Dietary advice and care guidelines for patients with a venting percutaneous endoscopic gastrostomy (PEG)

What is a venting PEG?

A PEG is a soft tube placed through your skin into your stomach. The term ‘PEG’ describes the way it is placed:

• Percutaneous – through the skin
• Endoscopic – the equipment used to examine the stomach
• Gastrostomy – opening into the stomach

A venting PEG enables the stomach to be decompressed (remove all the air) and emptied. It is placed to prevent and manage nausea and vomiting.

Why do you need to have a venting PEG?

If you have an obstruction in your bowel then food and fluids cannot move through your digestive system. This will cause a build up with likely nausea and vomiting along with possible pain and discomfort. The venting PEG allows draining of any built up food and fluid, preventing these unpleasant symptoms.

What can I eat and drink?

When you have a venting PEG placed, you will need to receive alternative nutrition to provide all your daily nutrients as the usual route via your gut is blocked or bypassed. This alternative nutrition may be via a tube inserted into the small bowel (JEJ tube) or via intravenous nutrition (PN). The venting PEG will enable you to continue eating and drinking for pleasure and comfort.

It is important that the tube is draining at all times. Therefore, any foods that you eat need to be able to pass through it easily. This may mean chewing food well and choosing soft, moist options. The following guidance should help you make the most suitable choices:

• Try using sauces, gravy, butter, cream or custard to soften foods e.g. have fish in sauce, sponge with custard or cream.
• Soften foods by pureeing, chopping, mincing or mashing.
• Small sips of drink with a meal can help keep food moving through the tube.
• Meats should be well cooked and tender – try stewing, casseroling etc.
• Try to avoid foods that are dry or require a lot of chewing eg tough gristly meat, raw vegetables and nuts

Ideas for food choices

Meat and poultry

• Shepherd’s pie, cottage pie, corned beef hash, meat loaf
• Minced meats with gravy or sauce
• Skinless sausages
• Tender meat in stews, hotpots or casseroles
• Potted meat and smooth pates

Fish

• Flaked fish in white/cheese/parsley sauce
• Fisherman’s pie, fish mornay, fish and potato nests
• Fish mousse or light pate
• Tinned fish eg tuna, salmon, sardines

Eggs*

• Serve scrambled, poached, boiled or an omelette (add cheese if desired)
• Egg Mayonnaise
• Egg dishes eg sweet/savoury egg custard, soufflés

* Ensure that eggs are well cooked

Pasta dishes (well cooked)

• Lasagne, moussaka, bolognaise sauce over pasta
• Macaroni cheese, ravioli
• Pasta in creamy sauce eg carbonara

Potatoes and vegetables

• Soft/ mashed/ pureed carrots, turnip, swede, cauliflower, marrow
• Serve with a white/ cheese sauce or gravy
• Instant mashed potato is a quick alternative
• Mash the inside of a jacket potato with butter and add a suitable filling

Desserts and snacks

• Sponge pudding with custard/cream/ice cream
• Milk puddings eg rice pudding, semolina.
• Whip, mousse, fruit fool, jelly, crème caramel, blancmange, trifle
• Dip biscuits in warm drinks to soften
• Pancakes-savoury with a sauce, sweet with cream/ice cream
• Yoghurt, fromage frais, milk jelly
• Ice cream, sorbet
• Cheese triangles, cheese spread
• Tinned/stewed/mashed fruit with cream
• Custard, ice cream, yoghurt

Two types of tubes commonly used for venting PEGs

There are two types of tubes commonly used for venting PEGs which are:

• balloon-retained gastrostomy (BGT) or
• the Wilson Cooke tube (which is bumper retained)

You will be told the type of tube you have and the best way to care for it.

My tube is …

How to clean the PEG site for the first week

• Remove the dressing the day after your tube is inserted, this is no longer required.
• Clean the tube and site daily.
• Use the gauze swabs provided. Carefully clean under the circular flange using neat Octenisan body wash, then cleanse with warm water. Dry well and apply the Mupirocin ointment around where the tube exits the skin.
• It is important not to move the circular flange for the first week as keeping it in place helps the site to heal better.

Can I have a bath?

For the first two days after your tube is placed don’t have a bath or shower. Wash using the Octenisan body wash.

For the rest of the first week you may have a shallow bath or a brief shower still using the Octenisan body wash.

After the first week

After the first week, if the skin around your site is clean and dry you may return to your normal bathing routine.

• It is no longer necessary to use the Octenisan and Mupirocin but you will still need to clean the PEG site daily with warm soapy water.
• You may now release the circular flange and move it away from your skin to enable easier cleaning.
• Do not forget to clean and dry the underside of the circular flange as well.
• Make sure you replace the flange approximately 2mm from the skin so that the tube does not slide in and out as this can cause leakage

If you have any concerns about returning to your normal bathing routine, please contact the nutrition nurse specialists.

