ABDOMINAL WALL CELLULITIS COMPLICATING TO ABDOMINAL WALL MACERATION : A RARE AND UNFORTUNATE COMPLICATION OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) TUBE
Vishal Chandel*1, Veronica West2, Neel Chandel3, Sridhar Reddy Patlolla1, Mathew Mathew1
1Internal Medicine, Suburban Community Hospital, East Norriton, PA; 2Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 3Roxborough Memorial Hospital, Philadelphia, PA
Percutaneous endoscopic gastrostomy (PEG-tube) is used to provide enteral nutrition in patients with stroke, brain injury, head and neck cancers. Its complications can be minor (wound infection, bleeding, ulceration, tube dysfunction, inadvertent removal, gastric outlet obstruction) or major (colo-cutaneous fistula, necrotizing fasciitis). Abdominal wall cellulitis due to a leaking or dislodged PEG-tube is common, but abdominal wall maceration without peritonitis is a rare and life-threatening complication.
We report a case who developed this lethal complication, and the current literature was reviewed.
A 71-year-old female with a history of bladder cancer, iron deficiency anemia, dementia, atrial fibrillation, COPD, GERD, ventilator dependent respiratory failure, and hypertension presented from nursing home because of leaking from PEG tube. Patient had tachycardia, tachypnea, and leukocytosis of 56k on presentation, along with acute on chronic anemia. Examination showed PEG tube in place with leaking and erythema around the site, with surrounding skin excoriations. Patient also had pneumonia and was started on antibiotics. Upon surgical evaluation, the leaking PEG needed repair/replacement. She was not deemed a candidate for open PEG revision or endoscopic repositioning due to serial excoriation which had progressed to maceration of the abdominal wall (from cellulitis). Interestingly, patient did not develop peritonitis. Patient received broad spectrum antibiotics. After PEG removal, patient was kept on nutritional support by TPN to wait for abdominal wall maceration to start healing while waiting for a new PEG, which took few weeks due to her nutritional status and comorbidities.
Abdominal wall cellulitis is common due to leaking PEG tubes and it usually resolves after treatment. Maceration of abdominal wall is a rare complication of PEG-tubes seen in less than 0.1% of gastrostomy procedures with high mortality. Old age, obesity, diabetes mellitus, immunocompromised status, and even COVID-19 infection are risk factors. In our patient, leakage from the dislodged tube into abdominal wall caused infection by gas-producing organisms. Her poor nutritional status and multiple comorbidities delayed wound healing. Our review of literature included 5 chart reviews from different hospitals noting their PEG success rates. In total, there were 902 reported PEG procedures with 129 (14.3%) reported cases of cellulitis post PEG tube placement.
Prompt recognition, aggressive debridement, skin care and broad-spectrum antibiotics offer favorable outcome. Nutritional support to allow skin healing and wound care is a must. Since PEG-tubes are widely used in critically ill patients, physicians must be aware of this rare but life-threatening complication and their silent manifestation in this COVID era.
ABDOMINAL WALL CELLULITIS LEADING TO MACERATION WITHOUT PERITONITIS DUE TO PEG LEAK
REVIEW OF LITERATURE
Back to 2023 Posters