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Indications / Contraindications
Indications
- Long-term enteral nutrition (malnutrition): Neurologic dysphagia (stroke, ALS, dementia), head/neck cancer (pre- or post-treatment), trauma, burns
- Gastric decompression: Chronic obstruction (gastric outlet, distal bowel), gastroparesis
- Medication administration when oral route unavailable
- Prior failed PEG or gastric anatomy not suitable for endoscopy (post-esophagectomy, etc.)
Contraindications
- Absolute: No safe gastric window (liver/colon interposition that cannot be displaced); Massive unresectable ascites (high leak risk); Uncorrectable coagulopathy
- Relative: Prior gastric surgery (altered anatomy — review CT carefully); Active PUD or gastric outlet obstruction (relative — drainage tube may still be placed); Pregnancy (transperitoneal access — fetal risk); Obesity (thick abdominal wall — consider CT guidance)
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Pre-Procedure Checklist
CT scan (mandatory — IR-specific). Review for colon and liver position relative to anterior stomach. Identify safe transabdominal window. A single CT showing an "unsafe" window is not a reason to abort — reposition patient, use barium, displace colon. Only fixed hepatomegaly without safe window = abort.
Labs. CBC, coagulation (INR <1.5, Plt >50K). Routine coags for SIR Cat 2 procedure.
Antibiotics. Ceftriaxone 1g IV 1 hour before procedure. Reduces peristomal infection and peritonitis risk.
NPO 6 hours. Moderate sedation protocol.
Colon visualization plan (at time of procedure). Options: oral barium 12–24h before (barium in colon = fluoroscopic visibility); rectal contrast enema (opacify colon under fluoroscopy); air insufflation of stomach via NG tube to displace colon; ultrasound to confirm safe window; cone-beam CT for difficult cases.
Consent. Inadvertent colon/bowel puncture (0.5–1%), peritonitis, bleeding, tube dislodgement, peristomal infection, aspiration, internal bumper erosion, buried bumper syndrome.
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Relevant Anatomy
Stomach Anatomy & Target
- Regions: Cardia (GEJ), fundus (superior), body (main), antrum/pylorus (distal)
- Target: Anterior gastric body/antrum — most accessible, safest window
- Avoid fundus (adjacent to spleen/diaphragm) and proximal body (overlapped by liver in some patients)
- Two approaches: Retrograde transabdominal (IR preferred — direct access through abdominal wall, faster, less sedation) vs. Antegrade transoral pull technique — used when retrograde not feasible
Danger Structures
- Transverse colon: Most commonly interposed — MOBILE, can be displaced with positioning or air. Barium enema/oral barium essential for visualization. This is the key hazard to identify before sticking.
- Liver (right lobe): Can overhang anterior stomach — fixed, cannot be displaced. Review CT carefully. If unsafe window without alternative → abort.
- Left lobe of liver: Can extend into epigastric region — check on CT.
- Epigastric vessels: Run in anterior abdominal wall. Access lateral to rectus or use Doppler US to avoid.
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Technique
Retrograde transabdominal technique + community cards
Supplies
NG tube (gastric distension)
Fluoroscopy
ChloraPrep
Sterile drape
1% lidocaine
T-fasteners × 3–4 (gastropexy anchors)
18G access needle
0.035" × 180 cm Amplatz stiff guidewire
8 × 4 Conquest balloon
14–20 Fr balloon-retained G-tube (MIC-Key / Bard)
10 mL syringe (balloon)
Sterile water (balloon inflation)
Omnipaque contrast
External fixator plate
Steps
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NG tube + gastric distension
Place NG tube. Infuse 300–500 mL of air via NG tube to distend stomach against anterior abdominal wall. Confirm on fluoroscopy — rugal folds of stomach should be visible under the anterior wall. Glucagon IV (1 mg) can be given to reduce peristalsis and improve distension if struggling.
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Colon visualization + safe window confirmation
Confirm transverse colon is NOT in the planned access path. Use oral barium (taken night before), rectal contrast enema under fluoroscopy, or air displacement with positioning. Never assume the colon isn't there. Check in the lateral position and save image.
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Gastropexy (T-fasteners)
Identify planned tube site and mark. Create a triangle around the tube site for T-tacks. Swing arm lateral. Under fluoroscopic guidance, pass T-fastener needles (3–4) in triangular/rectangular pattern around intended tube site. These tack the stomach wall to the anterior abdominal wall, preventing the stomach from pulling away during tube passage and reducing post-procedure peritoneal leak risk.
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Contrast confirmation
Inject small amount of dilute contrast through T-fastener needle to confirm intragastric position. Gastric rugae should be visible; contrast should flow freely within the gastric lumen. Save image.
