At the Bedside

  • First question: Is the tube still in the right place and is the patient unstable?
  • Immediate concerns
  • Aspiration / respiratory compromise: cough, dyspnea, hypoxia, vomiting after feeds. Place upright, suction as needed, oxygen, consider CXR if aspiration suspected.
  • Malposition / displacement: tube out of length, external bumper position changed, pain with flushing, inability to aspirate/feed.
  • Perforation / peritonitis: severe abdominal pain, guarding, fever, tachycardia, rigid abdomen, shock—especially after new PEG placement or tube replacement.
  • Bleeding: hematemesis, melena, blood around stoma, hemodynamic instability. Consider upper GI bleed pathways.
  • Obstruction/clogging: inability to flush, resistance to meds/feeds.
  • Leakage / skin breakdown / infection: erythema, purulence, cellulitis around stoma.
  • Buried bumper syndrome: pain, leakage, resistance to infusion, immobile PEG bumper.
  • Tube-specific bedside assessment
  • Inspect external marking/length and compare with baseline if known.
  • Check stoma for erythema, drainage, tenderness, crepitus, or leakage.
  • Do not blindly use a tube of uncertain position.
  • If bedside aspiration is possible, gastric contents support intragastric placement but do not exclude malposition.
  • Imaging
  • Contrast study via tube is often the fastest confirmatory test for PEG/G-tube position if the tract is mature and the tube may still be usable.
  • CT abdomen/pelvis with contrast if concern for perforation, peritonitis, buried bumper, abscess, or unclear anatomy.
  • Chest x-ray if aspiration, esophageal placement, or respiratory symptoms.
  • If a tube was newly placed or replaced and position is uncertain, involve GI/surgery before using it.
  • Initial management
  • Hold tube feeds until placement is confirmed if there is any doubt.
  • NPO if perforation, aspiration, or peritonitis suspected.
  • IV fluids, analgesia, antiemetics.
  • Broad-spectrum antibiotics if peritonitis, abdominal wall infection, or aspiration pneumonia is suspected.
  • Surgical or GI consultation for malposition, buried bumper, perforation, abscess, or inability to replace a dislodged tube.
  • Disposition
  • Discharge only if uncomplicated clogging or mild local irritation is definitively addressed and the patient can safely resume feeds/meds.
  • Admit for aspiration pneumonia, peritonitis, GI bleed, sepsis, or uncertain tube position requiring procedural management.
  • Urgent consult for new PEG dislodgement early in tract maturation, perforation, buried bumper, or failed replacement.
  • Pearl: Early PEG tracts are not mature; blind reinsertion can create intraperitoneal feeding and catastrophic peritonitis.
A Classic Presentation
A 78-year-old man with a PEG tube placed 10 days ago presents with increasing abdominal pain, fever, and leakage around the tube after his facility tried to restart tube feeds. He is tachycardic with diffuse abdominal tenderness and guarding, and the external bumper seems looser than before. CT shows free air and intraperitoneal contrast extravasation. He is made NPO, given IV fluids and broad-spectrum antibiotics, and surgery is urgently consulted for suspected PEG dislodgement with peritonitis.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 78-year-old man with a recent PEG placement presenting with abdominal pain and leakage around the tube after feeds were restarted today. My main concern is malposition or intraperitoneal feed leakage causing peritonitis, especially because this started after a recent tube manipulation and he now has fever and tachycardia. On exam he’s tender diffusely with some guarding, and the stoma is leaking with a changed external tube length. I’m less reassured by simple clogging because he has peritoneal signs rather than just inability to flush. We’ve held feeds, made him NPO, started IV fluids, and obtained CT with contrast through the tube; surgery and GI are involved. If the study shows extravasation or he worsens clinically, he’ll need operative or procedural management and admission.

Study Directive

  • Draw the difference between mature and immature gastrostomy tracts from memory.
  • Make a one-page checklist for “tube not working”: inspect, aspirate, flush, compare length, assess stoma, decide imaging.
  • Review your institution’s algorithm for declogging feeding tubes and when to involve GI vs surgery.
  • Practice explaining why a patient with abdominal pain after PEG restart needs CT or contrast study before feeds can resume.

Recent Literature