Non-urgent advice: Important information about your appointment
Before your appointment
- All medications should be taken as normal with a little water.
If you take warfarin or clopidogrel or other blood thinning medication, please contact the endoscopy nurses when you receive this information on 01223 216515. You may need to stop your medication prior to your procedure. If you take aspirin only please continue. - If you have diabetes, please see below.
- If you have any questions about the procedure or find that you cannot keep this appointment, please contact the endoscopy office between 9:00 (9am) and 17:00 (5pm) Monday to Friday on 01223 257080.
On the day
- Have nothing to eat for six hours and nothing to drink for four hours before your appointment.
- You will have been informed if you are staying in hospital overnight, ensure that you bring anything you may require for an overnight stay in hospital.
At the hospital
- Please come to the endoscopy department on level 3 of the Addenbrooke’s Treatment Centre (ATC).
- Use Car Park 2. The car park is busy early in the morning, so please allow yourself enough time to arrive in time for your appointment. Take your parking ticket to the endoscopy reception desk to have your ticket stamped; this will enable you to have discounted parking.
- Please note you need to arrive 30 minutes before your appointment time for your pre-procedure check. The length of time you will be here will vary enormously but may be anything from two to four hours or more. Please ask your admitting nurse for further information during your admission check.
This information leaflet is for patients considering a gastrostomy tube. This may take place as a day case procedure or may require a short hospital admission. Your healthcare team will explain what is involved and answer any questions you may have.
Why do I need a gastrostomy tube?
Your medical condition may cause you to be unable to take enough food and/or drinks by mouth to meet your nutritional requirements. This may be due to:
- Difficulty swallowing (dysphagia) that arises from changes to the function of muscles involved in swallowing. These changes can increase the risk of food and/ or drinks to your lungs, which can result in a chest infection called aspiration pneumonia.
- Changes to your appetite and/or ability to take food orally due to reduced physical function.
A gastrostomy tube can help as it bypasses the need to swallow, meaning nutrition and/or medications can be delivered directly into your stomach.
Feeding gastrostomy
This is used for ‘feeding’. It allows you to receive liquid feed, water and sometimes liquid medicines. It is usually used if people have difficulty with swallowing.
Venting gastrostomy
If you have an obstruction (blockage) 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 percutaneous endoscopic gastrostomy (PEG) tube allows draining of the built-up food and fluid, preventing these unpleasant symptoms.
About gastrostomy tubes
A gastrostomy tube is a tube which is placed directly into the stomach. It is also known as a ‘PEG’, which stands for:
- percutaneous (through the skin)
- endoscopic (instrument used to examine the stomach)
- gastrostomy (opening into the stomach)
We use two types of gastrostomy tubes:
- PEXACT (balloon gastrostomy) tube
- Freka PEG
You will be shown how to look after the tube by your nutrition nurse specialist or local feed company nurse.
Advice applicable to both types of tube:
- Do not clamp the tube unless you are about to connect or disconnect the feed.
- When using the clamp, clamp as close to the end port as possible.
The PEXACT gastrostomy tube
A PEXACT is a type of feeding tube placed through your skin into your stomach and is held in place by a balloon filled with sterile water.
The Freka PEG
A Freka PEG is a type of feeding tube placed through your skin into your stomach and is held in place by a silicone disc.
Can I still eat and drink?
Depending on your medical condition it may be possible to continue eating and drinking even with the tube in place. If you are experiencing dysphagia, your speech and language therapist will assess your swallowing and help you to be able to do this.
What are the benefits of having a gastrostomy tube?
Gastrostomy tubes are placed when there are problems with feeding. By placing the tube we can provide you with optimal nutrition. This will improve your energy, your sense of wellbeing and help your body fight infection.
How long will I need the tube for?
This depends entirely on the reason for placing the tube and will be discussed with you personally.
If you have a PEXACT tube, this is usually replaced after four weeks, at which time your stitches will be removed. An appointment for this will be arranged for you here at Addenbrooke’s to attend the nutrition nurses’ clinic. After this, we usually recommend a routine tube replacement every four to six months and usually this can be changed at home by your local nutrition or feeding company nurse.
