ALS From Both Sides


The Procedure

Although we often refer to a feeding tube as a PEG, technically the tube is a “feeding tube” and “PEG” is just one of three possible methods used to put the tube in place:

Another feeding tube option is a J tube which can be placed by either PEG, PRG or surgical method. For this, the feeding tube is placed in the jejunal section of intestine just beyond the stomach. Since the stomach is mainly a blender that liquefies food before it moves into the jejunum, the digestive process isn't disrupted. This type of tube is used for people who have problems with gastric reflux (food moving backwards from the stomach into the esophagus). That causes heart burn and scarring of the esophagus. The potential for that liquid food to move upward far enough to get into the lungs is a concern especially for ALS patients who can't sit up after tube feedings.

Either way, a tube is placed through a tract through the abdominal wall so that liquefied food can be poured directly into the digestive tract rather than being swallowed. Regardless of the method used, the tube itself will be chosen from several similar brands. Rather than calling it a PEG, it should be referred to as a G tube or J tube, technically accurate regardless of the procedure used. Feel free to call it a feeding tube, G tube, J tube, Harold, Eloise, or other name of your choosing.

Breathing is a big concern during this otherwise minor procedure. For respiratory support he may use BiPAP or, if your respiratory status is poor, intubation (a breathing tube through the mouth into the trachea) may be needed. Whether or not you will spend a night in the hospital depends primarily on whether your breathing becomes a problem and your doctor's preferences.

The decision regarding which method to use for insertion of the feeding tube will be made based on your breathing status and possibly the availability of a Radiologist who performs PRG's. Although PEG is more common, PRG is now being used more frequently for ALS patients who have a moderate or severe level of respiratory involvement. (Moderate = lung capacity of 30 to 50%, Severe = less than 30%) It is especially helpful in cases where the weak diaphragm (the muscle that separates the abdominal organs from the chest) has allowed the stomach to move further upward under the rib cage.

The PEG procedure is generally done in the Endoscopy Department of the hospital. An Endoscopic tube is placed through the mouth and into the stomach. The camera of the endoscopic tube allows the inside of the stomach to be seen. The PRG procedure is done in the Radiology department with radiography (live x-rays) being watched during the procedure. The x-rays allow the stomach and other organs to be seen.

For either procedure the patient will have an IV for medication and be sedated. BiPAP can be used during the procedure and breathing will be monitored. The sedative may be given with pain medication for deeper relaxation and sleep. The amount of sedation/pain medication for the PEG procedure is generally higher because the endoscopic tube is quite large. For the PRG a much smaller and softer tube is put through the mouth to the stomach.

After sedation the Endoscopic or smaller tube is inserted. From this point the procedures are very similar. The direction to best enter the stomach is identified and the area on the upper left abdomen is numbed. A guide wire is used to make a path from the small abdominal incision to the stomach. The feeding tube is pulled along the same path by the guide wire. The guide wire is then removed by pulling it up the endoscopic tube or the smaller tube and out the mouth. Done!

Immediately after you wake up after the tube is placed, you will probably want some strong pain medication. By the next morning the pain should be considerably less but you will still want some kind of medication. Tylenol will soon be enough. Because placing the tube requires going through abdominal muscle, pain when moving will last several days. Using a pillow to support your abdomen when lying on your side in bed will reduce pain.

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