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Access
Go back to AP. Advance 18G needle between T-fasteners into gastric lumen under fluoroscopic guidance directed slightly towards the pylorus. Confirm intraluminal position with contrast injection before advancing wire. Swing needle up towards fundus.
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Wire + balloon dilation
Place 0.035" Amplatz stiff guidewire — coil securely in stomach. Load 8 × 4 balloon coaxially through the G-tube. Load on the wire. Inflate under fluoroscopy and save image when waist disappears.
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Tube placement + balloon inflation
Bring down the balloon and simultaneously advance gastrostomy tube and balloon over wire into the stomach. Remove balloon. Inflate retention balloon with 5–10 mL sterile water. Gently pull back to feel stomach wall apposed to abdominal wall. Confirm position on fluoroscopy. Apply external fixator plate to skin.
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Contrast check + completion
Inject contrast through tube — confirm intragastric position and free flow. No peritoneal extravasation. T-fastener sutures cut and removed at 5–7 days once fistula tract matures.
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4b
Push-Type Gastrostomy Placement
Antegrade transoral pull-through technique
Supplies
T-fastener × 1 (gastropexy anchor)
18G access needle
0.035" × 180 cm Glidewire
0.035" × 145 cm Amplatz stiff wire
8 Fr short sheath
5 Fr × 90 cm Kumpe / MPA catheter
7 Fr × 90 cm end-hole catheter
Pull-type gastrostomy kit (20 Fr tube)
1% lidocaine
Scalpel (small stab incision)
Xylocaine spray (oropharyngeal anesthesia)
0-Silk suture
Steps
- Anesthetize the oropharynx with Xylocaine spray.
- Insufflate the stomach — use an indwelling NGT or pass a Kumpe catheter and Glidewire through the abdominal wall into the stomach to insufflate with air.
- Place a single T-fastener gastropexy tack at the planned access site.
- Access the stomach with an 18G needle. Advance the Amplatz stiff wire into the stomach.
- Remove the needle and place the 8 Fr short sheath over the Amplatz wire.
- Use the Glidewire and Kumpe/MPA catheter to cannulate the esophagus from the abdominal access site. Advance up through the esophagus and exit the mouth.
- Exchange the Kumpe for the 7 Fr end-hole catheter and bring the catheter out of the mouth.
- Thread the endoscopic pull-string from the gastrostomy kit through the 7 Fr end-hole catheter from the abdominal wall side, feeding it out through the patient's mouth.
- Tie the 20 Fr gastrostomy tube firmly to the pull-string. Pull both antegrade — tube passes from the mouth, through the esophagus and stomach, and exits through the abdominal wall.
- Remove the dilator tip on the end of the tube and snare. Suture the tube in place with 0-Silk.
- Inject contrast through the tube to confirm intragastric position. Cut and remove the T-fastener tack.
Tumor seeding risk: This technique passes the tube through the oropharynx — do NOT use in patients with active oropharyngeal or esophageal malignancy due to risk of abdominal wall tumor seeding at the tube exit site. Use the retrograde transabdominal (push) technique instead.
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Troubleshooting
Problem
Cannot distend stomach adequately
Likely cause: NG tube malpositioned, gastroparesis, or tube kinked.
Next step: Check NG tube position. Add more air. Give glucagon IV (1 mg) to reduce gastric peristalsis and improve distension. Change patient position (lateral decubitus). Consider placing tube further into stomach or repositioning in antrum.
Problem
Colon interposed — cannot find safe window
Likely cause: Transverse colon overlying planned access site.
Next step: Perform contrast enema under fluoroscopy to map colon. Reposition patient (prone, lateral decubitus) to displace colon with gravity. If truly unable to displace: abort and reassess with dedicated CT — consider CT-guided approach or surgical PEG referral. Remember: colon is mobile; do not give up after one attempt.
Problem
Peritoneal tube position (not intragastric)
Likely cause: Stomach not adequately tacked (inadequate gastropexy) or tube pulled through gastric wall during dilation.
Next step: Contrast injection through tube shows free peritoneal flow rather than gastric rugae pattern. Remove immediately. Monitor closely for peritonitis (fever, pain, leukocytosis). Surgical consultation if peritonitis develops.
Problem
Bleeding during dilation
Likely cause: Epigastric vessel injury or abdominal wall vessel laceration.
Next step: Apply manual pressure. If venous/minor — usually resolves with pressure. If arterial (pulsatile, continued bleeding) — abort and consider surgical conversion or embolization. Avoid the rectus sheath medially.
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Complications
Immediate
- Inadvertent bowel puncture (0.5–1%) — most serious; can cause peritonitis; colon visualization critical for prevention
- Bleeding — minor (from dilation) common; major rare; arterial injury → surgical consultation
- Peritonitis — from tube misplacement or bowel transgression; urgent surgical evaluation
Delayed
- Tube dislodgement — if fistula tract not mature (<4 weeks), stomach moves away from wall → peritoneal leak risk. Most common delayed complication. Dislodgement within 4 weeks = emergent IR return.
