Multidisciplinary practical guidelines for gastrointestinal access for enteral nutrition and decompression from the Society of Interventional Radiology and American Gastroenterological Association (AGA) Institute, with endorsement by Canadian Interventional Radiological Association (CIRA) and Cardiovascular and Interventional Radiological Society of Europe (CIRSE).

IntroductionTube feeding has been practiced for more than 400 years.1DiSario J. Baskin W. Brown R. et al.Endoscopic approaches to enteral nutritional support.Gastrointest Endosc. 2002; 55: 901-908Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar In addition to feeding, gastrointestinal (GI) access can be used for decompression in cases of enteral obstruction.Temporary access can be achieved with a nasogastric (NG), oral gastric (OG), nasojejunal (NJ), or oral jejunal (OJ) feeding tube. These tubes can be placed “blindly” at the bedside, with the use of image guidance (eg, fluoroscopy, ultrasound), or with the use of endoscopic guidance. Unfortunately, natural orifice tubes often fail because of clogging as a result of their relatively small diameter or inadvertent dislodgement.2Patrick P.G. Marulendra S. Kirby D.F. DeLegge M.H. Endoscopic nasogastric-jejunal feeding tube placement in critically ill patients.Gastrointest Endosc. 1997; 45: 72-76Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar More permanent enteral access can be obtained surgically (open or laparoscopic) or percutaneously with endoscopic or image guidance, resulting in a gastrostomy, a jejunostomy, or a combination gastrojejunostomy. Although the indications for these enteral access devices are often similar, there are specific situations in which a particular enteral access tube may be more appropriate. More recently, the placement of a tube into the cecum (ie, cecostomy) has been described for GI decompression and as a treatment of fecal incontinence and constipation.3Chait P. Shandling B. Richards M. Connolly B. A fecal incontinence in children: treatment with percutaneous cecostomy tube placement--a prospective study.Radiology. 1997; 203 (631–624)PubMed Google ScholarThis document was written to be used as a practical guideline for the health care providers involved in creating and maintaining percutaneous gastroenteric access in adult patents, and covers the following topics: (i) patient selection, (ii) preprocedure evaluation, (iii) technical aspects of the procedures, and (iv) maintenance of the access. Quality assurance outcome measures for these processes, such as indications, success rates, and complication rates, are reported in this document.DefinitionsGastroenteric access is the establishment of an artificial access into the GI tract to provide feeding and decompression. This communication to the GI tract can be percutaneous or through natural orifices.An NG/NJ tube is a flexible synthetic tube that is inserted into the stomach/jejunum through the nostril to provide feeding and/or decompression.Orogastric/Orojejunal tube is a flexible synthetic tube that is inserted into the stomach/jejunum through the mouth to provide feeding and/or decompression.Percutaneous gastrostomy is an artificial access into the stomach that is created through a small incision in the abdominal wall to provide food.Transabdominal access is created when the gastrostomy tube is inserted through the abdominal wall into the stomach.Transoral access is created when the gastrostomy tube is inserted through the mouth and then pulled or pushed through the stomach and abdominal wall.A gastropexy is created by insertion of a gastropexy device (eg, T-fastener, suture) through the abdominal and stomach walls to secure the stomach while placing an enteric tube.A venting gastrostomy is a gastrostomy created to decompress the upper GI tract for symptomatic relief in patients with distal obstruction or severe dysmotility.Percutaneous jejunostomy is the creation of an artificial access into the small intestine through a small incision in the abdomen to provide feeding and/or decompression. Similar to gastrostomy, jejunostomy tubes can be inserted transorally or transabdominally.Primary jejunostomy is the creation of a jejunostomy de novo.Secondary jejunostomy is the percutaneous reestablishment of a previously created jejunostomy via a prior access site.Similar to gastrostomy, jejunostomy tubes can be inserted transorally or transabdominally.Gastrojejunostomy is the creation of access to the jejunum through the stomach.Cecostomy