Abdominal Wall Necrotizing Fasciitis from Dislodged PEG Tube

Abstract

Purpose: Introduction: Percutaneous endoscopic gastrostomy (PEG) is considered s safe method for supplying long-term enteral nutrition to patients who are unable to take food by mouth. Necrotizing fasciitis is a rare complication of PEG tube. Patients with pre-existing diabetes, wound infections, malnutrition and immune suppression are at increased risk for NF. Case Report: A 74-year-old AAF with history of DM, HCV, ESRD on HD, HTN, CVA with residual aphasia presented to hospital with altered mental status due to sepsis. Patient was poorly nourished, had stage 4 sacral decubitus ulcer and had PEG tube which was inserted by an experienced endoscopist under aseptic conditions approximately a month prior. During hospital stay, patient developed respiratory failure and possible anoxic brain injury. She was intubated, subsequently had tracheostomy placed. Diverting colostomy was performed to give bowel rest for sacral decubitus ulcer healing. On admission day 100, despite being on multiple antibiotics, patient developed fever and new bacteremia. Two days later, she developed hypotension refractory to fluid challenge so placed on pressors. Blood cultures revealed proteus. On day 103, exam revealed anterior abdominal wall discoloration and crepitations. CXR showed subcutaneous gas in left lower chest wall. AXR showed subcutaneous emphysema over left anterior abdominal wall. Patient was taken to OR. Anterolateral chest and abdominal wall were debrided. Dislodged PEG tube was found with end in subcutaneous fat with tube feeds that had dissected through tissue planes. All necrotic tissue was debrided, pockets were irrigated. The gastrostomy tube was removed. The antibiotic coverage was extended. Repeat debridement was done. Patient still remained febrile. Following protracted ICU stay, acute care was deemed futile; palliative consult was called. The gravity of condition was discussed with family and patient was made DNR. Pressors and IV antibiotics were stopped, and patient passed on palliative care. Discussion: Multiple aerobic and anaerobic microorganisms are responsible for NF. Treatment includes surgical debridement, planned operative reassessment, antibiotics, hyperbaric oxygen &extensive patient support. Traction and improper use of PEGtube increases risk of developing NF. It is important for healthcare providers, to maintain proper care of the PEG-tube and utilize safe measures.