PEG (Percutaneous Endoscopic Gastrostomy) tube - Stomach Tube

Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points

A PEG tube is a stomach tube that is placed into the stomach, through the body wall on the left side of the pet, usually with the assistance of a flexible camera called an endoscope

This is an excellent means to provide a route for feeding if your pet will not eat

PEG tube

  • A PEG tube is a stomach tube that is placed into the stomach, through the body wall on the left side of the pet, usually with the assistance of a flexible camera called an endoscope
  • The procedure
    • the pet is anesthetized
    • the left side of the abdomen is shaved
    • an endoscope is placed into the stomach via the mouth
    • a strong suture is placed through the outer body wall into the stomach which is distended with gas
    • the suture is retrieved with the scope and pulled from the stomach to the mouth
    • the stomach tube is tied to the suture and pulled into the stomach and out of the body wall
    • the stomach tube is secured in place
    • a cap is placed on the end of the stomach tube

 

Indications for a PEG tube

  • Any animal that refuses to eat or take in adequate amounts of food and water
  • Many diseases can cause lack of appetite
  • Injury or fracture of the jaw bones
  • In cats, fatty liver disease is an indication to have the tube placed
  • Below is a cat that has a PEG tube in place; a shirt is used to cover the tube

      

      

Care of PEG tube

  • For the first 2 weeks the skin around the PEG tube should be gently cleansed to remove any discharge using a clean Q-tip and hydrogen peroxide or dilute antiseptic solution such as Betadine or Chlorhexidine; thereafter, occasional cleaning may be needed

      

  • After the site has been cleansed, triple antibiotic ointment such as Neosporin is applied to help heal the site

      

 

Feeding through the PEG tube

  • Prior to feeding, the amount of stomach contents is measured by aspirating on the stomach tube with a 35 or 60 ml catheter tip syringe
  • If the residual fluid in the stomach is greater than 15 ml, the feeding is delayed for a couple of hours and the residuals are rechecked again
  • Generally the residual fluids are removed and discarded; it is unusual that discarding the fluid will cause alkalosis or significant electrolyte problems in the blood
  • A total needed amount of feeding will be calculated for your pet; this amount is divided into about 4 equal feedings per day
  • We usually recommend a dense food such as Eukanuba Maximum Calorie diet as smaller volumes of food are needed versus other brands; after a can of food is opened it should be refrigerated; it should be warmed to a luke warm temperature prior to feeding; usually a small amount of water is added to the food to make it more liquid and easier to pass through the PEG tube
  • Always flush the PEG tube with 15 ml of luke warm water after administering food or medications through the PEG tube
  • Place the cap back on the tube after feeding or administration of medications via the tube
  • If your pet is not drinking, additional water is recommended
    • Daily requirement of water is roughly 60 ml/kg/24hours
    • calculate the amount of water that is in the food (about 70% of total food fed per day) and subtract this from the daily requirement
    • Subtract also the 15 ml of water that is used to flush the tube after each feeding
  • Always offer food free choice of food - once the pet is eating well the PEG feedings can be stopped or gradually weaned off

 

Improving passage of food through the stomach

  • If you find that the residual amount of fluid/food in the stomach is greater than 15 ml prior to a feeding, your pet likely has poor motility of the stomach, thus the food and fluids are not being properly pumped out of the stomach
  • Encouraging your pet to walk around after the feeding will help to get the stomach to pump the food into the intestine
  • Medications are sometimes prescribed to help empty the stomach

 

Unclogging a PEG tube

  • If food has not been adequately flushed through the PEG tube after a feeding, the tube may become clogged
  • Try flushing the tube with luke warm water
  • If this is not effective, put 5 ml Coca cola down the tube and let it sit for about 30 minutes, then flush with luke warm water
  • If this is not effective consult us or your regular veterinarian

 

Removal of a PEG tube

  • A PEG tube must stay in place for about 10 days prior to removal so that peritonitis or infection of the abdominal cavity does not occur
  • The PEG tube should be removed by a veterinarian; the tube is simply pulled out and does not require anesthesia
  • The tube is generally removed once the pet is eating well

 

Potential complications

  • Anesthetic death - rare
  • Infection  - uncommon
  • Poor stomach motility
  • Vomiting from feeding too fast or too much food at one time
  • Premature dislodgement of the stomach tube

Frequently Asked Questions After Surgery - General Information

When should my cat have the first bowel movement after surgery?

  • Many cats will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a cat will not have regular bowel movements after surgery include:
    • The cat has been fasted prior to surgery
    • Cats do not eat well during the hospital stay
    • They frequently do not eat well when the go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as fentanyl patches, tramadol, morphine) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home a stool softener such as metamucil can be fed
    • Dose of metamucil 1/4 tsp per mixed in with each meal (canned cat food)

My cat had surgery and will not eat.  What can be done?

  • Offer smelly foods that contain fish such as tuna or smelly cat foods
  • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
  • Hand feeding;  place a small amount of food in the mouth so that they get the flavor
  • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature with your finger; it should  be only luke-warm.
  • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
  • Petting and stroking your cat frequently will help to stimulate appetite
  • Remember that most pets will not eat the first day or two after they get home from surgery
  • Appetite stimulants such as cyproheptadine may be helpful
  • If your cat refuses to eat anything for 7 days a stomach tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My cat is vomiting now that he/she is at home.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the cat usually just opens the mouth and fluid or food will be expelled.  Usually the regurgitant will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be happening the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics are a common cause of vomiting after surgery.  In order to see which medication is causing the problem the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • Unusual cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves with holding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then.  In order to decrease the acidity of the stomach Pepcid AC 0.5 mg/kg given by mouth twice daily for 5 days can sooth an upset stomach.  Metoclopramide is a good anti-vomiting medication for cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, which is called esophagitis.  This results in poor motility of the esophagus so water and food will accumulate in this structure.  In most cases esphagitis is self-eliminating and will resolve within two or three days. 
    • Regurgitation also can be caused by a neuromuscular degeneration of the esophagus and this problem will persist.  It is not associated with surgery, rather other underlying diseases.
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus, does not allow passage of food down the esophagus, thus the pet has persistent regurgitation.  This problem should be brought to the attention of your doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent such as sucralfate.  You should consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs as signs can be more subtle and they usually do not vocalize
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs and they should be given only for a few days

Is it okay for my cat to lick or scratch the incision?

  • If a cat licks the incision it will actually delay the healing process because they usually lick too much and traumatize the area.
  • Cats have a barbed tongue, therefore a lot of damage can be done in a short period of time
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Cats will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking/scrtaching the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • If the incision is over the chest an infant tee shirt can be put on your pet and the waist of the shirt fastened in place with an ace bandage or duct tape.
    • If the incision is over the paw or lower limb a bandage or sock could be put on and kept up with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons

What does it mean?

  • Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

  • Experience in the development of new surgical treatments

  • Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

  • Assurance that a veterinarian is a surgical specialist

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