is the creation of an opening in the cecum to facilitate an antegrade enema or to provide cecal decompression.Blind placement is the placement of feeding tubes through the natural orifices without visualization of the access route.Endoscopic guidance is the use of endoscopic equipment to visualize the intestinal tract to assist in the creation of enteric access.Image guidance is the use of image guidance equipment, such as fluoroscopy, US, or computed tomography (CT), to visualize the intestinal tract to assist in creation of the enteric access.IndicationsOral or Nasal Enteric TubesNG, OG, NJ, or OJ tubes are generally recommended for short-term use (ie, from a few days to 6 weeks). This can be for gastric or small bowel feeding or gastric decompression.In general, patients who have facial trauma, nasal injury, or abnormal nasal anatomy that precludes nasal access are candidates for oroenteric tubes.4Muzumdar D. Ventureyra E.C. Inadvertent intracranial insertion of a soft rubber tube in a patient with Treacher-Collins syndrome: case report and review of literature.Childs Nerv Syst. 2008; 24: 609-613Crossref PubMed Scopus (5) Google Scholar There have been published data that indicate that patients with nasal airway intubation have more episodes of sinusitis than patients with oral airway intubation.5Salord F. Gaussorgues P. Marti-Flich J. et al.Nosocomial maxillary sinusitis during mechanical ventilation: a prospective comparison of orotracheal versus the nasotracheal route for intubation.Intensive Care Med. 1990; 16: 390-393Crossref PubMed Google Scholar From this study and other similar studies, the belief that there is a decreased incidence of sinusitis with an oroenteric feeding tube versus a nasoenteric feeding tube has been extrapolated. A prospective epidemiologic study6George D.L. Falk P.S. Umberto Meduri G. et al.Nosocomial sinusitis in patients in the medical intensive care unit: a prospective epidemiological study.Clin Infect Dis. 1998; 27: 463-470Crossref PubMed Google Scholar performed in patients in an intensive care unit noted that feeding through a nasoenteric tube, in addition to other factors, was associated with an increased risk of nosocomial sinusitis (odds ratio, 14.1) In patients with preexisting sinusitis, an oroenteric tube is preferred.Gastric FeedingThe gastric route is the most common artificial nutrition route used for feeding.7Silver H.J. Wellman N.S. Arnold D.J. Livingstone A.S. Byers P.M. Older adults receiving home enteral nutrition: enteral regimen, provider involvement, and health care outcomes.JPEN J Parenter Enteral Nutr. 2004; 28: 92-98Crossref PubMed Google Scholar Candidates for gastrostomy generally must have normal or near-normal gastric and small bowel motility. Their gastric anatomy has to be adequate to receive a gastric access tube. If a bolus feeding regimen is required for a patient, gastric feeding is most commonly prescribed, although there are no published, prospective, randomized trials demonstrating a superiority of bolus versus continuous gastric feeding.8Bowling T.E. Cliff B. Wright J.W. Blackshaw P.E. Perkins A.C. Lobo D.N. The effects of bolus and continuous nasogastric feeding on gastro-oesophageal reflux and gastric emptying in healthy volunteers: a randomised three-way crossover pilot study.Clin Nutr. 2008; 27: 608-613Abstract Full Text Full Text PDF PubMed Scopus (10) Google ScholarSmall Bowel FeedingPatients who are unable to tolerate gastric feedings, cannot receive a gastric enteral access tube as a result of altered anatomy, have gastric outlet or duodenal obstruction, have a gastric or duodenal fistula, or have severe gastroesophageal reflux disease should receive a jejunal feeding tube.There has also been a great deal of discussion and clinical investigation regarding the use of small bowel feeding for the prevention of aspiration pneumonia. A metaanalysis by Heyland et al9Heyland D.K. Montalvo M. MacDonald S. Keefe L. Su X.Y. Drover J.W. Total parenteral nutrition in the surgical patient: a meta-analysis.Can J Surg. 2001; 44: 102-111PubMed Google Scholar, 10Heyland D.K. Drover J.W. MacDonald S. Novak F. Lam M. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial.Crit Care Med. 2001; 29: 1495-1501Crossref PubMed Google Scholar reported a reduction in ventilator-associated pneumonia with small bowel feeding compared with gastric feeding. A separate metaanalysis by Marik et al11Marik P.E. Zaloga G.P. Gastric versus post-pyloric feeding: a systematic review.Crit Care. 2003; 7: R46-R51Crossref PubMed Google Scholar noted an odds ratio of 1.44 (95% CI, 0.84–2.46; P = .19) for the risk of gastric feeding and the development of aspiration pneumonia compared with small bowel feeding. One prospective randomized trial12Hsu C.W. Sun S.F. Lin S.L. et al.Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.Crit Care Med. 2009; 37: 1866-1872Crossref PubMed Scopus (45) Google Scholar compared duodenal and gastric feeding showed that the nasoduodenal feeding group had a higher average daily calorie and protein intake compared with the nasogastric feeding group and achieved nutritional goals earlier. In terms of clinical outcomes, patients in the nasoduodenal feeding group had a lower rate of vomiting and ventilator-associated pneumonia.12Hsu C.W. Sun S.F. Lin S.L. et al.Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study.Crit Care Med. 2009; 37: 1866-1872Crossref PubMed Scopus (45) Google ScholarThe use of small bowel enteral feeding during episodes of pancreatitis has been a relative recent change in clinical practice. Multiple prospective, randomized trials have demonstrated improved outcomes, including decrease length of hospital stay, decreased infectious complications, and reduced overall health care cost with the use of jejunal feedings compared with parenteral nutrition.13Abou-Assi S. Craig K. O'Keefe S.J. Hypocaloric jejunal feeding is better than total parenteral nutrition in acute pancreatitis: results of a randomized comparative study.Am J Gastroenterol. 2002; 97: 2255-2262Crossref PubMed Google Scholar, 14McClave S.A. Nutrition support in acute pancreatitis.Gastroenterol Clin North Am. 2007; 36: 65-74Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar More recently, the use of gastric feedings in patients with acute pancreatitis has been evaluated, although a definitive conclusion regarding its appropriateness has not been determined.15Eatock F.C. Chong P. Menezes N. et al.A randomized study of early nasogastric versus nasojejunal feeding in severe acute pancreatitis.Am J Gastroenterol. 2005; 100: 432-439Crossref PubMed Scopus (184) Google ScholarGI DecompressionFor patients with GI obstruction or a GI fistula, decompression can be used to remove GI secretions and oral intake. A gastric decompression tube can be placed through the nose or mouth or percutaneously. Gastric decompression using a gastrostomy tube has been used with good clinical success.16Felsher J. Chand B. Ponsky J. Decompressive percutaneous endoscopic gastrostomy in nonmalignant disease.Am J Surg. 2004; 187: 254-256Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Some gastrojejunostomy tube systems have two ports (openings)—one into the stomach and one into the small intestine—and can be used for concurrent jejunal feeding and gastric decompression. There are some reports regarding the placement of small bowel feeding tubes for decompression of a small bowel obstruction. Direct small bowel decompression in these cases has resulted in improved clinical results compared with gastric decompression tubes.17Gowen G.F. Long tube decompression is successful in 90% of patients with adhesive small bowel obstruction.Am J Surg. 2003; 185: 512-515Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarIntestinal Access for Biliary ProceduresRetrograde intestinal access can be the preferred access to the biliary system, especially in patients with previous surgically altered anatomy, such as Roux-en-Y anastomosis.18Maroney T.P. Ring E.J. Percutaneous transjejunal catheterization of Roux-en-Y biliary-jejunal anastomoses.Radiology. 1987; 164: 151-153Crossref PubMed Google Scholar, 19Martin E.C. Laffey K.J. Bixon R. Percutaneous transjejunal approaches to the biliary system.Radiology. 1989; 172: 1031-1034Crossref PubMed Google Scholar, 20Perry L.J. Stokes K.R. Lewis W.D. Jenkins R.L. Clouse M.E. Biliary intervention by means of percutaneous puncture of the antecolic jejunal loop.Radiology. 1995; 195: 163-167PubMed Google Scholar The advantage of this approach is the ability to get access to the entire biliary tree from one access site. This route was found especially useful in patients who required repeat interventions in cases of large stone burden and biliary strictures.21Cope C. Davis A.G. Baum R.A. Haskal Z.J. Soulen M.C. Shlansky-Goldberg R.D. Direct percutaneous jejunostomy: techniques and applications--ten years experience.Radiology. 