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Semisolid formulae are increasingly used in Japan to reduce the risks of gastroesophageal reflux (GER) and aspiration pneumonia in patients undergoing percutaneous endoscopic gastrostomy (PEG). We compared the incidences of GER after the use of liquid or semisolid contrast agents during PEG.Patients who planned to undergo PEG were randomly assigned to the liquid-first (LF) group (liquid contrast agent on day 1 after PEG and a semisolid contrast agent on day 2) or the semisolid-first (SF) group (reversed order). A 200-ml agent bolus was administered via a PEG tube to the patient in the supine position. The upper gastrointestinal tract was radiologically examined from onset to 1 min after the end of administration. The incidences of GER were compared. We also evaluated the daily changes in GER incidence, effect of hiatal hernia severity and adverse events.We analyzed the results of 66 patients (32, LF group; 34, SF group). The incidence of GER observed using only liquid contrast was 27% (18/66) and that using only semisolid was 11% (7/66) (P = 0.028). There was no difference in the GER incidences between day 1 and day 2. In patients with severe, mild and no hiatal hernia, GER incidences in the liquid contrast agent were 80% (4/5), 61% (11/18) and 33% (13/43), respectively (P = 0.031). GER incidence after using the semisolid contrast agent was lower in patients with no and mild hiatal hernia. The predominant adverse event was diarrhea; aspiration was not observed.Semisolid contrast agents reduced the incidence of GER after PEG.