PEG Tube Risks: Common and Serious Complications

Percutaneous endoscopic gastrostomy (PEG) tubes are among the most commonly placed feeding devices, and while the procedure itself is generally considered safe, complications range from minor skin irritation around the tube site to life-threatening infections and organ perforation. Most problems fall into the “minor but persistent” category, with peristomal wound infection being the single most frequent complication. Serious events like peritonitis, significant bleeding, or bowel perforation are uncommon but well documented, and the risk profile shifts depending on a person’s underlying health.

Peristomal Infection

The area where the PEG tube exits the skin is essentially an open wound that tunnels into the stomach, which makes it a natural entry point for bacteria. Wound infection at this site is the complication you are most likely to encounter. Redness, swelling, warmth, and discharge around the tube are the hallmarks, and they typically show up within the first two weeks after placement.

Giving antibiotics before the procedure cuts the rate of peristomal infection substantially. A Cochrane review pooling data from twelve trials found that prophylactic antibiotics roughly cut peristomal infection by about two-thirds compared to no antibiotics.¹ That said, the picture in real-world practice can look messier. One retrospective study of nearly 600 patients found that those who received prophylactic antibiotics did not have a statistically significant drop in overall wound infection rates, though the number of severe infections requiring systemic antibiotic treatment trended lower in the group that received prophylaxis.² The upshot is that a single dose of antibiotics before tube placement is standard practice in most hospitals, and for good reason, but it does not eliminate the risk entirely.

Most peristomal infections respond to local wound care and oral antibiotics. The danger is when infection is caught late or when the patient’s immune system is compromised. In rare cases, bacterial spread from a PEG site can escalate to necrotizing fasciitis, a rapidly progressing soft-tissue infection that destroys skin, fat, and muscle. One published case described a bedridden elderly woman who developed extensive abdominal wall necrotizing fasciitis after her PEG tube dislodged and gastric contents leaked into surrounding tissue.³ This is an extreme outlier, but it illustrates why even routine-sounding wound care around a PEG tube matters.

Organ Injury During Placement

Placing a PEG tube involves passing a needle through the abdominal wall and into the stomach under endoscopic guidance. Most of the time the path is clear, but occasionally the colon, small bowel, or another organ sits between the abdominal wall and the stomach and gets punctured in the process. The transverse colon is the most commonly injured structure because it can drape over the stomach, particularly in patients who are thin, have altered anatomy from previous surgeries, or have a distended bowel.

When the tube inadvertently passes through the colon on its way to the stomach, the patient may develop a colocutaneous fistula, an abnormal connection between the colon and the skin. This sometimes goes unrecognized for weeks or even months. One case report documented a PEG tube that was found on CT imaging to be traversing the transverse colon.⁴ In another case, the fistula only became apparent when a routine tube replacement led to contrast filling the colon instead of the stomach on imaging.⁵ Both scenarios required surgical intervention. These injuries are uncommon but worth knowing about, especially because the symptoms can be subtle: diarrhea after feeds, abdominal pain, or recurrent infections around the tube site may be the only clues.

Peritonitis From Tube Replacement

People tend to think of the initial PEG placement as the moment of highest risk, and it is, but replacing a tube that has fallen out or worn down also carries real danger. When a mature PEG tract is well established, the replacement tube usually slides into the existing channel without issue. When it does not, the tip can end up inside the abdominal cavity instead of the stomach, and formula or fluids pumped through a misplaced tube will spill directly into the peritoneal space. This causes peritonitis, an emergency that can be fatal.

A case series and literature review found that serious complications from PEG placement overall occur in fewer than about three percent of patients and are concentrated in the first few days. But among cases of inadvertent intraperitoneal placement during tube replacement, the outcomes were grim: across eight reported adult cases, four deaths were directly attributed to the complication.⁶ The lesson here is practical: after any PEG tube replacement, confirming correct position before using the tube (often by flushing with water-soluble contrast and taking an X-ray, or by aspirating stomach contents and checking pH) is not optional caution. It is essential.

Bleeding

Some bleeding at the PEG site during or immediately after placement is normal. Clinically significant hemorrhage is rarer but does happen, and it tends to involve either a blood vessel in the abdominal wall that was nicked during puncture or an injury to the gastric wall. Patients on blood thinners or those with liver disease and impaired clotting are at higher risk.