1998; 209: 747-754PubMed Google ScholarCecostomy TubesDecompressive or lavage cecostomy tubes can be placed surgically or percutaneously with endoscopic or image guidance.22Chait P. Sclomovitz E. Connolly B. et al.Percutaneous cecostomy: updates in technique and patient care.Radiology. 2003; 227: 246-250Crossref PubMed Scopus (32) Google Scholar, 23Lynch C. Jones R. Hilden K. Wills J. Fang J. Percutaneous endoscopic cecostomy in adults: a case series.Gastrointest Endosc. 2006; 64: 279-282Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Percutaneous cecostomy is indicated in patients with neurologic disease that results in fecal incontinence (eg, spina bifida, meningomyelocele, spinal cord injury, cerebral palsy) to facilitate cleansing enemas.24Chait P.G. Shandling B. Richards H.M. Connolly B.L. Fecal incontinence in children: treatment with percutaneous cecostomy tube placement--a prospective study.Radiology. 1997; 203: 621-624PubMed Google Scholar Percutaneous cecostomy may also be indicated for chronic refractory constipation, chronic colonic pseudoobstruction, and colonic obstruction.25Chevallier P. Marcy P.Y. Francois E. et al.Controlled transperitoneal percutaneous cecostomy as a therapeutic alternative to the endoscopic decompression for Ogilvie's syndrome.Am J Gastroenterol. 2002; 97: 471-474Crossref PubMed Google ScholarContraindications to Enteral AccessAbsolute ContraindicationsAbsolute contraindications to tube placement include mechanical obstruction of the GI tract (unless the procedure is indicated for decompression), active peritonitis, uncorrectable coagulopathy, or bowel ischemia.Relative ContraindicationsA number of other conditions represent relative contraindications to enteral access, such as recent GI bleeding, hemodynamic instability, ascites, respiratory compromise, and certain anatomic alterations. Recent GI bleeding from peptic ulcer disease with a visible vessel or from esophageal varices is associated with a high rate of recurrent bleeding, and therefore the decision to achieve access and initiate enteral nutrition should be delayed for 72 hours. Patients bleeding from angiodysplasia, gastritis, or stress gastropathy are at less risk for recurrent bleeding and therefore do not require a delay in seeking enteral access.In case of interposition of the colon between the abdominal wall and stomach, percutaneous placement of a gastrostomy is contraindicated. In these cases, gastrostomy can be placed surgically.Gastrostomy placement in the presence of ascites is difficult, increases the risk for bacterial peritonitis, and may impair maturation of the stoma tract. Gastrostomy tubes may be placed successfully after paracentesis if reaccumulation can be prevented for a period of 7–10 days after placement to allow the tract to mature. Gastropexy devices could be used to secure the stomach to the anterior abdominal wall.Placement of the gastrostomy in the presence of the ventriculoperitoneal shunts may increase the risk of ascending meningitis.26Gassas A. Kennedy J. Green G. et al.Risk of ventriculoperitoneal shunt infections due to gastrostomy feeding tube insertion in pediatric patients with brain tumors.Pediatr Neurosurg. 2006; 42: 95-99Crossref PubMed Scopus (13) Google Scholar, 27Sane S.S. Towbin A. Bergey E.A. et al.Percutaneous gastrostomy tube placement in patients with ventriculoperitoneal shunts.Pediatr Radiol. 1998; 28: 521-523Crossref PubMed Scopus (23) Google ScholarMorbidly obese patients with a panniculus are at increased risk, as shifting of the panniculus in the postoperative period may dislodge the gastrostomy tube out of the stomach and into the peritoneal space.Although fever and ongoing infection are a concern, they do not represent an absolute contraindication to tube placement.Anatomic alterations such as an open abdomen, presence of ostomy sites or drain tubes, and surgical scars may alter the location for gastrostomy tube placement. Staying more than 2 cm away from a surgical scar reduces risk, as intervening loops of bowel tend to get trapped in the scar tissue immediately below the skin.Specific problems that may preclude endoscopy guided placement include facial fractures, selective skull fractures with leakage of cerebral spinal fluid, high cervical fractures, and upper GI obstruction. In these cases, image-guided gastrostomy placement can be used successfully.Problems that may impede image-guided placement include those conditions that prohibit transport to the radiology suite, such as hemodynamic instability, head injury with increased intracranial pressure, or cardiac dysrhythmias.Preprocedure AssessmentManagement of Anticoagulant and Antiplatelet TherapyRecently, the American Society for Gastrointestinal Endoscopy (ASGE) and Society of Interventional Radiology (SIR) issued recommendations regarding the management of patients receiving anticoagulant or antiplatelet therapy and patients with coagulopathy.28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 29Malloy P.C. Grassi C.J. Kundu S. et al.Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions.J Vasc Interv Radiol. 2009; 20: S240-S249Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar Similar in essence, these recommendations are different in their approach. For that reason, both sets of recommendations are included here.ASGE RecommendationsAccording to the ASGE recommendations,30Eisen G. Baron T. Dominitz J. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar the risk from bleeding related to the procedure itself must be evaluated with respect to the risk of a thromboembolic event if the anticoagulant or antiplatelet therapy is stopped. Preoperative assessment should focus on differentiating high-risk from low-risk procedures, and then determining whether the patient has a high-risk or low-risk condition.28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google Scholar Procedural risk refers to the propensity for a given procedure to produce significant or uncontrolled bleeding should anticoagulant or antiplatelet therapy be continued throughout the intervention. A low-risk procedure would include routine use of endoscopy or fluoroscopy for tube placement, where no percutaneous incision is made. A high-risk procedure would include any enteral access technique that involves an incision or establishment of a fresh stoma (Table 1) .28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google Scholar Risk based on patient condition relates to the probability of a thromboembolic complication occurring should anticoagulation or antiplatelet therapy be stopped before the procedure (Table 2) .28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google ScholarTable 1Determination of Risk for Patients Receiving Anticoagulant or Antiplatelet Therapy Based on Procedure28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google ScholarLow-risk procedure Nasogastric/nasojejunal tube placement Orogastric/orojejunal tube placement Placement of jejunal tube through existing gastrostomy (mature stoma) Secondary percutaneous jejunostomy (through mature stoma)High-risk procedure Percutaneous gastrostomy (image-guided, endoscopic) Venting gastrostomy Primary percutaneous jejunostomy (image-guided, endoscopic) Percutaneous gastrostomy with immediate conversion to gastrojejunostomy Cecostomy Open table in a new tab Table 2Determination of Risk for Patients Receiving Anticoagulant or Antiplatelet Therapy Based on Clinical Condition28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google ScholarPatients receiving anticoagulant therapy Low risk Aortic metal valve Atrial fibrillation without valvular disease Xenograft valve Deep vein thrombosis > 3 mo after event High risk Mitral metal valve Atrial fibrillation with prosthetic valve Atrial fibrillation with mitral valve stenosis Deep venous thrombosis < 3 mo after event Thrombophilia syndromesPatients receiving antiplatelet therapy Low risk Coronary artery disease without stents Coronary artery disease with drug-eluting stents > 12 mo out Coronary artery disease with bare stents > 1 mo out Cerebrovascular accident Arteriosclerotic peripheral vascular disease High risk Coronary artery disease with drug-eluting stents < 12 mo out Coronary artery disease with bare stents < 1 mo out Open table in a new tab Recommendations for low-risk procedures regardless of patient condition are as follows.28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google Scholar Anticoagulant therapy should be continued. If the patient is receiving warfarin, the International Normalized Ratio (INR) should not exceed therapeutic range and antiplatelet therapy should be continued. Recommendations for a high-risk procedure in patients with a low-risk condition are different. Warfarin should be stopped 5 days before the procedure. The INR should be checked on the day of the procedure and should be confirmed to be lower than 1.5. Warfarin may be started later on the night of the procedure, with the INR checked 1 week later. Clopidogrel therapy should be discontinued 7 days before the procedure, with aspirin therapy