Clinical Investigation of Upper Gastrointestinal Bleeding After Percutaneous Endoscopic Gastrostomy

Abstract

Introduction: Percutaneous endoscopic gastrostomy (PEG) is a standard access for enteral feeding in patients who cannot maintain oral intake. However, there are various kinds of complications associated with the placement and maintenance of PEG, including gastrointestinal (GI) bleeding. We examined the medical records of patients who underwent PEG, and investigated the causes for upper GI bleeding. Methods: We retrospectively studied 397 consecutive patients who underwent PEG from Sept. 1996 to Sept. 2008 at our institution. Among them, 10 patients who were diagnosed as having gastrointestinal tumors at the PEG were excluded in this study. In a total of 387 patients (124 males and 263 females, mean age: 82.3 ± 8.4 years), upper GI bleeding was identified by the medical records in 16 patients (7 males and 9 females, mean age: 81.3 ± 9.1 years). Bleeding of the upper GI lesions was detected by EGD, which was conducted due to the symptoms of hematoemesis, tarry stool, or bloody drainage material from the gastrostomy tube. Results: The mean follow-up observation period was 488 ± 571 (SD) days. The mean interval between the PEG placement and GI bleeding was 325 ± 482 (SD) days (range: 1 to 1,906 days). The most frequent cause of the bleeding was reflux esophagitis (5 patients), followed by vascular injury upon replacement of the gastrostomy tube (4 patients), those upon placement of the gastrostomy tube (2 patients), gastric ulcer (2 patients), gastric erosion caused by traction of the mucosa into the side hole of the internal bolster when decompressing a PEG tube (2 patients), and duodenal diverticular bleeding (1 patient). Anticoagulants had been administered to the 4 patients with vascular injury upon the replacement of a gastrostomy tube, 1 of 5 patients with reflux esophagitis, and 1 of 2 patients with gastric ulcer. In the 5 patients with reflux esophagitis, gastric decompression through the PEG and the administration of proton pump inhibitor were effective. Endoscopic hemostasis was required in 3 patients with vascular injury and 2 patients with gastric ulcer. Compression by the internal bolster was done to treat the vascular injury located just beneath the internal bolster, which occurred upon replacement (2 patients) and upon placement (1 patient) of the gastrostomy tube. Blood transfusions were carried out in 4 patients. There was no lethal case due to GI bleeding. Conclusion: Reflux esophagitis and vascular injury upon the replacement of a gastrostomy tube were found to be two major reasons for GI bleeding after PEG. Anticoagulants should be suspended during the replacement of a gastrostomy tube to minimize GI bleeding.