If you have a PEG tube, and if it is well cared for, it can last for up to five years. One way of increasing the life of your tube is to leave the clamp undone when the end connector is in place. This prevents the clamp squashing the tube. You can also change the place the clamp sits along the tube to avoid squashing the same part of the tube each time.
What if I decide not to have a feeding tube?
Again, we will check that you fully understand the risks of not having a tube but will support your decision.
If you are finding it difficult to eat and drink due to lack of appetite or difficulty swallowing but decide not to have a feeding tube, we will again support your decision. Your speech and language therapist and dietitian will continue to work with you to help you make the most of eating and drinking, and to make it as easy as possible, for as long as you find this helpful.
What do I do if I have questions?
Your community nurses, GP, dietitian and nutrition nurse will be available to help and support you. Your dietitian or nutrition team will provide regular follow up but if you have any concerns
- Nutricia: 03457 623672
- Abbott: 0800 0183799
- Fresenius Kabi: 0808 100 1990
- Addenbrooke’s nutrition nurses: 01223 216037 (Option 1)
Getting ready for the procedure
Wear loose-fitting washable clothing and leave valuables at home.
On arrival at the department
Please register your arrival with the receptionist, they will ask for your pre-procedure questionnaire. Some patients may arrive after you but be seen quicker; we have seven procedure rooms all undertaking different procedures therefore patients are not seen in arrival order.
Before your procedure you will meet one of the nurses who will ask you some health questions and explain the procedure to you.
Once this is completed, you will be escorted to a single sex changing area. You can wear your own clothes for this procedure. Your escort cannot wait with you from this point and can leave the department until you are ready to go home.
You can change your mind about having the procedure at any time.
Sedatives
Most patients undergoing insertion of a gastrostomy tube are given sedation but, in some cases, (such as motor neurone disease) the procedure is performed without sedation. In exceptional cases a general anaesthetic may be necessary. This will be discussed with you and explained well in advance.
There are two options for this procedure:
- No sedation: we will spray a local anaesthetic to the back of your throat or into your nostril. This will make it numb so that you cannot feel the gastroscope. The numbness will last for about half an hour. The advantage is that you may resume your normal activities such as working and driving. You will be fully aware of the procedure; most patients find this acceptable.
If you choose sedation, you must arrange for a responsible adult to collect you from the department and take you home. You will not be able to drive yourself. You cannot be collected in a taxi without your escort present. Please provide reception with the contact details of your escort, they need to be available to collect you from 90 minutes after your appointment time. Escorts do not need to wait in the department. If you are entitled to use hospital transport, an escort is not required. - Intravenous sedation: this will be administered via a plastic tube called a cannula which is inserted into a vein and will make you feel relaxed and sleepy but not unconscious (this is not a general anaesthetic). This option means you may not be aware of the procedure. You will need to be escorted home. The injection will continue to have a mild sedative effect for up to 24 hours and may leave you unsteady on your feet for a while.
What happens during the procedure?
You will be collected from the changing room by the endoscopist and taken to a private bay to complete your consent form. When this has been completed, they will escort you to the procedure room. The team in the procedure room will introduce themselves and ask you some questions; this is to confirm you ready and prepared to continue with the procedure.
In the procedure room, we will ask you to remove false teeth, glasses and hearing aids in the left ear. We will make you comfortable on a couch lying on your left side. The endoscopist will give you the injection or throat spray. We will put a plastic guard into your mouth so that you do not bite and damage our instrument. We will also put a plastic ‘peg’ on your finger to monitor your pulse and oxygen levels. For your comfort and reassurance, a trained nurse will stay with you throughout.
Local anaesthetic
Local anaesthetic is used to numb the skin where the tube comes out of the stomach.
You will be given local anaesthetic through an injection into the skin where the gastrostomy tube will be placed. The anaesthetic works almost immediately and from then on, the skin should be numb. You will be able feel only light pushing on your abdomen.
Inserting the gastrostomy tube
You will be supported by the team during the procedure however, if you make it clear that you are too uncomfortable the procedure will be stopped. The team can arrange a stop signal with you before starting the procedure.
