Gastrostomy (PEG / RIG)

A feeding tube through the abdominal wall into the stomach. The two that bite in the ED: a dislodged tube (the tract closes in hours) and a buried bumper (pain on feeding).

Adult & paediatricGI & nutritionStated practice - no UK guideline found

Also called: PEG, percutaneous endoscopic gastrostomy, RIG, radiologically inserted gastrostomy, feeding tube, gastrostomy tube, stomach tube, G-tube

What it is

A gastrostomy is a tube passed through the abdominal wall directly into the stomach for feeding, fluids and medication, in a patient who cannot safely swallow enough - commonly after stroke, in neurodisability, or in head and neck cancer. A PEG is placed endoscopically; a RIG radiologically. The tube is held in by an internal retention device - either a soft bumper/flange or a water-filled balloon (see the balloon-gastrostomy entry for why that difference matters).

The problems that reach an ED are dislodgement (the tube has come out, and the tract starts to close within hours), buried bumper (the internal bumper erodes into the stomach wall), blockage, and leakage/site infection. Gastrostomies are common in both adults and children (paediatric neurodisability especially); the principles here apply to both, with the child's nutrition/paediatric team directing care.

How to recognise it

A tube exiting the upper abdomen, with an external fixation plate or flange against the skin, a feeding port and often a measured external length marked on the tube.
A balloon-retained tube has a small balloon-inflation port (often labelled with the balloon volume in mL); a bumper/flange tube does not - this decides whether it can be replaced at the bedside.
A patient or carer on home enteral feeding, usually with a feeding regimen and the tube type documented.
Buried bumper is suggested by the BAPEN decision tree's cluster of pain and tenderness at PEG site, pain on feeding, tube blockage, extravasation of feed, site breakdown, peristomal infection, often with a tube that will not rotate or push in.

What it gets confused with

A balloon gastrostomy is retained by a water-filled balloon and is designed to be changed through the tract - look for the balloon-inflation port. A bumper/flange PEG cannot be pulled out without endoscopy. If you are thinking of replacing a dislodged tube, you must know which retention type it is.

Open that entry →

What goes wrong

Dislodged or fallen-out tube

The tube has come out completely, or been pulled partly out. The patient or carer often brings the old tube.

Red flag
The established gastrostomy tract begins to close within hours of the tube coming out. The department must decide early whether to keep the tract open - a balloon tube or a Foley catheter can often be placed through a mature tract by a competent clinician to preserve it - while definitive replacement and position confirmation are arranged. Do not feed through any replaced tube until its position in the stomach is confirmed.

Buried bumper syndrome

Pain on feeding, leakage, a tube that will not rotate or advance, and site problems. The BAPEN tree defines it: Buried bumper is the partial or complete growth of gastric mucosa over the internal bumper.

Red flag
It is driven by Excessive tension between the internal and external bumpers. Suspect it when feeding hurts and the tube is fixed; it needs the nutrition team and usually endoscopy. Do not force feed through it.

Blocked tube

Feed or medication will not pass; often caused by inadequately flushed or crushed medication, or thickened feed.

Red flag
Try gentle flushing with warm water; do not use excessive force or improvised wires, which can perforate or split the tube. Persistent blockage is a nutrition-team problem.

Leakage and site infection

Feed or gastric content leaking around the tube, with surrounding redness, soreness or discharge (peristomal infection).

Red flag
Treat infection, assess for over-granulation and for a loose or over-tight external fixation. Significant leakage with a buried bumper or an enlarging stoma needs the nutrition team.

The first ten minutes

If the tube is out, act on the clock. The tract closes within hours. Establish the retention type and tube size from the records or the old tube, and if the department's policy and skills allow, place a balloon tube or a Foley through a mature tract to keep it open - then confirm position before any use. But if the gastrostomy is recent (roughly the first 2-4 weeks - an immature tract), do NOT place a blind replacement: the stomach is not yet sealed to the abdominal wall, so a tube can pass into the peritoneum. Keep the patient nil by mouth and refer urgently to surgery/endoscopy.
Never feed or give medication through a newly (re)placed or displaced tube until its gastric position is confirmed (aspirate pH and/or contrast/imaging per local policy). A misplaced tube delivers feed into the peritoneum.
For pain on feeding or a fixed tube, suspect buried bumper and stop feeding through it; involve the nutrition team and arrange assessment (the BAPEN diagnosis tree uses imaging or gastroscopy).
For a blocked tube, try gentle warm-water flushing; do not force or push wires down it.
For leakage or site infection, treat the infection, check the external fixation, and refer non-trivial problems to the nutrition team.
Call the nutrition / gastroenterology team (or paediatric equivalent) for replacement confirmation, buried bumper and feeding decisions.

