A sixty-two year-old female with an unusual complication of a PEG tube —a case report

Abstract

A 62 year-old female with a history of laryngectomy, secondary to laryngeal carcinoma, and percutaneous endoscopic gastrostomy (PEG) tube placement eight months prior to hospitalization presented with two days of coffee ground emesis. The patient had one epidsode of melena on the day of admission. She denied having any abdominal pain, use of nonsteroidal anti-inflammatory drugs, history of peptic ulcer disease or alcohol use. On admission, the patient's blood pressure was 140/80 mm Hg and her pulse was 110 beats/min. Physical exam revealed an intact PEG tube without evidence of infection around the site and a benign abdomen. Initial laboratory values revealed HGB 14.8 mg/dl, HCT of 44 mg/dl, and platelet of 108,000 with normal PT and PTT. Lavage through the PEG tube was positive for coffee ground material. The patient underwent an upper endoscopy which revealed an intact PEG tube with a buldging mass, believed to be duodenal intussusception into the stomach, obtructing the pylorus. Under the supervision of a surgeon, the intact PEG tube was removed. Several hours later, the patient had another episode of coffee ground emesis. As a result, upper endoscopy was repeated. The endoscopy revealed persistence of the duodenal intussusception into the stomach. The patient underwent surgical exploration which confirmed gangrenous small bowel with intussusception of the duodenum into the stomach. At that time, gastrojejunostomy and choledochoduodenostomy was performed. A few days after the operation, the patient became febrile and hypotensive. A swan ganz cathether was placed and was consistent with septic shock. Chest x-ray was suggestive of acute respiratory distress syndrome. The patient did not improve with antibiotics, aggressive ventillatory support and vasopressors. After much deliberation, her family decided to withdraw care and she subsequently expired a few hours after extubation. Percutaneous endoscopic gastrostomy (PEG) tubes have several indications. However, they are also associated with numerous complications. It is believed that migration of a PEG tube provides a focal point for the formation of intussusception. This case demonstrates an unusual complication, intussusception of the duodenum into the stomach, of PEG tube placement.