Please note that you may feel a little bloated and have some wind-like pains because of the air in your gut after the PEG insertion; these usually settle down quickly.
PEXACT tube insertion
A gastroscope is inserted into your mouth; this passes through your throat and into your stomach. Alternatively, a nasal scope may be used which passes into your nostril, through your throat and into your stomach. This may cause you to gag slightly; this is quite normal and will not interfere with your breathing. Your stomach will be inflated with air so that we have a clear view to position. When the correct point is found in the stomach, two stitches are inserted to hold the stomach up against the abdominal wall, and then the tube is inserted from the outside.
The stitches will remain in place until the first tube change is carried out, usually four weeks after insertion. The tube is prevented from coming out of the stomach by a balloon which is inflated inside. The whole procedure usually takes 30 to 40 minutes.
Freka PEG insertion
A gastroscope is inserted into your mouth; this passes through your throat and into your stomach. This may cause you to gag slightly; this is quite normal and will not interfere with your breathing. Your stomach will be inflated with air so that we have a clear view to position. Once the endoscope is within the stomach, we pass a needle directly into the stomach. Using a small hole that we create from the outside, we place the gastrostomy tube and then secure it from the outside.
What are the risks of the procedure?
All patients being considered for PEG insertions are discussed at a weekly Feeding Issues Multidisciplinary team meeting to ensure this is an appropriate intervention. Additionally, the gastroenterology consultant will discuss the risk of the procedure with you when you attend for the procedure.
- Sedation: There is a small risk that sedation can relax the muscles needed for breathing. If we feel that sedation may be best avoided in your case, we will consider placing the tube without sedation. We may consider placing it using a nasal endoscope, which is safest and often the best tolerated approach.
- Aspiration: There are some risks associated with the endoscopic examination of the stomach when placing the tube, which could lead to aspiration and may cause pneumonia.
- Bleeding: while inserting the tube, there is a small risk of internal bleeding or puncturing an organ.
- Infection: after the procedure there is a small risk of infection within the abdomen (peritonitis), which is rare but can be serious.
- Death: Severe complications arising from the insertion of the tube are very rare. The risk of dying after the procedure is extremely low. Where deaths have occurred in our practice within the following 30 days of tube insertion, they have been due to the underlying disease process rather than the procedure to place the tube itself.
You will be given a single dose of the broad-spectrum intravenous antibiotic called gentamicin immediately after the procedure to minimise this risk. Gentamicin is safe to use in patients with penicillin allergy. If you have an allergy to gentamicin or suffer with myasthenia gravis, co-amoxiclav will be the alternative used.
Please note:
- You will be required to stay in the endoscopy recovery area for four hours where you will be closely monitored and 50ml of sterile water will be given through the PEG before you are discharged.
- If any strong (opioid) analgesia is given during the recovery period, you will need to be collected upon discharge as you will not be able to drive.
How long will I need to stay in hospital?
Gastrostomy insertion is usually performed as a day-case procedure in the Endoscopy Unit. You will be required to stay in the endoscopy recovery area for four hours where you will be closely monitored. The nutrition nurses will teach you and/or your family how to look after the feeding tube if you have not had pre-insertion training. The PEG will be flushed before you are discharged.
We will always do our best to respect your privacy and dignity, for example with the use of curtains. If you have any concerns, please speak to the department sister or charge nurse.
We advise you not to drive, operate machinery, return to work, drink alcohol or sign legally binding documents for a 24-hour period after the procedure. We also advise you to have a responsible adult to stay with you for the next 12 hours. You can eat and drink as normal.
After the procedure
The endoscopist (particularly if admitted via the day-case ward) or the medical team looking after you will be able to inform you before you leave hospital. The result, as a written report, will be filed in your electronic notes before you leave the endoscopy department so that the information is immediately available for the medical team on your ward.
The sedation can affect your ability to remember any discussion. If you would like someone with you when you talk to the endoscopist or endoscopy nurse please inform the nurse looking after you who will arrange for you to be seen in a private room with your escort when they arrive.
