A Migrated Percutaneous Endoscopic Gastrostomy Tube Inducing Gastric Outlet Obstruction and Acute Pancreatitis

Abstract

INTRODUCTION Patients unable to tolerate oral intake may undergo percutaneous endoscopic gastrostomy (PEG) tube insertion to provide enteral feeding, hydration, and medications. Seldom, gastric outlet obstruction (GOO) presents as a late complication with migration of the tube's balloon into duodenum. Rarely and documented in only a few cases, the balloon may cause obstruction of the ampulla of Vater, impede biliary flow, and, ultimately, induce acute pancreatitis. CASE DESCRIPTION A 41-year-old Caucasian male with a history of traumatic brain injury resulting in ventriculoperitoneal shunt placement and quadriplegia, small bowel obstruction status-post PEG tube who was brought to the emergency room with acute diffuse abdominal pain, nausea and vomiting. At baseline, he is non-verbal, but communicates with head nods and some motion with his upper extremities. Vital signs were within normal limits. Abdominal exam revealed hypoactive bowel sounds, moderate distension, and mild diffuse tenderness to palpation without guarding or rebound tenderness. The PEG tube appeared to have migrated with the external bumper no longer visible with resistance to gentle retraction. Laboratory analysis revealed a lipase of 5760 U/L with liver function studies within normal limits. Abdominal computed tomography showed migration of the PEG tube with an over-distended balloon component located within the first portion of the duodenum contributing to a GOO. Patient was admitted for GOO due to migration of the 18 French PEG tube through the pylorus into the duodenum and acute pancreatitis due to GOO obstructing drainage from the ampulla of Vater. The PEG tube was easily retracted into normal positioning with deflation of the balloon. Patient was treated with conservative management with improvements of his symptoms. DISCUSSION The incidence of acute pancreatitis secondary to PEG tube migration and GOO is not well documented and only documented in case reports and series. In past cases, onset of GOO to development of pancreatitis has varied from 1 to more than 100 days. Early recognition of this potential severe complication can aid physician in proper immediate management. By simply deflating the balloon and withdrawing the tube back to proper position, the external bumper can be re-fastened. Removal of the the biliary obstruction is crucial and allows rapid resolution of the pancreatitis with proper fluid resuscitation.1330.tif Figure 1: Interval migration of PEG tube with an over distended balloon component located within the first portion of the duodenum and contributing to a gastric outlet obstruction.