On the Bleeding Edge: Mastering GI Emergencies and Inpatient GI Consultation (Live and Virtual)| September 2026-Stein_Enternal Access and Managing Complications

Stein_Enternal Access and Managing Complications

Pdf Summary

This talk reviewed modern endoscopic options for enteral access, especially when standard PEG placement is difficult. It covered three main approaches: PEG tubes beyond the traditional pull technique, PEG-J tubes, and direct PEJ tubes, along with common complications and their management.<br /><br />For PEG placement, the Russell introducer technique was highlighted as useful when the esophagus is too narrow for a pull PEG or when tumor seeding is a concern. The 2024 ASGE guidelines were summarized: in patients with normal foregut anatomy, PEG is preferred over IR-guided gastrostomy, antiplatelet agents usually do not need to be held, anticoagulation decisions should be individualized, and feeds can generally begin 4 hours after placement.<br /><br />PEG-J tubes were described as useful but technically challenging, mainly because advancing and maintaining the jejunal extension can be difficult. Several placement methods were reviewed, including fluoroscopic wire guidance, endoscopic wire guidance, rat-tooth forceps techniques, and clip-guided methods. The speaker emphasized that newer one-piece balloon tubes and low-profile designs can reduce leakage, clogging, and patient dissatisfaction.<br /><br />Direct PEJ was presented as a strong option for patients with altered anatomy or when the stomach cannot be accessed. It may be done with balloon-assisted techniques and has good overall success rates, with complication rates similar to PEG in experienced hands.<br /><br />The second half focused on complications: peristomal leakage, buried bumper syndrome, tube dislodgement, infection, hypergranulation, clogging, gastrocolocutaneous fistula, and aspiration. Key themes included identifying the underlying cause, avoiding upsizing for leaks, not blindly reinserting early dislodged tubes, using antibiotics and local care when indicated, and preventing complications with proper tube fit, flushing, skin care, and positioning.<br /><br />Overall, the message was that enteral access is feasible in most patients, but selecting the right technique and anticipating complications are essential.

Keywords

enteral access

PEG placement

PEG-J tube

direct PEJ

Russell introducer

ASGE guidelines

jejunal extension

balloon-assisted technique

tube complications

peristomal leakage