Abstract Background The utility of esophagogastroduodenoscopy (EGD) performed at the time of percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of PEG yielded clinically useful information important in patient care. We also reviewed the outcome and complication rates of EGD-PEG performed by trauma surgeons. Methods Retrospective review of all trauma patients undergoing EGD with PEG at a level I trauma center from 1/01–6/03. Results 210 patients underwent combined EGD with PEG by the trauma team. A total of 37% of patients had unsuspected upper gastrointestinal lesions seen on EGD. Of these, 35% had traumatic brain injury, 10% suffered multisystem injury, and 47% had spinal cord injury. These included 15 esophageal, 61 gastric, and six duodenal lesions, mucosal or hemorrhagic findings on EGD. This finding led to a change in therapy in 90% of patients; either resumption/continuation of H2 -blockers or conversion to proton-pump inhibitors. One patient suffered an upper gastrointestinal bleed while on H2-blocker. It was treated endoscopically. Complication rates were low. There were no iatrogenic visceral perforations seen. Three PEGs were inadvertently removed by the patient (1.5%); one was replaced with a Foley, one replaced endoscopically, and one patient underwent gastric repair and open jejunostomy tube. One PEG leak was repaired during exploration for unrelated hemorrhage. Six patients had significant site infections (3%); four treated with local drainage and antibiotics, one requiring operative debridement and later closure, and one with antibiotics alone. Conclusion EGD at the time of PEG may add clinically useful data in the management of trauma patients. Only one patient treated with acid suppression therapy for EGD diagnosed lesions suffered delayed gastrointestinal bleeding. Trauma surgeons can perform EGD and PEG with acceptable outcomes and complication rates.</p

