Endoscopic Management of Colo-Cutaneous Fistula Masquerading as Unexplained Diarrhea and Malabsorption

Abstract

Purpose: 82-year old woman with dysphagia secondary to stroke, who underwent placement of a percutaneous endoscopic gastrostomy (PEG) 6 months earlier presented with chronic diarrhea. On exam, the external bolster of the PEG was only 2 cm outside the skin, suggesting migration of the PEG, with a freely mobile and functioning tube. Laboratory data revealed severe hypokalemia and hypomagnesaemia due to chronic diarrhea and malnutrition. CT scan showed PEG tube located in distal parts of the transverse colon. EGD confirmed healing and closure of the gastric site of PEG. On colonoscopy, the bumper of the PEG was located in transverse colon. The tip of the PEG tube at skin level was severed and the bumper was snared and retrieved out from colon. Four Resolution ® endoclips were deployed to close the colonic defect (Figure A). Antibiotics were administered for 48 hours. No leak was reported, and patient's diarrhea resolved. A new PEG was inserted uneventfully 7 days later.Figure A: Closed fistula after endoclips placement.Discussion: The practice of PEG placement had revolutionized the delivery of human nutrition in certain clinical settings. While this is a relatively safe procedure, complications may rarely occur such as tube migration. This is suspected when the external part of the tube is pulled into the abdominal cavity. Enterocutaneous fistulae are direct complications of tube migration. Gastro-cutaneous fistula is a rare sequel following the removal of the PEG. Colocutaneous fistula, on the other hand, is an extremely rare complication of PEG placement, yet the management can be quite challenging. Our case illustrates an unusual presentation of PEG migration as chronic diarrhea and malabsorption, primarily due to small bowel bypass. Successful endoscopic extraction of the PEG tube from colon and closure of the fistula tract with resolution clips promptly restored the continuity of the bowel and reversed the pathophysiological derangement. Conclusion: We presented a case of colo-cutaneous fistula, a rare and unusual complication of PEG placement, with successful endoscopic retrieval of the migrated PEG tube and closure of the colonic defect utilizing endoclipping technique.