In unusual cases, the bleeding can be delayed and dramatic. One case report described a patient who developed a pseudoaneurysm, an outpouching of a damaged artery wall, in the abdominal wall tissue near the PEG site. Over two weeks, infection weakened the artery further, and the pseudoaneurysm ruptured, causing massive hemorrhage with loss of consciousness and dangerously low blood pressure.⁷ That patient survived thanks to interventional radiology. The broader point is that new or worsening bleeding from a PEG site in the days or weeks after placement should not be written off as normal oozing, particularly if there are signs of infection.

Buried Bumper Syndrome

A PEG tube is held in place by an internal bumper that sits against the inside of the stomach wall and an external fixator that sits against the skin. If too much pressure is applied between these two parts, the internal bumper gradually erodes into the tissue and migrates along the tube tract until it is no longer inside the stomach at all. This is called buried bumper syndrome (BBS), and once it happens, the tube stops working correctly. The classic signs are an inability to push formula through the tube, resistance when trying to move the tube, and leakage of stomach contents around the site.⁸

Estimates put the incidence of BBS at roughly one percent of PEG placements, with reported rates ranging from about 0.3 to 2.4 percent.⁸ Most cases develop gradually over months or years of use, but early BBS has also been reported. In one case, a patient developed fever and oozing from the PEG site, and CT imaging revealed that the internal bumper had retracted into the subcutaneous tissue just outside the stomach wall.⁹ BBS is largely preventable: the external fixator should not be clamped too tightly against the skin, and the tube should be regularly pushed in and rotated during routine care to keep the internal bumper from adhering to the gastric wall.

Chronic Skin Problems Around the Tube

Even when everything goes well at placement and no acute complication arises, many people with long-term PEG tubes deal with ongoing skin irritation at the stoma site. Two issues dominate: granulation tissue and peristomal leakage.

Granulation tissue is the spongy, reddish tissue that can grow up around the tube opening. It is fragile, bleeds easily, and sometimes hurts. It forms because the wound around the tube never fully closes; instead, the body keeps trying to heal a gap that cannot actually close as long as the tube is in place. Friction from a poorly secured tube and bacterial colonization around the site both increase the risk. Treatment usually involves silver nitrate cauterization or topical steroid application.¹⁰

Peristomal leakage, where stomach acid and formula seep out around the tube, has been reported in up to about ten percent of patients in some studies. The leaking fluid irritates and breaks down the surrounding skin, sometimes causing painful excoriation. Contributing factors include excessive cleaning with hydrogen peroxide (which actually damages healing tissue), infection at the site, excess stomach acid production, and excessive side-to-side movement of the tube.¹⁰ These problems are not dangerous in the way peritonitis or necrotizing fasciitis are, but they significantly affect day-to-day comfort and are the complications that caregivers tend to struggle with most.

Aspiration Pneumonia

One of the main reasons PEG tubes are placed is to bypass a mouth and throat that cannot safely swallow. Ironically, PEG feeding does not eliminate the risk of aspiration pneumonia, which is the inhalation of formula, saliva, or stomach contents into the lungs. Reflux of stomach contents can still travel upward and enter the airway, especially in patients who are fed lying flat, who have poor cough reflexes, or who have neurological conditions affecting the muscles that protect the airway.

A large analysis of over two million hospital admissions involving patients with PEG tubes found that those who developed aspiration pneumonia were older, more often male, and had higher rates of dementia, chronic lung disease, heart failure, and cerebrovascular disease. Aspiration pneumonia in this population was associated with roughly 60 percent higher odds of dying during the hospital stay and double the odds of developing severe sepsis compared to PEG patients without aspiration pneumonia.¹¹ Elevating the head of the bed during and after feeds, using continuous rather than bolus feeds in high-risk patients, and managing reflux with medication are the main strategies for reducing this risk.

Refeeding Syndrome

When a person who has been malnourished or eating very little suddenly receives full-calorie feeds through a PEG tube, the body’s shift from fasting metabolism to fed metabolism can cause dangerous drops in phosphorus, magnesium, and potassium. This is called refeeding syndrome, and it can lead to heart rhythm problems, muscle weakness, confusion, and in severe cases, cardiac arrest.

A study of patients starting enteral nutrition found that roughly one in five met criteria for being at risk of refeeding syndrome. Among those at-risk patients whose electrolyte levels were checked, about 40 percent had low phosphorus, a quarter had low magnesium, and around 16 percent had low potassium.¹² The practical implication is that feeds should be started slowly and ramped up over several days in malnourished patients, and electrolytes should be monitored closely during that window. This is a complication that is almost entirely preventable with awareness and careful nutrition management, but it gets missed when the urgency to “start feeding” overrides caution.

