1. Gastroenterology Nurse Practitioner
T o PEG or not to PEG
Case Studies
Donald MacDonald
Gastroenterology Nurse Practitioner
St John’s Hospital
Livingston

2. CR 48yr old female Multiple strokes since her 30’s
Admitted chest infection
Deteriorating swallow. Low BMI. Uncommunicative. Bed bound
Assessed for PEG – unfit
Discussed with daughter – agrees with decision due to frailty and poor quality of life

3. CR 48yr old female
Enquiry from Leonard Cheshire Home – deaths door with chest infection every winter
Daughter visits twice a year
Patient reads OK and HELLO and goes swimming every week
IV antibiotics, improved, PEG inserted, discharged back to Leonard Cheshire Home

4. Learning Point
Consult as widely as possible when making the decision

5. PP 44yr old male SAH during sex Married 2 children 18 and 22
Previously fit and well
Persistent vegetative state. No prospect of recovery.
Wife distraught. Wants everything done to give husband a chance

6. PP 44yr old male
“Can you guarantee that there is absolutely no possibility he will recover?”
PEG inserted

7. PP 44yr old male 1 year later “Why are you doing this to my husband?”
Advice from NHS legal department – written agreement of family – 2nd degree relatives
Cousins in Australia – court proceedings in Australia to obtain affidavits from cousins
PEG falls out - heals over before replacement can be attempted

8. Learning Point
Give people time to come to a decision

9. RC 66 year old male Known Parkinson's disease – 20 yrs
Referred for PEG from GP
Unsafe Swallow – video fluoroscopy
Weight loss – BMI 15.8
Dysphagia

10. RC 66 year old male Discussed with: Patient Parkinson’s Nurse SALT
Dietician
Dr Ramsay

11. RC 66 year old male Endoscopy – PEG insertion 11/09/12
Oesophagus grossly abnormal
Food residue, inflamed, oedematous
? Oesophagitis related to dysmotility and stasis as a consequence of Parkinson’s
Biopsies – inflammation and ulceration

13. RC 66 year old male Post PEG insertion Developed chest infection
CXR – R pleural effusion
CT – extensive retroperitoneal lymphadenopathy, highly suspicious for malignancy. Oesophagus abnormally thickened through most of its length
Pleural tap – metastatic carcinoma

14. RC 66 year old male 26/09/12 Chest drain inserted
27/09/12 Lymph node biopsy
27/09/12 Died suddenly
Likely pulmonary embolism
Oesophageal biopsies reviewed - adenocarcinoma

15. Learning Point
The simplest hypothesis is not always the right one

16. BD 36yr old male Cerebral palsy – aphasic 3 month history: Vomiting
Off food
Losing weight
Referred for PEG

18. BD 36yr old male Endoscopy for PEG – iphone sock
Missing for three months
3 admissions where family had said he had swallowed an iphone cover

19. Learning Point
Check the history