Endoscopic Therapy - Nutrition

Naso gastric and naso jejunal tubes

These are often placed endoscopically and used to feed people either into the stomach (naso-gastric or NG tube) or in those where naso-gastric (NG) feeding has failed, where vomiting is an issue or gastro-paresis means the emptying of the stomach is delayed naso-jejunal (NJ) tubes may be required.

PEG and PEJ tubes​

These are longer term tubes inserted using an endoscope. A light is shone from the stomach (into which the endoscopic has passed) onto the abdominal wall (transillumination), in order to identify which part of the skin a small needle should be inserted to anaesthetise the skin. Once anaesthetised a small cut is made in the skin and a larger needle is passed, through the abdominal wall, the stomach wall and into the lumen of the stomach. A thread is then passed via this needle into the stomach and "caught" using equipment (snare or forceps) passed down the endoscope. the thread is then brought out of the mouth. A flexible tube is then attached to the thread (the other end of which is still coming out of the hole through which the larger needle was passed on the wall of the abdomen (tummy). This tube is then pulled gently over the back of the throat, through the stomach and onto the abdominal wall. A button or internal balloon prevents the tube from being pulled out altogether. The tube can then be secured on the abdominal wall.

​

Of course such a procedure is not without significant risk. As well as the usual risk associated with endoscopy other risks arise. On occasion the endoscopist and team are unable to transilluminate the abdominal wall and so cannot procced with the insertion. Because needles are being passed into the abdomen there is a risk of the nedle being passed into a structure other than the stomach, including the bowel, significant blood vessels, the gallbladder or the liver. All such events are potentially life threatening. Bleeding and perforation are recognised risks. Once the PEG is placed it may of course be pulled or fall out. If this occurs within the first few days perforation and peritonitis may ensue. Once again this is potentially life-threatening. In the long-term infection and irritation can arise around the external PEG site, causing soreness and irritation and occasion significant pain and distress. Nevertheless in patients who are unable to swallow and unlikely to do so in the immediate futre PEG insertion is sometimes the least invasive or risky way of providing nutrition. On the "flip side" PEGs should be avoided where it is anticipated there insertion will not significantly alter the prognosis for people approaching the end of life. In such cases PEG insertion exposes individuals to signifcant potential distress without clear benefit (just because we can doesn't mean we should). PEG tubes secure nutrition, they do not significantly reduce the risk of aspiration since we make significant quatities of saliva every day, which we still have to swallow or dispose of, even when we cannot eat.

​

PEJ tubes simply extend the delivery point of nutrition from the stomach to the small bowel. Unfortunately they do have a tendency to sli back into the stomah from time to time.

​