continued. Alternatively, if the patient is not receiving aspirin, aspirin therapy should be started as the patient discontinues receiving clopidogrel. Clopidogrel therapy may be restarted the day after the procedure.28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google ScholarRecommendations for a high-risk procedure in a patient with a high-risk condition are as follows. Warfarin should be stopped 5 days before the procedure. A therapeutic dose of low molecular weight heparin should be substituted, with the dose withheld on the morning of the procedure. That night, following the procedure, warfarin should be restarted at the full therapeutic dose. For clopidogrel therapy, the clinician should discuss the necessity of the procedure first with the primary care physician, as risk is significant. If the procedure is deemed to be essential, clopidogrel should be stopped 7 days before surgery and the patient given aspirin therapy in the interim. Clopidogrel therapy may be restarted on the morning after the procedure.28Eisen G.M. Baron T.H. Dominitz J.A. et al.Guideline on the management of anticoagulation and antiplatelet therapy for endoscopic procedures.Gastrointest Endosc. 2002; 55: 775-779Abstract Full Text Full Text PDF PubMed Google Scholar, 31Barclay L. Anticoagulant and antiplatelet therapy for endoscopic procedures Medscape Medical News 2008.http://www.medscape.org/viewarticle/574397Google ScholarSIR RecommendationsAccording to SIR recommendations,29Malloy P.C. Grassi C.J. Kundu S. et al.Consensus guidelines for periprocedural management of coagulation status and hemostasis risk in percutaneous image-guided interventions.J Vasc Interv Radiol. 2009; 20: S240-S249Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar GI interventions involving percutaneous incision (eg, gastrostomy, jejunostomy, and cecostomy) are designated as category 2 procedures (ie, those with a moderate risk of bleeding). For this group of procedures, the following recommendations were issued:1INR: If greater than 1.5, correct until it is less than 1.5.2Platelets: If platelet count is lower than 50,000/μL administer transfusion until the count is greater than 50,000/μL.3Clopidogrel: Withhold for 5 days before the procedure.4Aspirin: Do not withhold.5Low molecular weight heparin (therapeutic dose): Withhold one dose before the procedure.Antibiotic ProphylaxisPatients undergoing gastrostomy placement are often at increased risk for infection secondary to poor nutritional status, advanced age, comorbidities, and immune compromise. Factors that increase risk for infection are patient-related (eg, diabetes, obesity, malnutrition, chronic steroid administration), technique-related (eg, transoral technique vs transabdominal technique or failure to provide antibiotic prophylaxis), and external bolster traction–related. The incidence of peristomal infection following percutaneous transoral tube placement ranges from 5.4% to 30.0%.32McClave S.A. Chang W.K. Complications of enteral access.Gastrointest Endosc. 2003; 58: 739-751Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar The majority of infections (> 70%) are minor.32McClave S.A. Chang W.K. Complications of enteral access.Gastrointest Endosc. 2003; 58: 739-751Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 33Gossner L. Keymling J. Hahn E. Ell C. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial.Endoscopy. 1999; 31: 119-124Crossref PubMed Scopus (118) Google Scholar Major infections requiring specific medical or surgical therapy are rare, involving fewer than 1.6% of cases.33Gossner L. Keymling J. Hahn E. Ell C. Antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG): a prospective randomized clinical trial.Endoscopy. 1999; 31: 119-124Crossref PubMed Scopus (118) Google Scholar A metaanalysis of 11 prospective randomized trials34Lipp A. Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.Cochrane Database Syst Rev. 2009; 4https://doi.org/10.1002/14651858.CD005571.pub2Crossref Scopus (44) Google Scholar involving more than 1,100 patients has shown that there is a statistically significant decrease in the incidence of peristomal infection with the use of prophylactic antibiotics. A first-generation cephalosporin or some other similar agent that covers typical cutaneous organisms should be selected.34Lipp A. Lusardi G. Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy.Cochrane Database Syst Rev. 2009; 4https://doi.org/10.1002/14651858.CD005571.pub2Crossref Scopus (44) Google Scholar,