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PEG vs J tube?

Discussion in 'General Residency Issues' started by andrea, Dec 5, 2006.

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  1. andrea

    andrea

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    So I am on my surgery month and I am getting confused as to why they use certain tubes. For example, what does PEG stand for, and in what circumstances would a surgeon put one in? Why would a J tube be put in instead of a PEG? What is the difference between G tube and PEG? Similarly, why would someone put in a PICC line instead of a central line? I appreciate your answers! Thanks.
  2. supercut

    supercut Senior Member

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    Glad you are interested enough to learn. I see incorrect terminology all the time.

    PEG: Percutaneous Endoscopic Gastrostomy tube. This is placed into the stomach (implied by Gastro) using and endoscope. GI docs can do this as well as surgeons. It can be done in the ICU , endoscopy suite or OR. Usually done when the pt doesn't need any other surgery (execept at trach, then you have the infamous Trach/PEG combo)

    G tube: Gastrostomy tube. Also a tube in the stomach but is placed by making an incision in the abdomen and surgically placing the tube in the stomach. Most frequently not done alone, but during another operation requiring an incision. Also necessary if the pt pulls out the PEG soon after insertion.

    J tube: Jejunostomy tube, which goes in the jejunum. Placed at the time of surgery for a procedure on the stomach or duodenum, especially if you plan to wait to allow PO intake for anastamoses to heal (eg Whipple...you want to allow the pancreatic and billiary anastamoses time to heal. So placing the J tube distally allows enteric feeds which are better)

    PICC: Peripherally inserted central catheter: Is a form of central access, but it can be left in the pt for longer time than any other form of central access. Usually only used when you anticipate the pt will need central access for weeks. What makes a line central is where the tip winds up inside the pt (hence the need to check the x ray), not were the line is inserted on the outside.

    As far as why choose one over the other for a particular patient, that is a question that is totally approprate to ask your residents.
  3. f_w

    f_w 1K Member

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    In addition, a G-tube can be placed percutaneously under fluoroscopic and ultrasound guidance. It has a slightly lower risk of non-target organ damage than a PEG and can be performed in patients who cannot undergo upper endoscopy (e.g. in a palliative setting for patients with esophageal ca or lung-ca). And in contrast to an 'open-G', this can be done in moderate sedation, an issue in patients whose pulmonary status makes general anesthesia less desireable.
  4. napoleondynamite

    napoleondynamite Chief Resident

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    But how can you tell, just by looking at the pt and the tube, whether it is a G, PEG or J tube? Does a PEG stick out of the gut, or the mouth? thanks, this has confused me too..
  5. ekydrd

    ekydrd Senior Member

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    It is very hard to tell "just by looking" at the tube whether it is a G-tube, PEG, or J-tube. Depending on the brand used there may be a long tube sticking out of a small hole in the LUQ (usually a G or J-tube), a "button" which is a cap over the access to the tube (usually a PEG will look like this), or a combination of a tube with a plastic collar around the insertion site. All three will come from the abdominal wall and not the mouth or nose. Just to make it more interesting... the J-tube is simply an extention of a G-tube so that the iternal portion of the tube extends beyond the duodenum and into the jejunum, or may be a direct connection into the jejunum done at placement.

    The term for tubes that come from the nose or mouth that end up in the GI tract are called NG (nasogastric) or OG (orogastric), and are usually only temporary, whereas the above types of tubes are semi-permanent or permanent.
  6. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    Buy the books Surgery Recall and First Aid for Surgery. Trust me. If you are asking these questions, you need a lot more information before taking the shelf.
  7. SLUser11

    SLUser11 CRS

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    Honestly, I don't remember those types of questions from the shelf, and your post is pretty condescending.

    I think it's probably pretty easy to go through an entire surgical clerkship and never know what a J-limb, etc is, especially in an environment where you're discouraged from asking "dumb" questions.
  8. core0

    core0 Which way is the windmill

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    I'll add a little more here. There are essentially three type of tubes G tubes, J tubes and GJ tubes. One important thing to remember is that if one of these is put in, you need to leave it in for two to three months even if it is not being used. If you take it out before then there is a chance the stomach will fall away leaving a hole in the stomach draining into the abdomen.

    Another helpful tip is determining who put in the tube (GI or IR) is that generally there is a bumper on the GI version and not one on the IR version (depending on the kit used). Also endoscopically placed version tend to be larger than the IR version. The reason that this is important is that the IR version is usually sown in and the GI version is usually not sewn in. This can be embarrising if you go to pull one out.

    A final helpful tip is if someone pulls one out in the middle of the night, you can place a foley of the same size in the tract and keep the tract open. Your GI colleagues will not have to come in then. Be careful when doing this in a fresh placement.

    As far as why you would use one over another, this is a pretty complex subject. Generally G tubes are preferrable as they have less complications. So if you can put in a G tube then thats what you want. If you have a biliary surgery generally you will put in a J tube to let things heal. There is also school of thought that states that J tube feeding is the treatment for sever pancreatitis (this is controversial). Also if you have someone that is aspirating on regular feeds then a J tube may help. Finally GJ tubes are nice since you can decompress the stomach while feeding the distal gut.

    Finally there are some IR docs and GI docs putting in percutaneous J or GJ tubes.


    David Carpenter, PA-C
  9. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    Yeah, but if you have those books, they say what every device, instrument, and tube is. They are even more helpful if you are in an environment where you can't ask. Self learning and all, people don't need to hold your hands.
    And yes, enteral feeding was on the Shelf.