Bochicchio, Grant V

Haan, James M

Scalea, Thomas M

English

PubMed

James M Haan

Grant V Bochicchio

Thomas M Scalea

Springer - Publisher Connector

BioMed Central
World Journal of Emergency 
Surgery
ssOpen AcceResearch article
Utility of esophageal gastroduodenoscopy at the time of 
percutaneous endoscopic gastrostomy in trauma patients
James M Haan*, Grant V Bochicchio and Thomas M Scalea
Address: Department of Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, 
Maryland, USA
Email: James M Haan* - jhaan@umm.edu; Grant V Bochicchio - gbochicchio@umm.edu; Thomas M Scalea - tscalea@umm.edu
* Corresponding author 
Abstract
Background: The utility of esophagogastroduodenoscopy (EGD) performed at the time of
percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of
PEG yielded clinically useful information important in patient care. We also reviewed the outcome
and complication rates of EGD-PEG performed by trauma surgeons.
Methods: Retrospective review of all trauma patients undergoing EGD with PEG at a level I
trauma center from 1/01–6/03.
Results: 210 patients underwent combined EGD with PEG by the trauma team. A total of 37% of
patients had unsuspected upper gastrointestinal lesions seen on EGD. Of these, 35% had traumatic
brain injury, 10% suffered multisystem injury, and 47% had spinal cord injury. These included 15
esophageal, 61 gastric, and six duodenal lesions, mucosal or hemorrhagic findings on EGD. This
finding led to a change in therapy in 90% of patients; either resumption/continuation of H2 -blockers
or conversion to proton-pump inhibitors. One patient suffered an upper gastrointestinal bleed
while on H2-blocker. It was treated endoscopically. Complication rates were low. There were no
iatrogenic visceral perforations seen. Three PEGs were inadvertently removed by the patient
(1.5%); one was replaced with a Foley, one replaced endoscopically, and one patient underwent
gastric repair and open jejunostomy tube. One PEG leak was repaired during exploration for
unrelated hemorrhage. Six patients had significant site infections (3%); four treated with local
drainage and antibiotics, one requiring operative debridement and later closure, and one with
antibiotics alone.
Conclusion: EGD at the time of PEG may add clinically useful data in the management of trauma
patients. Only one patient treated with acid suppression therapy for EGD diagnosed lesions
suffered delayed gastrointestinal bleeding. Trauma surgeons can perform EGD and PEG with
acceptable outcomes and complication rates.
Background
Enteral nutrition has been shown to be far superior to
parenteral nutrition following injury. Percutaneous endo-
scopic gastrostomy (PEG) is a common procedure for
enteral access following severe injury [1-4]. PEG is a rela-
tively straightforward procedure that can be performed at
Published: 5 July 2007
World Journal of Emergency Surgery 2007, 2:18 doi:10.1186/1749-7922-2-18
Received: 22 February 2007
Accepted: 5 July 2007
This article is available from: http://www.wjes.org/content/2/1/18
© 2007 Haan et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
World Journal of Emergency Surgery 2007, 2:18 http://www.wjes.org/content/2/1/18the bedside and has become the procedure of choice in
many trauma centers [5-11]. Performing an esophago-gas-
troduodenoscopy (EGD) at the time of PEG placement
may be helpful, but the exact role is not clear. Some series
exist, but a large percentage of those patients underwent
PEG for an indication other than trauma [4-10,12,13].
The yield of EGD at the time of PEG in those series was
variable. Trauma patients may be at special risk for inci-
dental gastrointestinal pathology as the high stress state
following injuries such as traumatic brain injury or spinal
cord injury may predispose patients for conditions such as
stress gastritis or duodenal ulcers despite prophylaxis.
In 2001, the trauma service at the R Adams Cowley Shock
Trauma Center began performing its own PEGs. EGD was
performed at the time of all PEG placements. We retro-
spectively reviewed our experience over two years in order
to determine the clinical utility of EGD at the time of PEG
placement. In addition, we wished to determine whether
general surgeons on the trauma service could safely and
effectively perform both EGD and PEG placement.
Methods
In January 2001, the attending surgeons on the trauma
service at the R Adams Cowley Shock Trauma Center
began performing EGDs and PEGs. Previously to this,
PEGs had been placed by the surgical endoscopy service in
the Department of Surgery at the University of Maryland
School of Medicine. Six surgeons from the trauma service
were credentialed to place PEGs. These surgeons had sig-
nificant experience during residency and/or fellowship
training sufficient to credential them for EGD with PEG
placement. A PEG service was created and referrals made
to it.
By protocol, patients had to tolerate nasogastric feedings
before PEG placement was considered. A full survey of the
esophagus, stomach and proximal duodenum was
attempted before PEGs were placed. PEG tubes were
inserted using the pull method modified from the original
technique as described by Ponsky using a commercially
available kit [7].
We retrospectively reviewed the 2-1/2 year period, January