How do I look after my venting PEG?

For both tubes

The tube will need to be flushed daily with 50ml of cooled boiled water. This will help prevent blockage and enable to tube to drain well. Occasionally you may need to flush more often depending on what you have eaten or the viscosity of your secretions.

For the Wilson Cooke tube

It is important to insert and rotate your tube once a week to stop the bumper in your stomach getting stuck. To do this, follow these instructions:

Remove and empty your drainage bag. Do not re attach until tube insert and rotate is completed

• Wash your hands.
• Clean and dry the skin at the exit site.
• Release the circular flange by untwisting the white clip and slide the circular flange back.
• Push the tube in about 5cm, rotate the tube 360 degrees and then pull the tube back out until you feel resistance and refasten the circular flange about 2mm from your skin.

If your Wilson Cooke PEG needs to be replaced, an endoscopic change which will be done by your consultant.

For the BGT

It is important to perform a balloon patency check once a week to prevent accidental displacement of the tube. To do this, follow these instructions:

• Wash your hands.
• Clean and dry the skin at the exit site.
• Fill a 10ml syringe with 10ml of cooled boiled water.
• Have another empty 10ml syringe ready.
• Release the circular flange by moving it back up along the tube length.
• Push the tube in about 5cm and secure the tube with tape.
• Using an empty 10ml syringe, insert into the inflation port (balloon port) and withdraw the water
• Using a new 10ml syringe filled with cooled boiled water, attach to the inflation valve and insert the 10ml of water.
• Keeping your thumb of the syringe plunger, twist the syringe to release it from the balloon port.
• Pull the tube back out until you feel resistance and move the circular flange downwards about 2mm from your skin.
• If the volume of water withdrawn from the balloon is less than 5ml this could be a sign that the balloon is not working properly. Secure the tube to your stomach with tape or an adhesive dressing then contact either your company nurse or the Nutrition Nurse Specialists for advice.

BGTs are routinely replaced every three to four months and will be decided on an individual basis.

An ideal time to complete your water balloon change is on a week day morning as there will be more support available to you should it be needed.

What else do I need to look out for?

You need to look at your site regularly to check for signs of infection. The things to look out for are:

• redness
• pain
• discharge which is yellow and smelly

If you notice these signs, contact GP or the nutrition nurse specialists.

It is also possible for the skin at the exit site to become pink and/or lumpy and it may bleed easily. This may be an overgrowth of tissue which can be easily treated with a special dressing or treatment. Again, contact the nutrition nurse specialists or your GP if you are worried.

What happens if the tube is blocked?

If your tube blocks you may become nauseous or start vomiting. Flushing may help unblock the tube and relieve the nausea. To unblock:

1. Draw up 10mls air in an empty 60ml syringe and attach to your PEG
2. Using the push and pull technique, try to push the air into the tube, then withdraw plunger. Repeat this action a couple times
3. If you are able to get any air into the tube, try to flush with some warm water.
4. The tube can be massage with your fingers to help break up any deposits.
5. If the methods above are unsuccessful try a solution of sodium bicarbonate (one teaspoon in 100ml water); leave in the tube for one hour and then use the push and pull method (step 2), followed by a warm water flush.

If your tube is a Wilson Cooke, please check that it is not pulled to tight to your abdomen as this can cause the tube block, preventing free drainage. Try releasing your circular flange and insert tube first before starting the above steps.

If your tube falls out

If your Wilson Cooke is accidentally pulled out, please contact your nutrition nurse specialist during office hours (see below). Outside of office hours you will need to attend your local emergency department.

If your BGT has come out and if you feel able to, push the tube back in and secure it with tape. Then contact the nutrition nurse specialists within office hours or attend you local emergency department out of office hours.

Where can I find more information?

Please contact your dietitian if you require further advice about your nutrition:

Dietitian: ___________________________________________________________

Contact number: 01223 216 655

Contact email ___________________________________________________ ___

(An email consent form must be completed to enable Addenbrooke's staff to contact patients by email).

Please contact your nutrition nurse specialist if you require further advice about the management and care of your tube:

Nutrition nurse specialists: ____________________________________________

Contact number: 01223 216037 (Option 1)

Contact email: _____________________________________________________

(An email consent form must be completed to enable Addenbrooke's staff to contact patients by email.)

Out-of-hours

Please telephone your GP or NHS 111 should you have any worries or concerns with your percutaneous endoscopic gastrostomy (PEG).