2731 Duodenal Pressure Ulcer Secondary to Migratory PEG Tube

Abstract

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term nutritional support in patients with preserved gastrointestinal function and dysphagia. The procedure and long-term presence of a PEG tube is well tolerated, with a complication rate of 0.4% to 4.4%. Adverse events include infection, skin breakdown, and aspiration. Upper GI bleeding, secondary to gastric or duodenal pressure ulcers is a rare complication. We present a case of duodenal pressure ulcers secondary to a PEG tube, along with a review of the literature and a proposed mechanism for this injury. CASE DESCRIPTION/METHODS: A 94-year-old non-verbal woman with a history of dementia and oral squamous cell carcinoma presented to the ED for RLQ abdominal pain. She was found to have leakage around the replacement PEG tube. Given comorbidities, patient was initially managed conservatively, but eventually underwent an endoscopy (EGD) due to persistent melena and down trending hemoglobin. The EGD demonstrated that the intragastric retention balloon had migrated beyond the pyloric channel resulting in a partial gastric outlet obstruction. The balloon was deflated revealing a large nonbleeding duodenal pressure ulcer. Since no stigmata of bleeding were identified, the replacement PEG was removed and new mushroom catheter and internal bumper was placed through the original tract. The patient was placed on an IV PPI to allow for adequate healing and melena resolved. DISCUSSION: Standard replacement PEG tubes are secured with an external bumper on the skin with an intragastric saline filled balloon. Ideal distance between the retainer and skin is 1-2 cm. If a PEG balloon is pulled too tightly there is a risk for pressure ulcer formation at the gastrostomy site. Conversely, if the PEG tube is too loose there is the risk of PEG balloon migration. With intense gastric peristalsis, the saline-filled balloon can migrate through the stomach, pylorus, and into the duodenum. While this is rare, case reports of gastric and duodenal outlet obstruction have been observed. In this case, the migration of the balloon into the duodenum led to a partial gastric outlet obstruction leading the patient to present with leakage, pain, melena, and anemia due to a large duodenal pressure ulcer. Proper PEG placement and care should be the main source of pressure ulcer prevention, and this rare complication should be considered in patients with melena and anemia.