Urgent advice: Issues immediately after discharge
Important
If you are discharged within 72 hours of having your PEG placed and you notice any of the following symptoms:
- leakage of fluid around the PEG tube
- pain on feeding or flushing with water (stop the feed)
- prolonged or severe pain with possible abdominal bloating
- new bleeding from the PEG site
do not put anything through the PEG. Contact your GP (in working hours), Call 111 for advice or go to your nearest Accident and Emergency urgently.
PEG insertion aftercare
There will be some discomfort after a gastrostomy insertion. However, if any of the following occur after the procedure, you must immediately stop feed or medicine delivery through the tube and contact your local feed company nurse (please see contact details below)
- leakage of fluid around the tube
- pain on feeding or flushing your tube
- new bleeding
- redness
- yellow and smelly discharge
You will be trained in all the necessary techniques to look after the tube and what to do if you do have problems. Your dietitian or nutrition team will provide regular follow up, and the company delivering your feed will have a nurse helpline; details will be provided before you go home.
What problems might I encounter after placement of a gastrostomy tube?
Pain
The site where the tube enters the stomach can be painful for a few days after the procedure. Patients are usually encouraged to use painkillers (analgesia) regularly for the first two to three days following insertion. This will be discussed this with you on the day of your procedure and painkillers prescribed if required.
Infection at the site of insertion
This can occur if the PEG site is not kept clean and dry but is rarely serious. You will be provided with a PEG treatment kit containing Octenisan antimicrobial wash and Mupirocin antimicrobial ointment to clean the PEG insertion site for the first seven days. After this period patients are usually encouraged to clean with soap and water then dry well. Dressings are not usually required.
Leakage around the gastrostomy site
Occasionally, feed or gastric (stomach) fluid may leak around the tube; this commonly occurs if the triangle plate or circular disc is not close to the skin allowing the tube to slide in and out of the stomach causing leakage. This can be corrected by tightening the retention plate (external bumper) close to the skin. The surrounding skin should be cleaned and kept dry. A protective skin barrier spray maybe applied to resolve any redness/ skin irritation caused by the leakage. In exceptional circumstances, the tube may need to be replaced, or repositioned at a different site.
Over granulation at the gastrostomy site
This is the appearance of light red or deep pink flesh that forms beyond the surface of the stoma opening. There are many reasons this may develop, and the treatment plans will be patient specific.
PEG tube related problems
Blockage of the tube
This can usually occur after giving some medications or not flushing the tube at the end of a feed. Though blockages can be resolved, you are encouraged to prevent this by flushing before and immediately after feed. Additional advice will be provided if you will be giving medications down the PEG tube.
Balloon failure (burst balloon)
If the balloon that retains your gastrostomy tube bursts the tube fall out. You will be required to attend your nearest Accident and Emergency department within an hour of your tube falling out to prevent the stoma (hole) from closing.
If the tube remains in place but balloon malfunction is suspected, you should secure the external triangle or round disc with tape to your abdomen to prevent the tube falling out before contacting your nutrition nurse for advice.
| Medication | Morning appt | Afternoon appt |
|---|---|---|
| Medication Lantus, Levemir, Abasaglar, Semglee, Humulin I, Insulatard, Toujeo, Tresiba | Morning appt Take 80% of usual morning dose | Afternoon appt Take 80% of usual morning dose. |
| Medication Novorapid, Trurapi, Humalog, Apidra, Humulin S, Actrapid, Fiasp, Lyumjev, Admelog | Morning appt Do not take until eating and drinking | Afternoon appt Take usual dose with breakfast then omit until after the procedure. |
| Medication Novomix 30, Humalog Mix 25, Humalog Mix 50, Humulin M3 |
Morning appt
Do not take in the morning. Take 50% of the morning dose with a meal after the procedure. |
Afternoon appt Take 50% usual dose with breakfast. |
| Medication | Morning appt | Afternoon appt |
|---|---|---|
| Medication Insulin pump therapy | Morning appt Reduce basal rate to 80% from 06:00 (6am). | Afternoon appt Reduce basal rate to 80% from 10:00 (10am). Bolus with breakfast as per carbohydrate count. |
| Medication Lantus, Levemir, Abasaglar, Semglee, Humulin I, Insulatard, Toujeo, Tresiba | Morning appt Take 80% of usual morning dose. | Afternoon appt Take 80% of usual morning dose. |
| Medication Novorapid, Trurapi, Humalog, Apidra, Humulin S, Actrapid, Fiasp, Lyumjev, Admelog | Morning appt Do not take till eating and drinking. | Afternoon appt Take usual dose with breakfast, then omit until after the procedure. |
| Medication Novomix 30, Humalog Mix 25, Humalog Mix 50, Humulin M3 | Morning appt Take 50% of usual morning dose. (Contact your usual diabetes specialist nurse for advice if needed.) |
Afternoon appt
Take 50% of usual morning dose. (Contact your usual diabetes specialist nurse for advice if needed.) |
If your diabetes medication or insulin is not listed above, contact your usual diabetes specialist nurse for advice.
