GI Endoscopy · 7 min read
PEG: Prefer Endoscopic Placement, Feed by 4 Hours, Do Not Bury the Bumper
Transillumination plus 1:1 finger indentation is the safe tract. The pull technique is still the workhorse. The bumper is not a tourniquet.
Clinical Bottom Line
| Question | Practical answer |
|---|---|
| First gastrostomy | PEG when anatomy allows. ASGE 2025 suggests PEG over IR-guided gastrostomy for initial placement (PMID 39520459). IR is acceptable if PEG is not available or has already failed. |
| Safe tract | Transillumination plus a single 1:1 finger indentation plus a safe-tract (air in the syringe as you enter stomach, not stool or urine). Intervening colon is the injury you are trying not to make. |
| When to feed | Within 4 hours if the patient is otherwise stable. ASGE recommends this. |
| Antithrombotics | Do not routinely stop antiplatelets, including DAPT. Anticoagulants: multidisciplinary, bleed versus thrombosis. Do not crush the bumper for a day and leave it crushed. |
| What PEG is not | Not aspiration prophylaxis. Not a substitute for a swallow plan. Not automatic in malignant dysphagia (pull or direct PEG are both allowed). |
How do you actually place it?
Insufflate so stomach meets abdominal wall. Confirm a single bright transillumination and a matching 1:1 indent. Needle, wire, snare. Pull technique: the tube follows the wire out the mouth, then down and out the abdominal wall until the internal bumper seats. Direct/introducer PEG never travels the oropharynx, which is why some teams prefer it in head and neck cancer. ASGE 2025 allows either for malignant dysphagia.
The leftover stub described a surgeon 'violently yanking' a mushroom through the esophagus. That language is gone. You pull until the bumper meets mucosa, then leave a 1 cm gap at the skin so the tract can form without necrosis.
What goes wrong after?
Buried bumper is an overtight external bolster plus time. Early leak and peritonitis mean you missed colon or did not appose. Pneumoperitoneum on a film is common and not, by itself, a trip to the OR. Wound infection is why most units give a pre-procedure antibiotic. Thirty-day death after PEG is usually the disease that indicated the tube, not the puncture.
Replace a mature tube through the tract. Do not put a new PEG through a fresh hole because the first bumper vanished into the wall unless you can see stomach again.
Selected references
Last reviewed September 20, 2026. Written for clinicians deciding whether a patient with weeks of unsafe swallow should get a PEG, and how not to bury the bumper if they do.
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