treated systematically with antibiotics until the infection is resolved, and a moderately sized incision in the skin of the abdominal wall will allow space around the fistula to facilitate bacterial drainage. Displacement of the head of the catheter from the gastric lumen into the subcutaneous tissue is also commonly encountered, and this is almost always due to excessive tension applied to the catheter. To prevent fistulae of gastric contents and to ensure a tight fit between the stomach and the abdominal wall, the fistula is usually operated by lifting the fistula and pushing the cushion downward to maintain local tension. Although this method secures the gastric wall to the abdominal wall, it can also lead to ischemic necrosis of the abdominal wall tissue between the two. During the operation, when the head of the catheter touches the mucosa of the stomach, the cushion is only loosely touched to the skin at this time, which prevents excessive tension from being generated, and this method leads to better adhesion between the stomach and the abdominal wall without tissue necrosis.

Gastric fistula can also occur after PEG, usually due to the separation between the stomach wall and the abdominal wall, which is mainly due to excessive local tension leading to abdominal tissue necrosis. The possibility of gastric fistula and peritonitis should be considered when the patient presents with abdominal pain, fever, and elevated white blood cells. PEG tube contrast should be performed at this time. The presence of contrast leakage into the abdominal cavity indicates a gastric fistula. If the imaging shows that the head end of the catheter is still in the stomach, and the external fistula of the contrast medium is around the catheter, then the catheter should be pulled outward to increase the tension to block the fistula, and the catheter should be opened for drainage, which can be followed by intravenous rehydration and antibiotic treatment. If the imaging result shows that the catheter is detached from the stomach and the stomach and abdominal wall are completely separated, then the catheter should be removed and a nasogastric tube should be placed for drainage, and intravenous rehydration and antibiotic therapy should be performed. The same treatment should be given to patients who experience catheter prolapse within 2 weeks after PEG. However, if at any time the patient's general condition deteriorates, or if peritonitis worsens, a cesarean section should be performed to repair the catheter.

Gastrocolic fistulas are rare after PEG, but are usually caused by puncture of the colon during placement of the tube or by ischemic necrosis of the colon wall due to entrapment of the colon between the stomach and the abdominal wall, resulting in a fistula. This complication is usually more pronounced a few weeks after PEG and is mainly characterized by severe diarrhea with tube feeding. At this point it can be clarified by upper gastrointestinal misery or barium enema. Almost all patients presenting with gastrocolic fistulae are treated by removal of the gastrostomy tube, which closes quickly once the PEG tube is removed. A widening of the gastrostomy opening around the PEG tube occurs in some patients, and although this can be caused by applying excessive tension to the PEG tube, it occasionally occurs in patients with a well-established PEG pathway. Malnutrition also plays a role in causing this problem, possibly due to the fact that the PEG tube is not easily immobilized in such patients and the tube is constantly displaced. Attempts to remove the fistula and replace it with a thicker diameter tube only temporarily block the enlarged fistula, which will soon enlarge again. A better solution is to simply remove the PEG tube, close the fistula gradually, and then insert a thinner PEG tube after it has been reduced in size. Also in order to minimize the displacement of the tube on the skin, the tube should be properly immobilized, also by placing pacifier-like immobilizers and similar devices are also very effective.

Pneumoperitoneum is also often prone to occur after PEG, mainly due to leakage of gas into the abdominal cavity from around the puncture needle during puncture. Abdominal plain films need not be performed routinely. Studies have shown that gas can remain in the abdominal cavity for up to 5 weeks after PEG. Once a patient is found to have pneumoperitoneum a clinical evaluation must be performed, if there are no signs of peritonitis, elevated white blood cells, or fever, no further evaluation is necessary. However, once the patient shows these signs, imaging through a PEG tube should be performed to identify any separation of the stomach from the abdominal wall or leakage of contrast into the abdominal cavity. One case of a patient who developed tension pneumoperitoneum after PEG resulting in hemodynamic disturbances has been reported, but this complication is, after all, rare.

Skin implantation has also been reported after PEG in patients with oropharyngeal and esophageal cancer. If the gastrostomy is performed only for palliative treatment, the occurrence of skin implantation metastasis is not controversial, but the occurrence of this complication is questionable when the gastrostomy is performed as part of the overall treatment, such as in neoadjuvant radiotherapy for esophageal cancer. It may be better if the insertion method is used at this point, but it has not been validated. The need for re-insertion of the endoscope to confirm once the PEG tube has been pulled out (or pushed out) into the correct position has been questioned by some physicians. The supine position makes it more difficult to insert the endoscope into the esophagus and easier to insert it into the trachea. However, it is important to confirm the position of the PEG tube, as there have been reports of obstruction due to ectopic positioning of the PEG tube in the cardia and pyloric regions of the fundus. Re-endoscopy can also help to confirm the adequacy of the tension between the gastric wall and the cushion, as well as to rule out any injuries caused by the tube placement, such as esophageal lacerations due to inappropriate maneuvers. This can be made easier by allowing the endoscope to follow the PEG tube into the esophagus before it is dragged into the oropharynx, when only a slight force is required to allow the endoscope to follow the PEG tube into the stomach and avoid re-injury. Good skin care after gastrostomy is very important and it is common to see discharge or granulation around the orifice due to rejection. This is relatively easy to manage and can be treated by scrubbing away the secretion with hydrogen peroxide and exposing the area. The granulation tissue can be cauterized with silver nitrate solution, and impermeable dressings are avoided as they tend to cause the underlying skin to soak and soften.