Do not

Do not leave a dislodged tract empty while you deliberate.

An established gastrostomy tract can close within hours. If nothing is placed to hold it, the route is lost and the patient needs a new procedure. Preserve the tract early (balloon tube or Foley through a mature tract, per local skills), then confirm position.

Do not feed through any tube until its position is confirmed.

A tube that has been replaced into a false passage, or displaced, can deliver feed into the peritoneal cavity - a cause of fatal peritonitis. Confirm gastric placement before use.

Do not blindly reinsert a tube into a recently-formed gastrostomy (first few weeks).

Before the tract matures (roughly 2-4 weeks) the stomach is not fixed to the abdominal wall, so a blindly placed tube can enter the peritoneum and any feed then causes fatal peritonitis. For a new gastrostomy, keep nil by mouth and refer urgently to surgery/endoscopy rather than reinserting.

Do not keep feeding through a tube that hurts or will not rotate.

Pain on feeding with a fixed tube suggests buried bumper; feeding against it worsens the problem. Stop and get the nutrition team.

Do not attack a blocked tube with force or a wire.

Excessive pressure or improvised instruments can split the tube or perforate the tract. Gentle warm-water flushing first; refer if it fails.

Who owns it

The nutrition support team / gastroenterology (or interventional radiology for a RIG, and the paediatric team in children) own the tube. Tell them the tube type (bumper vs balloon) and size, whether it is out/displaced/blocked/buried, how long it has been out, and whether position has been confirmed.

Who to call

The team and the criteria are national. The phone number is local, and this tool does not know it. Find it once, now, and write it on the department's own card — that is the part no website can do for you.

Say the device name first: Open with laryngectomy, LVAD, shunt — the single word changes who comes and what they bring. Do not bury it in the history.
Say what you have already established: Whether the device is patent, whether it has been removed or disturbed, and what you have already tried. The specialist is deciding whether to walk or run.
Ask who owns it out of hours: Device ownership and the on-call route often differ from the implanting specialty, and it is frequently a regional centre rather than your own hospital.
The patient's own team is a resource, not an afterthought: Named nurse specialists, home-care companies and device helplines answer questions nobody else can, and the patient usually has the number.

When the device is not the problem

A patient with a device gets pneumonia, sepsis, pulmonary oedema and myocardial infarction at the same rate as everybody else. The device is the most visible thing about them and it attracts the whole assessment.

The NTSP says it out loud: The project's own manual warns that patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy. The same sentence applies to every device in this tool.
Clear the device, then leave it: Establish that the device is doing its job — the stoma is patent, the line draws back, the pump is running — and then assess the patient as you would anyone else.
The anchoring runs both ways: The opposite error is treating a device complication as a medical illness: a blocked gastrostomy read as vomiting, a baclofen pump failure read as sepsis.

NTSP manual — Red flags · read in full

What the patient will be carrying

Home enteral-feeding patients usually carry details of the tube type, size and insertion date, their feeding regimen, and the nutrition team's contact. The carer often knows how to replace a balloon tube and will have brought the old one.

Scope of this page

This page covers the ED response to gastrostomy problems: preserve a closing tract, never feed before confirming position, recognise buried bumper, and manage blockage, leakage and site infection. It does not teach PEG insertion, endoscopic buried-bumper removal, or routine tube changes beyond preserving a mature tract - those belong to the nutrition, gastroenterology, radiology and surgical teams. The buried-bumper recognition follows the BAPEN decision trees; the tract-preservation, position-confirmation and immature-tract steps are established national practice rather than drawn from those trees. Gastrostomies are common in adults and children; paediatric care is directed by the child's team.