Dear Editor,
Peristomal leakage is a common complication around the insertion site of a percutaneous endoscopic gastrostomy (PEG) tube (1). It is usually caused by leakage of stomach contents or nutritional product into the peristomal area, which can lead to skin irritation, infection, or hypergranulation. A small peristomal leak may occur in the week following placement, but leakage of stomach contents can lead to peristomal infection and even tube loss (1, 2).
Causes of Peristomal Leakage
Risk factors for peristomal leakage include skin infection, increased gastric acid secretion, gastroparesis, distension, constipation, lateral bending of the tube, increased tension between the internal and external bumpers, Buried Bumper Syndrome and hypergranulation tissue. Additionally, factors such as diabetes, immunosuppression, and malnutrition may impede wound healing (1-3).
Management of Peristomal Leakage
The skin around the PEG tube should be cleaned regularly and protected with barrier creams containing zinc oxide (4, 5). In addition, foam dressings can be used instead of gauze to reduce local skin irritation (foam draws drainage away from the skin, while gauze prevents skin maceration). Unnecessary tube movement or excessive pressure should be avoided. Proton pump inhibitors (PPI) can be used to reduce leakage by minimizing gastric acid secretion. It maybe useful to initiate prokinetic agents to manage gastric residual volume and switching from bolus feeding to intermittent or continuous infusion with pump. Hypergranulation tissue can be treated with silver nitrate or steroid creams. If all the above-mentioned measures fail, the PEG tube should be removed and a gastrostomy tube should be placed in a new location (1, 5). In one of our cases, NÖ was a 56-year-old mobile female patient with tracheostomy, diagnosed with stage 4 laryngeal cancer who is receiving chemotherapy and radiotherapy. The patient’s PEG tube started leaking 1 week after the PEG tube was placed (Figure 1). Her dressing is wetted 3 times a day. The patient’s anamnesis revealed no instances of constipation, a factor known to increase intra-abdominal pressure. However, the presence of cough was noted and also patient fed bolus. After physician’s order the patient was started on PPI (pantoprazole-once a day) and prokinetic agent (domperidone-three times a day). It was recommended that the dressings be changed as they got wet and applied with a barrier cream containing zinc oxide. The patient’s PEG insertion site image at the end of the first and second weeks after treatments is as shown in Figures 2,3.
Informing caregivers about possible complications and controls in PEG care education will reduce complications and contribute positively to the long-term use of the PEG tube. However, the importance of close follow-up of the patient in the presence of complications is also seen in the case presented here.