    It probably would have taken less time to google it. Condescending would be me saying that that person should have googled it.
  10. wook

    wook Just a hairy situation

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    They also don't appear on Step 2 or Step 3 from what I can recall.


    Wook
  11. f_w

    f_w 1K Member

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    In my experience, it tends to be the patient who takes it out.... (no, not the post-laryngectomy crowd, more the MMS<20 candidates)

    The IR version has a bumper, except that the bumper is a 20cc balloon filled with dilute contrast. The problem with that is that this gives the underpaid and often underqualified staff in 'skilled' nursing facilities another connector to play with. Attemps to 'flush' this port will often lead to deflation or rupture of the balloon and as a result a dislodgement of the percutaneous G-tube. Btw. the IR version would typically NOT be sown in beyond the immediate 10 day post placement period (what looks like a suture is actually something called a 'T-fastener', a little dohicky we use to pin the stomach against the anterior abdominal wall similar to what the surgeon does with his gastropexy during an open G-tube. Before you cut any of the 'sutures', make sure to talk to whoever put the tube in beforehand....).
    The most common etiology for the demise of an IR placed tube is however 'operator error'. In addition to the stunt of deflating the balloon port, an alltime favourite is putting 'crushed pills' into the G or G-J. Only liquid med formulations or meds finely ground by pharmacy using a mortar and pestle should ever be put into G-tubes (or even more importantly surgically placed sutured direct red-rubber J-tubes). The 'crushed pills' invariably aggregate to a impenetrable concrete like substance that neither 'warm tea' nor 'coca cola' will dissolve (and no, I can't 'just wire it' if it is clogged up).

    The GI version has a fixed plastic bumper and is actually placed by pulling the tube backwards through the patient over a wire. The upside of that is that the bumper can't deflate and that if necessary you can lift the patient off the table on a GI placed G-tube (the real PEG). The downside is that if you need to exchange the PEG (bc someone f-ed up the outside portion with some sharp instruments), it typically requires another endoscopic procedure (the IR placed version can be changed over a wire under fluoroscopy with the patient awake, just like a central line).

    PLEASE do this if you get called by nursing in the middle of the night. Just drop in a foley with some KY and carefully inflate the balloon (bench test it beforehand so you know how it feels when it inflates freely in the stomach as opposed to within the tract). Just make sure that nobody feeds the patient through the foley (suture the opening shut, put a big 'remove before flight' flag on it), bc sometimes the tip might not actually be in the stomach and your first bottle of 'ensure' ends up in the peritoneum. Deal with it the next day and call whoever 'owns' the tube (GI, IR or general surg) and ask them for help with the tube dislodgement.

    If you have a G-tube, it can typically be converted into a G-J under fluoroscopy (try this: walk up to a first-year radiology resident and graciously offer to send him a 'G-J conversion'. He'll be your fast friend from this day forward ;))
  12. SLUser11

    SLUser11 CRS

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    Enteral feeding perhaps, but I'd feel safe in saying that the shelf won't ask the student to differentiate between different modes of enteral feeding (e.g. a. g-tube, b. PEG tube, c. rectal tube, d. both a and c are correct).

    As for "those book" having every device, tube, etc, they're far from being unabridged, but now I'm just arguing semantics.

    Anyway, the condescending part was the "trust me" line.....I envisioned a smart-ass smirk under your ninja mask when I read that.

    I think that being on night float, lack of sleep has made me simultaneously hypersensitive and self-righteous, so I'm unnecessarily coming to the aid of weaker people that I would normally be clowning on.

    Lack of sleep has also made me kind of misuse the term "semantics." Maybe I should have googled it..........:thumbup:
  13. andrea

    andrea

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    Thanks to everyone who replied! Your answers are very helpful, especially to a non-surgical resident. Thanks again.
  14. Mman

    Mman Senior Member

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    Another good point about PICCs is that they have a far lower infection rate than a "central" line (neck, subclav, or fem). The only real benefit that bigger lines have is they have more ports to run multiple infusions and are a bigger gauge so you can put volume in faster than a PICC.

    But longterm IV antibiotics or TPN? Gotta be a PICC.
  15. f_w

    f_w 1K Member

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    You can get PICCs with up to 3 lumens, how many more do you need ? most PICCS are of the single or double lumen variety)

    PICCs are for mid-term vascular access. Because they are not inserted into a central vein and their lumen is rather small, there is little concern with sending a patient home with a PICC (if you are anticoagulated and you pull out your 12Fr IJ line in your sleep, you might wake up dead).
  16. napoleondynamite

    napoleondynamite Chief Resident

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    :laugh:
  17. debvz

    debvz Wandering Spleen

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    Am I wrong to hope for an "a and b are correct" option? :scared:
  18. SLUser11

    SLUser11 CRS

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    Well, since there wasn't a question to go along with those answers.......
  19. Koil Gugliemi

    Koil Gugliemi Koil Gugliemi

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    Actually the comments about PICC catheters are mostly correct, but I will point out that we leave tunneled central catheters in patients for at least as long or longer than PICCs, infection rates are generally thought to be equivalent, though there's not really great data one way or the other.

    By tunneled central venous catheter I mean a catheter that exits from the chest wall ~ 4-5 cm from (usually an IJ) venotomy.
  20. Koil Gugliemi

    Koil Gugliemi Koil Gugliemi

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    (*^(*&^ double posts
  21. u_r_my_serenity

    u_r_my_serenity Member

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    I am an intern 6 months into my first year and I learned something about tubes from this post, so don't feel bad. PS: I aced my boards.

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