| Units: | 80% is: | 50% is: | Units: | 80% is: | 50% is: |
|---|---|---|---|---|---|
| Units: 1 | 80% is: 1 | 50% is: 1 | Units: 51 | 80% is: 41 | 50% is: 26 |
| Units: 2 | 80% is: 2 | 50% is: 1 | Units: 52 | 80% is: 42 | 50% is: 26 |
| Units: 3 | 80% is: 2 | 50% is: 2 | Units: 53 | 80% is: 42 | 50% is: 27 |
| Units: 4 | 80% is: 3 | 50% is: 2 | Units: 54 | 80% is: 43 | 50% is: 27 |
| Units: 5 | 80% is: 4 | 50% is: 3 | Units: 55 | 80% is: 44 | 50% is: 28 |
| Units: 6 | 80% is: 5 | 50% is: 3 | Units: 56 | 80% is: 45 | 50% is: 28 |
| Units: 7 | 80% is: 6 | 50% is: 4 | Units: 57 | 80% is: 46 | 50% is: 29 |
| Units: 8 | 80% is: 6 | 50% is: 4 | Units: 58 | 80% is: 46 | 50% is: 29 |
| Units: 9 | 80% is: 7 | 50% is: 5 | Units: 59 | 80% is: 47 | 50% is: 30 |
| Units: 10 | 80% is: 8 | 50% is: 5 | Units: 60 | 80% is: 48 | 50% is: 30 |
| Units: 11 | 80% is: 9 | 50% is: 6 | Units: 61 | 80% is: 49 | 50% is: 31 |
| Units: 12 | 80% is: 10 | 50% is: 6 | Units: 62 | 80% is: 50 | 50% is: 31 |
| Units: 13 | 80% is: 10 | 50% is: 7 | Units: 63 | 80% is: 50 | 50% is: 32 |
| Units: 14 | 80% is: 11 | 50% is: 7 | Units: 64 | 80% is: 51 | 50% is: 32 |
| Units: 15 | 80% is: 12 | 50% is: 8 | Units: 65 | 80% is: 52 | 50% is: 33 |
| Units: 16 | 80% is: 13 | 50% is: 8 | Units: 66 | 80% is: 53 | 50% is: 33 |
| Units: 17 | 80% is: 14 | 50% is: 9 | Units: 67 | 80% is: 54 | 50% is: 34 |
| Units: 18 | 80% is: 14 | 50% is: 9 | Units: 68 | 80% is: 54 | 50% is: 34 |
| Units: 19 | 80% is: 15 | 50% is: 10 | Units: 69 | 80% is: 55 | 50% is: 35 |
| Units: 20 | 80% is: 16 | 50% is: 10 | Units: 70 | 80% is: 56 | 50% is: 35 |
| Units: 21 | 80% is: 17 | 50% is: 11 | Units: 71 | 80% is: 57 | 50% is: 36 |
| Units: 22 | 80% is: 18 | 50% is: 11 | Units: 72 | 80% is: 58 | 50% is: 36 |
| Units: 23 | 80% is: 18 | 50% is: 12 | Units: 73 | 80% is: 58 | 50% is: 37 |
| Units: 24 | 80% is: 19 | 50% is: 12 | Units: 74 | 80% is: 59 | 50% is: 37 |
| Units: 25 | 80% is: 20 | 50% is: 13 | Units: 75 | 80% is: 60 | 50% is: 38 |
| Units: 26 | 80% is: 21 | 50% is: 13 | Units: 76 | 80% is: 61 | 50% is: 38 |
| Units: 27 | 80% is: 22 | 50% is: 14 | Units: 77 | 80% is: 62 | 50% is: 39 |
| Units: 28 | 80% is: 22 | 50% is: 14 | Units: 78 | 80% is: 62 | 50% is: 39 |
| Units: 29 | 80% is: 23 | 50% is: 15 | Units: 79 | 80% is: 63 | 50% is: 40 |