- Peristomal infection (7–45%) — most common overall; local wound care; antibiotics if cellulitis
- Buried bumper syndrome — internal bumper erodes into mucosa; requires endoscopic or surgical removal
- Tube migration into small bowel; tube occlusion; granulation tissue at site
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Post-Procedure Care
Immediate (0–24h)
- 24h tube check: Contrast injection to confirm intragastric position before initiating feeds
- Feeds: Start at 24h post-placement if tube position confirmed. Begin at 20 mL/hr; advance over 24–48h
- Monitor for fever, abdominal pain, peritonitis signs
- Check tube retention balloon — ensure appropriate fill (5–10 mL sterile water)
Ongoing Care
- Tube flushing: 30 mL water flush before and after each feed and medication; q4h if continuous feeding
- Site care: Daily cleaning around tube with mild soap and water. No submerging in water for 4 weeks.
- T-fastener removal: At 5–7 days post-placement (fistula tract matures)
- Tube exchange: Typically after 4–6 months initially, then every 6 months. Button G-tubes (MIC-Key) preferred long-term.
Tube Dislodgement — Critical Distinction
- Dislodgement within 4 weeks = EMERGENCY. Do NOT attempt reinsertion at bedside. Stomach may no longer be apposed to abdominal wall — blind reinsertion risks peritonitis. Return to IR for urgent fluoroscopic replacement or surgical referral immediately.
- Dislodgement after 4 weeks: Mature fistula tract — bedside Foley catheter replacement acceptable as bridge. Return to IR within 2–4 hours for proper tube replacement before tract closes.
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Critical Pearls
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COLON is the enemy — see it before you stick. Oral barium the night before is routine at most IR centers. Never assume the transverse colon isn't interposed between stomach and abdominal wall. Fluoroscopic visualization of the colon is mandatory before needle access.
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T-fasteners (gastropexy) are essential. They tack the stomach to the anterior abdominal wall, preventing displacement into the peritoneum during tube insertion and reducing post-procedure peritoneal leak risk. Do not skip this step.
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Retrograde (transabdominal) > antegrade (transoral/PEG pull). Less sedation, less radiation, less procedure time, equivalent safety. IR preference in the vast majority of cases.
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Glucagon IV (1 mg) → relaxes gastric muscle → better distension when struggling to adequately inflate the stomach against the anterior abdominal wall. Have it available in the room.
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Dislodgement within 4 weeks = stomach likely NOT apposed to wall. Peritonitis risk with blind reinsertion is real. This is always an urgent IR or surgical matter — not a bedside procedure.
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CT scan before every case. A single CT showing an "unsafe" window is not a reason to abort — reposition patient, use barium, displace colon. Only fixed hepatomegaly without any safe alternative window = abort. Technical success is 95–98% in experienced hands.
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Feeding Tube Reference
| Type | Size | Retention | Lifespan | Notes |
|---|---|---|---|---|
| Initial G-tube (balloon) | 18–22 Fr | Balloon (5–10 mL sterile water) | 3–6 months | Can be exchanged at bedside after 4–6 weeks |
| Button G-tube (MIC-Key) | 14–22 Fr | Balloon | 3–6 months | Flush entry daily; low-profile; preferred long-term |
| Low-profile silicone | 14–22 Fr | Balloon | 6–12 months | Very patient-friendly |
| G-J tube | 16–24 Fr | Balloon | 3–6 months | Jejunal extension for aspiration risk; IR/fluoro to confirm jejunal position |
Exchange Protocol
- Balloon failure (water leaks out) → exchange same day
- Complete dislodgement <4 weeks → IR urgently; do NOT attempt bedside reinsertion
- Complete dislodgement >4 weeks → 14 Fr Foley as bridge if available → IR within 4–8h before tract closes
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- ASGE Standards of Practice on Enteral Nutrition
- SIR Standards for GI Tube Placement
- ACR-SIR Practice Parameter for Fluoroscopic Percutaneous Gastrostomy
Primary References
- Simons ME, McLarney JH. Percutaneous radiologic gastrostomy: technique and complications. Semin Intervent Radiol. 1995;12(2):216-226.
- Wollman B, D'Agostino HB. Percutaneous radiologic and endoscopic gastrostomy: a 3-year institutional analysis of procedure performance. AJR Am J Roentgenol. 1997;169(6):1551-1553.
- Galaski A et al. Gastrostomy insertion by radiological, endoscopic and surgical methods in a tertiary care hospital: comparison of indications, complications and outcomes. Can J Gastroenterol. 2009;23(2):109-114.