1901 PEG Tube Induced Choledo-Duodenal Fistula: When to Expect the Unexpected

Abstract

INTRODUCTION: PEG tube has become the modality of choice for providing access for long term enteral nutrition. Despite a good safety record, complications due to PEG dislodgment do occur. We present a case of PEG tube causing Choledo-duodenal fistula, presenting with Ascending Cholangitis. To the best of our knowledge, this unusual complication of PEG tube hasn't been described before. CASE DESCRIPTION/METHODS: 38 y.o.male with anoxic brain injury, PEG tube placed 6 months ago, presented for evaluation of Jaundice. Vitals were BP 145/108 | Pulse 135 | Temp 101.5 °F. On exam, patient had jaundice, abdomen was soft, Non tender, PEG tube was in the LUQ and Murphy’s sign was negative. Labs showed WBC 12 10X3 U/L, AST 46 U/L, ALT 131 U/L, TB 2.2 mg/dL, DB 1.1 mg/dL. CT abdomen and Pelvis revealed intrahepatic, extrahepatic and CBD dilatation to 1.2 cm, normal Pancreas. PEG tube with fluid-filled balloon was at the level of the pylorus or proximal duodenum. Small and large bowel were nondilated. The diagnosis of ascending cholangitis was made and ERCP was performed. ERCP showed the PEG tube balloon in the duodenum. It was repositioned into the stomach and the scope was advanced to the 2nd portion of the duodenum. There was a large white base ulcer at the duodenal sweep extending into the 2nd portion of the duodenum. Occlusion cholangiogram showed extravasation of the contrast from the distal CBD into the duodenal ulcer. There was a fistulous tract between the CBD and the ulcer. Sphincterotomy was made and a biliary stent was placed to heal the fistula. Biospy of the ulcer showed small intestinal mucosa with ulceration, fibrinoid exudates and no malignancy. Repeat ERCP 8 weeks later for stent removal, showed a chronic entero-biliary fistula. DISCUSSION: Our case is unique in that, this is the first CD fistula described in the literature as a complication of PEG tube presenting with ascending cholangitis. We hypothesize that the inflated balloon migrated into the duodenum due to gastric peristalsis and got incarcerated into the duodenum. 90% cases of CD fistula are due to impacted stone in the distal CBD. Other causes are Ampullary carcinoma or Cholangiocarcinoma. Based on our literature review, this is the only reported case of CD Fistula resulting from dislodged PEG tube causing direct pressure necrosis of the duodenal mucosa leading to erosion and fistulation with the distal CBD. Our case brings to light a new and potentially avoidable complication of PEG tubes.