GASTRIC OUTLET OBSTRUCTION: A RARE AND UNUSUAL ADVERSE EVENT OF PERCUTANEOUS GASTROSTOMY (PEG) TUBE
Vishal Chandel*1, Veronica West2, Neel Chandel4, Fnu Vikash3, Sridhar Reddy Patlolla1, Mathew Mathew1
1Internal Medicine, Suburban Community Hospital, East Norriton, PA; 2Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 3Jacobi Medical Center, Bronx, NY; 4Roxborough Memorial Hospital, Philadelphia, PA
INTRODUCTION:
PEG is a procedure to provide enteral nutrition and long-term nutritional support to patients. In published meta-analyses and case series, PEG tube placement has been associated with notable patient morbidity (9%-17%) and mortality (0.53%). Although it is mostly well tolerated, complications do occur. Rare, and often initially unrecognized, late complications of PEG tube placement are gastric outlet obstruction (GOO) and duodenal obstruction. Here, we present a case of mechanical obstruction after migration of a gastrostomy tube, with a current literature review.
CASE PRESENTATION:
A 52-year-old male with history of subdural hemorrhage s/p hemicraniectomy, and ventilator dependent respiratory failure presented with altered mental status and many coffee ground emesis episodes on the day of presentation. Examination showed that abdomen was firm, distended, and tender to palpation but no peritoneal signs. The PEG site had no signs of infection. Patient was admitted to ICU due to septic shock. Imaging and evaluation confirmed GOO due to the tip of PEG balloon beyond pylorus. NG tube was placed to drain gastric contents. PEG was kept to gravity to drain the residuals. Patient's PEG tube balloon was obstructing the pylorus, so its removal was planned with site closure. Slowly over the course, once patient was hemodynamically stable and off pressors, PEG tube was removed with new PEG placement later to alleviate outflow obstruction. He was slowly weaned off ventilator and placed on trach-collar before discharge.
DISCUSSION:
Mechanical obstruction of pylorus results in abdominal cramping and intermittent vomiting, resolving with tube repositioning. Displacement of tip beyond pylorus can lead to GOO, causing gastritis, occasional bleeding, and coffee ground emesis. Migration of the inflatable balloon away from the abdominal wall led to sliding of the gastrostomy tube inside the GI tract and obstruction of the pylorus. In literature, GOO has been reported more in chronic indwelling catheters wherein dislodgement of the external bumper allows the tube to advance further into the stomach. Our literature review for PEG associated GOO included 14 case reports, all of which noted resolution of symptoms and improved subsequent gastrostomy feedings after the PEG tube was repositioned. 4 case reports also noted the use of a Foley catheter causing GOO in place of a PEG tube.
CONCLUSIONS:
The passage of PEG tube past the pylorus with insufflation of the balloon can result in fixation within the small bowel. Another theory implicates improper anchoring of the PEG tube to the abdominal wall causing GOO. In clinical practice, GOO secondary to gastrostomy tube migration is often misidentified as small bowel obstruction, leading to unnecessary tests. Timely recognition and adjustment of the gastrostomy tube can prevent unnecessary aggressive interventions.
AXIAL AND SAGITTAL IMAGING OF CAT SCAN SHOWING PEG TUBE WITH TIP DISPLACEMED BEYOND PYLORUS CAUSING GASTRIC OUTLET OBSTRUCTION
REVIEW OF LITERATURE OF PEG ASSOCIATED GASTRIC OUTLET OBSTRUCTION
Back to 2023 Posters