Risks of PEG tube placement in patients with cirrhosis-associated ascites

Abstract

This study examined the safety of placing percutaneous endoscopic gastrostomy (PEG) tube in people with liver cirrhosis. The target population was further subdivided into people with ascites (case group) and people without ascites (control). We compare the morbidity and the mortality difference of PEG placement in cirrhotic patients with ascites vs cirrhotic patients without ascites. We then examined multiple factors including sex, race, chronic illness including hypertension, congestive heart failure, and others and their influence on the inpatient mortality of all cirrhotic patients who had PEG placement. A total of 38,175 inpatient PEG tube placements were identified. Only 583 patients out of 38,175 had a history of cirrhosis. One hundred seven had ascites and the rest did not. Mean age of the patients was 61.14 years. Patient demography included (65.2%) male and the rest were female, 359 were white (64.4%), 90 black (14.8%), 84 Hispanic (13.7%), 23 Asians (3.3%), 7 Native Americans (0.4%), and 20 others (3.5%). Complications from PEG procedure in cirrhosis with ascites vs non-ascites included bleeding of 4 (0.8%) vs 2 (1.9%) (P=0.35), surgical site infection 2 (0.4%) vs 1 (0.9%) (P=0.51), and urinary tract infection 105 (22.1%) vs 34 (23.8%) (P=0.34), respectively. There was no colonic injury in either group. The total inpatient mortality was 75 out of the 583. Fifty-six (11.8%) were in the ascites group and 19 (17.8%) in the non-ascites group (P=0.097). Factors including ascites, postsurgical bleeding, and surgical site infection did not have influence on the inpatient mortality and there were no statistical differences between the two groups.

Endoscopic management of enteral tubes in adult patients – Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…A retrospective study of 29 patients with advanced cirrhosis undergoing PEG insertion [63] showed that the presence of ascites may be associated with increased mortality risk. However, a more recent study of 583 patients with cirrhosis (107 with ascites [18.3 %]), did not show any significant difference for bleeding, infection, or mortality in patients with ascites [64]. PEG tubes may be placed successfully after paracentesis, if re-accumulation can be prevented for a period of 7 -10 days after tube insertion, in order to allow tract maturation.…”

Nutrition Support of Children With Chronic Liver Diseases

“…In patients who are unable to consume adequate nutrition orally for appropriate growth, nasogastric (or nasojejunal) feeding is required. The insertion of a percutaneous gastrostomy carries significant risk in patients with portal hypertension and should be avoided (99,100). Failure to achieve adequate nutrition and growth using enteral feeds should prompt use of PN (82,83,85).…”

Trends and outcomes of percutaneous endoscopic gastrostomy in hospitalized patients with malignant and nonmalignant ascites: a nationwide population study

“…These results are in concordance with conventional practices, where ascites is considered a contraindication to PEG placement in most cases. Another study using the NIS showed that, although associated with a higher rate of complications, the presence of ascites among cirrhotic patients was associated with lower all-cause mortality as compared to cirrhotic patients without ascites [ 25 ]. Unlike this study, where only patients with cirrhosis-associated ascites were taken into consideration, our study analyzed the outcomes of PEG among all patients with ascites, irrespective of the underlying cause, over a much longer time period.…”