2001 through June 2003. Charts were reviewed and the
basic trauma demographic data obtained such as age, sex,
mechanism of injury and indication for PEG placement.
Findings on EGD were reviewed as well as treatment rec-
ommendations based on the endoscopic findings. Data
was then analyzed. The University of Maryland School of
Medicine Institutional Review Board approved the study.
Results
During the study period, 210 patients underwent EGD
with PEG placement at the R Adams Cowley Shock
Trauma Center. All patients were admitted following
injury. Seventy percent had traumatic brain injury and
failed a swallowing evaluation by a Speech Language
Pathologist. Ten percent of patients had multisystem
injury with dysphasia, and 23% had spinal cord injury
with dysphagia or were unable to tolerate sufficient PO
nutrition to maintain adequate caloric intake. Patient
characteristics are depicted in Table 1.
PEG placement was successful in 98% of patients. Full
endoscopic survey was successfully performed in 99% of
patients. PEG placement was aborted in three patients due
to an inadequate red light reflex. Full endoscopic survey
was unsuccessful in four patients. One patient was unable
to tolerate prolonged insufflation and in three patients,
the endoscopist was unable to intubate the duodenum.
Unsuspected endoscopic findings occurred in 37% of the
patients undergoing full EGDs. These included 15 esopha-
geal, 61 gastric, and 6 duodenal lesions. The specific find-
ings are detailed in Table 2. Unsuspected endoscopic
findings occurred in 35% of patients with traumatic brain
injuries, 47% of patients with spinal cord injuries, and
10% of patients with multisystem injury and dysphagia
(Table 3).
The majority of endoscopic findings were mucosal lesions
in the stomach or unsuspected ulcers. This lead to a
change of therapy in 90% of patients with positive endo-
scopic findings. These patients were all tolerating tube
feedings. By protocol at our institution, gastric prophy-
laxis is discontinued when gastric feedings are tolerated.
Patients found to have healing ulcers were continued on
H2 blockade for an additional month. However, 50% of
patients had significant gastritis, ulceration or evidence of
acute pathology and were converted to proton pump
inhibitor therapy. One of these patients developed an
upper GI bleed despite conversion to proton pump inhib-
itors. This patient was successfully treated endoscopically.
Three polypoid lesions were seen. Due to the patient's age
and severity of brain injury, these were not treated at the
time, but patients were referred for repeat endoscopy with
evaluation and biopsy when they had recovered.
Complication rates were low. There were no iatrogenic
visceral perforations in these patients. Three PEGs were
inadvertently removed by the patient (1.5%). One was
replaced by a Foley catheter, one was replaced endoscopi-
Table 1: Patient Characteristics
Total patients 210
Male 77%
Mean age (years) 37
Age range (years) 14–86Page 2 of 4
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World Journal of Emergency Surgery 2007, 2:18 http://www.wjes.org/content/2/1/18cally, and one patient underwent laparotomy, gastric
repair and open jejunostomy tube placement. One PEG
leak was repaired during exploration for unrelated hemor-
rhage. Six patients (3%) had PEG site infections. One was
successfully treated with IV antibiotics alone, four were
treated with local incision and drainage and antibiotics.
One patient however, required operative debridement of
the abdominal wall with delayed primary closure.
Discussion
The technique for PEG placement has evolved since is
original description and there is a large volume of litera-
ture describing the evolution of the technique [1-13].
PEGs have become the procedure of choice for enteral
access in patients requiring long-term tube feedings after
trauma [5-11]. PEGs are a relatively straightforward proce-
dure that can often be performed at the bedside, in the
Intensive Care Unit or Intermediate Care Unit. Feedings
can be started soon after PEG placement, thus minimizing
the risk of malnutrition. PEGs are relatively safe with an
accepted complication rate of <6–30%. [8,11].
While many series exist concerning the use of PEG place-
ment, most of these series contain a paucity of trauma
patients. Trauma patients may be different for a number
of reasons. Trauma creates a catabolic state with marked
increase in nutritional needs. Infection is a common
occurrence in the Intensive Care Unit following injury.
Patients with major torso trauma may be unable to toler-
ate enteral nutrition early on, condemning them to TPN
or even worse, no nutritional support at all. The high
stress ulceration rate following injury could predispose
trauma patients to a significant incidence of incidental
death or upper gastrointestinal pathology despite routine
use of gastrointestinal prophylaxis.
Unsuspected gastrointestinal pathology can be seen at the
time of PEG placement. Several studies have described
unsuspected pathologic findings in 10 to 60% of patients.
Scott et al reported medical treatment changes based on
EGD findings in approximately 38% of patients. In 5% of
these patients, pathologic ulceration and pyloric stenosis
was found, requiring duodenal feeding due to gastric out-
