Delayed Distal Small Bowel Obstruction from a Detached PEG Tube Bumper

Abstract

Case: A 90-year-old woman with advanced dementia was initially admitted from a nursing facility after pulling out her PEG tube which had been placed two years prior. It was noted that as she pulled out the tube, the most distal part of the tube including the bumper had fragmented off and could not be retrieved. A replacement gastrostomy tube could not be placed at the bedside. The patient was unable to provide any additional history. Past medical and surgical history was significant for a history of small bowel obstruction requiring a small bowel resection and lysis of adhesions. She was also status post hysterectomy and cholecystectomy. On examination, she appeared comfortable. The abdomen was soft and nontender with good bowel sounds. Abdominal xray showed no obstruction. A new PEG was placed endoscopically; however, the old bumper was not seen during this exam. The patient was soon discharged back to her nursing facility. Eleven months later, she returned with several episodes of vomiting and abdominal discomfort. Vital signs were stable. The abdomen was mildly distended but soft with good bowel sounds. Labs were unremarkable except for a WBC of 12.8 with a mild neutrophilic predominance. CT imaging showed the old PEG bumper in the distal small bowel causing a partial small bowel obstruction. The patient went to surgery soon afterwards where the button was found distal to her small bowel anastomosis. The button was gently brought back to the anastomotic area where there was a redundant area of bowel. This section of bowel, now containing the button, was resected. Discussion: While inward migration of PEG tubes causing a proximal small bowel obstruction is relatively common and easily managed, our case highlights an unusual and late complication of PEG tubes where obstruction occurs because of migration of a detached PEG button to the distal small bowel. While literature suggests that most patients should be able to pass the button spontaneously, there have been several reports of the PEG button causing small bowel obstruction in patients who underwent PEG removal by the “cut and push” method in which the PEG tube is cut at skin level and the remnant pushed into the stomach, to be passed naturally by the patient. Perforation of the small bowel caused by the PEG remnant has also been described. Fortunately, PEG tubes are available today which can be easily removed at the bedside with external traction, eliminating the need for a “cut and push” approach. Our case highlights the importance of confirming the removal of all parts of a PEG tube to avoid unnecessary patient morbidity and that symptoms of obstruction caused by a lodged PEG button can be delayed for several months.