| Units: 30 | 80% is: 24 | 50% is: 15 | Units: 80 | 80% is: 64 | 50% is: 40 |
| Units: 31 | 80% is: 25 | 50% is: 16 | Units: 81 | 80% is: 65 | 50% is: 41 |
| Units: 32 | 80% is: 26 | 50% is: 16 | Units: 82 | 80% is: 66 | 50% is: 41 |
| Units: 33 | 80% is: 26 | 50% is: 17 | Units: 83 | 80% is: 66 | 50% is: 42 |
| Units: 34 | 80% is: 27 | 50% is: 17 | Units: 84 | 80% is: 67 | 50% is: 42 |
| Units: 35 | 80% is: 28 | 50% is: 18 | Units: 85 | 80% is: 68 | 50% is: 43 |
| Units: 36 | 80% is: 29 | 50% is: 18 | Units: 86 | 80% is: 69 | 50% is: 43 |
| Units: 37 | 80% is: 30 | 50% is: 19 | Units: 87 | 80% is: 70 | 50% is: 44 |
| Units: 38 | 80% is: 30 | 50% is: 19 | Units: 88 | 80% is: 70 | 50% is: 44 |
| Units: 39 | 80% is: 31 | 50% is: 20 | Units: 89 | 80% is: 71 | 50% is: 45 |
| Units: 40 | 80% is: 32 | 50% is: 20 | Units: 90 | 80% is: 72 | 50% is: 45 |
| Units: 41 | 80% is: 33 | 50% is: 21 | Units: 91 | 80% is: 73 | 50% is: 46 |
| Units: 42 | 80% is: 34 | 50% is: 21 | Units: 92 | 80% is: 74 | 50% is: 46 |
| Units: 43 | 80% is: 34 | 50% is: 22 | Units: 93 | 80% is: 74 | 50% is: 47 |
| Units: 44 | 80% is: 35 | 50% is: 22 | Units: 94 | 80% is: 75 | 50% is: 47 |
| Units: 45 | 80% is: 36 | 50% is: 23 | Units: 95 | 80% is: 76 | 50% is: 48 |
| Units: 46 | 80% is: 37 | 50% is: 23 | Units: 96 | 80% is: 77 | 50% is: 48 |
| Units: 47 | 80% is: 38 | 50% is: 24 | Units: 97 | 80% is: 78 | 50% is: 49 |
| Units: 48 | 80% is: 38 | 50% is: 24 | Units: 98 | 80% is: 78 | 50% is: 49 |
| Units: 49 | 80% is: 39 | 50% is: 25 | Units: 99 | 80% is: 79 | 50% is: 50 |
| Units: 50 | 80% is: 40 | 50% is: 25 | Units: 100 | 80% is: 80 | 50% is: 50 |
We are smoke-free
Smoking is not allowed anywhere on the hospital campus. For advice and support in quitting, contact your GP or the free NHS stop smoking helpline on 0800 169 0 169.
Other formats
Help accessing this information in other formats is available. To find out more about the services we provide, please visit our patient information help page (see link below) or telephone 01223 256998. www.cuh.nhs.uk/contact-us/accessible-information/
Contact us
Cambridge University Hospitals
NHS Foundation Trust
Hills Road, Cambridge
CB2 0QQ
Telephone +44 (0)1223 245151
https://www.cuh.nhs.uk/contact-us/contact-enquiries/