Complications of a Minimally Invasive Procedure: The PEG Tube

Abstract

Percutaneous endoscopic gastrostomy (PEG) is a minimally invasive method of establishing enteral access by placing a tube through the gastric wall. It's one of the most common endoscopic procedures, with an estimated number of 100,000-125,000 performed annually in the US. Procedure-related complications are not uncommon; a large meta-analysis reported morbidity of 9.4% and mortality of 0.53%. Commonly reported complications are: aspiration, hemorrhage, peritonitis, gastric ulcer, fistulas, ileus, stomal leak, infection, buried bumper, visceral perforation, and accidental removal. We describe a patient who had a recent PEG tube replacement, now presenting with an upper GI bleed, found to have an ulcerated gastric wall hematoma. An 81 YOM with a PMHx of laryngeal carcinoma s/p chemoradiation and PEG tube placement due to a near complete obstruction of the cervical esophagus presented with melena and coffee ground discharge from his tube. He recently underwent PEG tube replacement due to tube malfunction; given significant stricture at the site, the tract required dilation prior to replacement. Admission labs were significant for anemia. He was not on any anticoagulation. Endoscopy via PEG site revealed a 2cm ulcer over a large non-mucosal mass in the gastric body, opposite the tube(Fig A). This was initially thought to be an ulcerated gastrointestinal stromal tumor (GIST). He was placed on a proton pump inhibitor and was scheduled for a repeat EGD and endoscopic ultrasound. During this follow up EGD there had been complete resolution of the lesion(Fig B). It was concluded that the non-mucosal lesion was likely a hematoma due to traumatic injury by passing the dilator. Traumatic placement of a PEG tube causing an ulcerated hematoma is an uncommon, frequently underreported entity that may have a similar appearance to that of a GIST. GISTs are mesenchymal neoplasms accounting for less than 1% of all GI tumors. They have a variety of appearances and can present as an intraluminal, extraluminal, solid or ulcerated mass anywhere along the GI tract. The most common site of a gastric wall hematoma includes the anterior wall due to needle insertion damaging small vessels contained within the deep submucosa. Theoretically, dilators used to relieve PEG tube strictures could cause damage to the posterior wall, however upon literature review there were no cases identified. This case emphasizes the need for caution when using dilators to treat PEG site strictures.Figure: Large non-mucosal mass with central ulceration.Figure: Complete resolution of large non-mucosal mass with central ulceration after one month.