Radiologically inserted gastrostomy (RIG)

Radiologically inserted gastrostomy (RIG) is a medical procedure that involves the placement of a feeding tube directly into the stomach to provide nutrition to patients who are unable to consume food orally. This method bypasses the mouth and esophagus, allowing for direct feeding into the stomach. While RIG tube insertion is generally considered safe, it can be associated with both minor and major complications. The rate of these complications can vary based on the study population. Despite the potential risks, RIG remains a vital tool in the management of patients with long-term nutritional needs, especially those with underlying comorbidities. Proper care and management of the RIG tube can mitigate many of the associated complications.

Indications for RIG Tube Placement:

Condition/Category	Specific Indications	Key points
Neurological Diseases	Cerebrovascular disease, Motor neuron disease (ALS), Multiple sclerosis, Parkinson’s disease, Cerebral palsy, Dementia, Cerebral tumor	Cerebrovascular disease/stroke - High incidence of dysphagia post-stroke (up to 45%). - NG tube for short-term (<4 weeks) feeding; - PEG superior to NG for long-term nutrition. Motor neuron diseases/ALS - PEG standard for ALS patients. Dementia - High mortality rate post-PEG insertion. Psychomotor retardation - PEG effective for nutrition but not recommended for aspiration and reflux.
Reduced Consciousness	Head injury, Intensive care patients, Prolonged coma	- Enteral feeding should start early. - PEG nutrition considered if no recovery in 14 days post-severe cerebral injury.
Congenital anomalies	Trachea esophageal fistula
Cancer	Head and neck cancer, Esophageal cancer	- Over 40% with head and neck malignancy are malnourished. - PEG can be prophylactic or therapeutic.
Miscellaneous	Burns, Fistulae, Cystic fibrosis, Facial surgery, Chronic renal failure, HIV/AIDS, Gastric decompression, Abdominal malignancy	Gastric decompression - PEG used for chronic unresolved GI stenosis or ileus. HIV/AIDS - PEG improves weight and nutritional markers in wasting syndrome. Cystic fibrosis - Better nutrition linked to better survival. - PEG improves nutritional and pulmonary status. Crohn’s disease - Enteral nutrition reduces steroid requirements. - PEG safety demonstrated, but rarely used due to other nutritional alternatives.

Contraindications for RIG Tube Placement:

Absolute Contraindications	Relative Contraindications
Serious coagulation disorders	Non-obstructing oropharyngeal/esophageal malignancy
Hemodynamic instability	Hepatomegaly, splenomegaly
Sepsis	Peritoneal dialysis
Peritonitis	Portal hypertension with gastric varices
Abdominal wall infection	History of partial gastrectomy
Marked peritoneal carcinomatosis	Gastric outlet obstruction (if for feeding)
History of total gastrectomy	Severe gastroparesis (if for feeding)
	Lack of informed consent for the procedure
	Severe ascites

Complications of RIG tube placement:

Complication Type	Description	Frequency	Management	Key Points
MAJOR COMPLICATIONS
Bleeding	Bleeding from PEG tract, gastric artery, splenic or mesenteric vein injuries, rectus sheath hematoma	Rare	Fluid support, pressure over wound, endoscopic/surgical exploration	Correct coagulation disorders before PEG insertion
Aspiration pneumonia	Serious complication of PEG tube feeding	Common in high-risk	Monitor feeding volume and position	Jejunal extension for high-risk patients, but associated with more tube dysfunction and dislocation rates
Internal organ injury	Injury to intra-abdominal organs (liver, spleen, colon, small bowel) during PEG placement	Rare (more common in elderly patients due to laxity of colon mesentry)	CT scan with water-soluble contrast or fluoroscopy to confirm the location Surgical management maybe required for active leak.	Watchful follow-up after PEG insertion
Necrotizing fasciitis	Rapidly spreading infection along fascial planes	Very rare	Immediate surgical debridement, antibiotics, intensive care	Keep external bumper 1-2 cm away from abdominal wall
Buried bumper syndrome	Migration of tube toward abdominal wall	Occurs post 3 weeks	Remove tube immediately	Occurs due to excessive tension between internal and external bumper leading to ischemic necrosis. Keep external bumper 1-2 cm away from abdominal wall
Tumour seeding of the stoma	Rare complication in patients with head and neck cancer	Rare	Biopsy and CT scan	Avoid "pull" or "push" method in oropharyngeal cancer patients
MINOR COMPLICATIONS
Granuloma formation	Hyper-granulation tissue around the gastrostomy tube	Common	Various treatments available (topical antimicrobial agent, low dose steroids), none proven superior	Caused by friction and moisture
Local wound infection	Tube site infection	5%-65% (Most common complication)	Local antiseptics, daily dressing changes, systemic/local antibiotics	Prophylactic antibiotics beneficial - single dose of cephalosporins 1 hour prior to procedure.
Periostomal leakage	Leakage around PEG site	Common in certain groups	Address specific causes, allow tract to close if mature, reinsert in new location	Avoid inserting larger tube Can leak into peritoneum causing peritonitis
Tube dislodgment	Tube slides in or out of gastrointestinal tract	Up to 12.8%	Replace through same tract if mature	Maintain external bumper 1-2 cm from skin
Gastric outlet obstruction	PEG tube migration to pyloric area, causing obstruction	Rare	Reposition tube	Keep external bumper 1-2 cm from skin
Pneumoperitoneum	Common post-PEG insertion	Up to 50%	Continue PEG feeding unless peritoneal signs	Consider bowel injury if persists after 72h

References