let obstruction. A prior study from this institution
described unsuspected pathologic findings in 38% of sur-
veyed patients. This occurred in the esophagus 7% of the
time, stomach 24% and duodenum 7%. In that series
however, the patients studied included trauma patients
and those with head and neck cancer and/or stroke. In our
series of only trauma patients, we found only an eight per-
cent incidence of duodenal pathology and no unsus-
pected gastric outlet obstructions. As we require that
patients scheduled for PEG tolerate gastric feedings, no
patients with unsuspected obstruction were scheduled for
PEG placement.
We retrospectively reviewed 210 patients who underwent
attempted PEG placement with survey endoscopy over a
2-1/2 year period. Our rate of unsuspected gastrointesti-
nal pathology was 37%, not different from many other
reports. The majority of these patients had non-specific
mucosal changes and/or inflammatory injury consistent
with stress pathology. It is perhaps not surprising that
stress gastritis and/or ulceration would be the most fre-
quent finding as over two-thirds of our patients sustained
spinal cord injury or traumatic brain injury, presumably
placing them at high risk for bleeding. All patients at our
institution undergo routine GI prophylaxis at the time of
admission. While the rate of unsuspected pathology is not
substantially different than the literature, it is not clear
from those studies, what percent of those patients under-
went routine prophylaxis.
Table 3: Positive Finding on EGD Based on Diagnosis
Spinal Cord Brain Injury Multisystem
Positive EGD 47% 35% 33%
% of Population 23% 70% 10%
Table 2: Pathologic Findings on EGD
Esophagus n (%) Stomach n (%) Duodenum n (%)
Esophagitis 15 (7%) Gastritis 24 (11%) Duodenal ulcer 6 (3%)
Bleeding Ulcer 5 (2%)
Recent ulcer 24 (11%)
Hiatal hernia 5 (2%)
Mass lesion 3 (1%)
N = with findings on EGD
% = % of total populationPage 3 of 4
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World Journal of Emergency Surgery 2007, 2:18 http://www.wjes.org/content/2/1/18It is perhaps reassuring to note that although there was a
substantial incidence of unsuspected GI pathology, the
majority were controlled or healing with standard stress
prophylaxis. In those patients, the prophylaxis was simply
continued. Approximately half of the patients had acute
changes at the time of EGD. These patients were changed
to proton pump inhibitor therapy. Only one failed medi-
cal management with an upper GI bleed, which was suc-
cessfully treated endoscopically.
It would seem then that there is a real role for surveillance
endoscopy at the time of PEG placement. These unsus-
pected lesions are clinically significant and in 90% of
patients, therapy was altered in some manner.
The overall complication rate in our series was 4.5%.
There were no iatrogenic complications at the time of PEG
placement. Only two patients required open therapy. One
patient who inadvertently pulled their PEG out required
laparotomy, gastric repair and jejunal feeding tube
replacement. A second patient had an unsuspected PEG
leak repaired at the time of laparotomy for unrelated hem-
orrhage. Other complications were relatively minor. We
were concerned about the fact that three PEGS were pulled
out by the patient and have modified our protocol since.
We now currently routinely place abdominal binders over
the PEG site and have the tube exit laterally out of the
binder. If a patient with brain injury or multi-system
trauma gets agitated and grabs the feeding tube, they
merely pull the adapter out of the PEG rather than remov-
ing the PEG. Other centers have described the use of T-fas-
teners for agitated patients to maintain the PEG tract if
inadvertently removed. Unfortunately many of these
products have been recalled and are not currently availa-
ble.
General surgeons specializing in trauma and critical care
seem to be able to safely place tubes. In our series, PEG
placement was successful in 98% of patients and full
endoscopic survey was successful 99% of the time. This is
not different than the 97% successful PEG placement and
99% successful endoscopic survey reported from our own
institution when PEGs were performed by the surgical
endoscopy service. EGD and PEG placement are basic
skills and should be able to be mastered by any well-
trained surgeon. Adding full surveillance endoscopy to
the examination at the time of PEG placement should
only add a few additional minutes to the procedure and
requires basic endoscopic maneuvers most of the time.
This does not require advanced endoscopic skills or inter-
vention, which almost certainly should be performed by a
specially trained endoscopist.
Conclusion
EGD at the time of PEG adds clinically useful information
in a substantial portion of trauma patients, potentially
decreasing risks of GI bleeding. Both EGD and PEG place-
ment can successfully be performed in the vast majority of
trauma patients by general surgeons on the trauma serv-
ice.
Authors' contributions
JMH drafted the manuscript and was responsible for the
majority of data acquisition. GVB assisted with data acqui-
sition. TMS provided editorial support. All authors read
and approved the final manuscript.
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