Sedation Concerns

PEG placement is typically done under sedation rather than general anesthesia. For most patients this is straightforward, but there is particular concern about sedation in people with neuromuscular diseases like amyotrophic lateral sclerosis (ALS), who may already have significantly reduced lung function. The worry is that sedation will suppress breathing in someone whose respiratory muscles are already weak.

An observational study of 45 ALS patients who underwent PEG placement under conscious sedation found no respiratory complications, even though over 40 percent of the patients had mild to moderate breathing impairment and nearly nine percent had severe impairment.¹³ This is reassuring but comes from a single center with experienced teams. The evidence supports doing the procedure sooner rather than later in ALS, before lung function deteriorates too far, which reduces both the sedation risk and the nutritional decline that comes from delayed intervention.

Mortality and Who Is at Highest Risk

PEG placement itself very rarely causes death directly, but the 30-day mortality rate after PEG insertion is not trivial, often reported between five and fifteen percent depending on the patient population. The catch is that most of these deaths are driven by the underlying diseases that led to PEG placement in the first place, not by the procedure. A study examining factors behind 30-day mortality found that being hospitalized in an ICU before the procedure and having low hemoglobin levels were independent predictors of early death.¹⁴ In other words, the sickest patients going into PEG placement are the ones least likely to survive the following month, which makes patient selection a critical part of the risk equation.

PEG Tubes and Advanced Dementia

Perhaps the most important risk discussion around PEG tubes involves whether to place one at all. This question comes up most often in advanced dementia, where patients lose the ability to eat safely. Families and clinicians sometimes assume that a feeding tube will prevent starvation, reduce aspiration pneumonia, and extend life. The evidence says otherwise.

Research has consistently found that tube feeding in advanced dementia does not stop disease progression or prevent imminent death.¹⁵ A systematic review and meta-analysis pooling eight studies found that advanced dementia patients with tube feeding actually had significantly higher mortality than those managed with careful hand-feeding, with roughly 80 percent higher odds of death. Sensitivity analysis also showed that PEG feeding in this group was associated with over three-fold higher odds of pneumonia and more than double the odds of pressure sores compared to patients fed by hand.¹⁶ The higher rates of pressure sores likely reflect the fact that tube-fed dementia patients are more often physically restrained to prevent them from pulling out the tube, which reduces mobility. This is one of the clearest examples in medicine where a seemingly logical intervention produces the opposite of its intended effect.

Comparing PEG to Radiologically Placed Tubes

Not all gastrostomy tubes are placed endoscopically. Radiologically inserted gastrostomy (RIG or PRG) uses fluoroscopic imaging rather than an endoscope, and it is sometimes chosen for patients who cannot undergo endoscopy because of head and neck tumors, severe throat narrowing, or other anatomical barriers. The complication profiles of PEG and radiologic gastrostomy differ in some ways.

A retrospective comparison found that radiologic placement had a higher success rate for getting the tube in (about 97 percent versus 91 percent for PEG), but PEG tubes had fewer tube-related complications both early and late. Early tube problems occurred in roughly 3 percent of PEG patients versus over 26 percent of radiologic gastrostomy patients, and late tube issues followed a similar pattern.¹⁷ Another study from an Australian hospital confirmed the tube dislodgement difference: radiologic tubes dislodged in over a quarter of patients compared to just 2.4 percent with PEG tubes.¹⁸ A more recent single-center study, however, found overall complication rates were similar between the two methods (about 16 percent for PEG versus 14 percent for radiologic), though infection trended higher with PEG.¹⁹ The choice between the two often comes down to which technique the patient’s anatomy and condition allow, not which is categorically safer.

Living With a PEG Tube

The complications discussed so far are medical events, things a clinician diagnoses and treats. But people living with PEG tubes and their caregivers face a set of challenges that do not always show up in complication tallies. A systematic review and meta-synthesis of qualitative studies identified three broad areas of difficulty: clinical challenges like troubleshooting the tube itself, psychological burdens including perceiving the tube as a source of stigma and social isolation, and impacts on personal and social life including economic strain.²⁰

Body image concerns and the loss of eating as a social and pleasurable activity are particular sources of distress. A study evaluating health-related quality of life in people receiving home tube feeding found that psychological concerns, including issues with body image and missing the experience of food, were more pronounced in female patients.²¹ Caregivers, meanwhile, often report feeling inadequately trained for managing the tube at home, anxious about tube dislodgement or blockages, and socially constrained by feeding schedules and equipment. These quality-of-life dimensions deserve weight in any pre-placement conversation alongside the medical risk statistics.