2754 A Gaping Hole in the Stomach - A Rare PEG Tube Complication

Abstract

INTRODUCTION: Up to 200,000 gastrostomy tubes (PEG) are placed in the United States each year, with a success rate over of 95%. Here we present a patient with complaints of abdominal pain and discharge from the PEG site, who was found to have an interesting EGD finding. CASE DESCRIPTION/METHODS: A 52 year old cachectic woman with a history of opioid abuse, roux-en-Y gastric bypass for obesity 14 years prior, and PEG placement due to inadequate oral intake almost 3 months prior to her admission, presents to the ED with worsening abdominal pain, nausea, intermittent vomiting and discharge of fecal like material from PEG site for the last few days. On exam patient appeared cachectic, disheveled, and had diffuse erythema of her abdominal wall. Vital signs were significant for hypothermia to 91.3 F, and bradycardia. Labs were significant for sodium of 152. CT abdomen and pelvis showed the PEG tube in satisfactory position. She was started on IV fluids and antibiotics but soon became hypoxic and tachycardic requiring medical ICU care. Subsequently, bleeding around the PEG tube was noted. Hemoglobin dropped from 9.8 to 7.2 within 9 hours. Lavage of the PEG tube revealed coffee ground material. Due to patient’s tenuous respiratory status, it was decided to perform an upper endoscopy by accessing the stomach via the gastrostomy fistula. The PEG tube balloon was deflated and the endoscope was easily inserted without resistance. The peritoneum was immediately visualized, which contained undigested food (Figure 1). The endoscope was withdrawn and was navigated into the body of the stomach, via a large opening. A significant amount of undigested material was seen in the remnant stomach (Figure 2). There was an opening between the remnant stomach and the gastric pouch (Figure 3), which was traversed with the endoscope. The gastric pouch was severely ulcerated and the gastrojejunal anastomosis could not be identified. The patient was then transferred to the hospital where her previous surgery and PEG tube were placed. There, her hospital course was complicated by ARDS requiring intubation. She eventually underwent replacement of PEG tube and after 50 days of hospitalization, she was discharged home. DISCUSSION: Procedure related complications such as perforation can occur anywhere from <0.5-1.8%. In this case, although the PEG tube may have initially been placed in the stomach, the replacement balloon PEG tube may have been inserted into the peritoneum. Complications such as these should always be a consideration.