Acute Pancreatitis Due to Percutaneous Endoscopic Gastrostomy Tube Migration

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Case Report: Percutaneous endoscopic gastrostomy (PEG) tubes provide a non-surgical alternative to long-term enteral feeding and are generally considered safe. Acute pancreatitis is a rare complication associated with migration of percutaneous endoscopic gastrostomy tubes into the duodenum. A 70-year-old female with a history of advanced dementia and PEG-tube feeding was admitted with recurrent nausea and bilious vomiting for one day. She had a similar presentation in the past, where she was found to have migration of the PEG tube into the duodenal bulb, which was causing functional gastric outlet obstruction. There was no prior history of alcohol abuse. Physical examination was significant for mild epigastric tenderness. Laboratory findings showed elevated lipase with normal liver function tests. A computed tomography (CT) scan showed diffuse swelling of the pancreas with peripancreatic edema suggestive of acute pancreatitis and migrated gastrostomy tube balloon into the second portion of the duodenum, lodged right at the level of the ampulla of Vater. There was no evidence of gallstones, chronic pancreatitis or biliary dilatation. Her triglyceride level was normal. The patient was not on any medication that classified under class 1 or class 2 causes of acute pancreatitis. Total IgG and IgG4 levels were normal. The percutaneous endoscopic gastrostomy tube was repositioned and secured. Over the next few days patient's condition improved and the pancreatic enzymes normalized. Patient has been symptom free over six months. Conclusion: Our case shows the importance of early recognition of PEG tube displacement as a preventable cause of acute pancreatitis. Patients, medical professionals, and caregivers would benefit from training in proper care of the PEG tube including daily assessment of the length of the tube, and securing the external bolster. In this subgroup of patients, PEG tube dislodgement should be considered in the differential diagnosis of acute pancreatitis.