Gastric Volvulus Caused by Gastric Tube Migration

Abstract

Percutaneous endoscopic gastrostomy (PEG) is a procedure for providing enteral feeding and long-term enteral nutritional support in patients. Despite it being a well-tolerated procedure, there can be complications that have been described including ulceration, bleeding, infection, and aspiration. A potential late complication is a gastric outlet obstruction. We report a case where a patient was admitted for abdominal pain caused by migration of the gastrostomy tube balloon into the duodenal bulb causing volvulus. A 80-year-old male with a history of chronic dysphagia due to bulbar palsy presented to the emergency department with a 2 week history of abdominal pain and hematemesis that started two days ago. His PEG tube was placed a year ago replaced a month ago after it had clogged with a balloon type replacement gastrostomy tube. His hospitalization stay was otherwise unremarkable. The patient's vital signs were stable with a Temp was 97.5F, BP was 110/55, HR was 70. On auscultation bowel sounds were normal and there was no organomegaly noted. Laboratory findings were remarkable for hemoglobin of 9.3 g/dL (his baseline hemoglobin was 11-12 g/dL).A Computed Tomography of the abdomen and pelvis was unremarkable. An esophagogastroduodenoscopy performed later revealed grade A reflux esophagitis in the lower third of the esophagus with contact bleeding. In the gastric body the replacement gastrostomy tube was present and initially the balloon was seen to have migrated distally into the duodenal bulb and caused a volvulus of the body of the stomach causing partial obstruction which was corrected after pulling the gastrostomy tube back with external bumper at 3cm. The rest of the stomach and duodenum were unremarkable. The PEG tube was replaced and feeding was initiated after 24 hours. A PEG is a relatively safe procedure. However, the number of patients who are dependent upon gastrostomy tube feeding is increasing and therefore complications may become increasingly prevalent. Internal bumper migration is one such rare complication that can result in gastric outlet obstruction leading to imaging and procedures. Since most patients that have PEG tubes have an underlying motor or cognitive dysfunction they may not be able to provide a comprehensive history, further imaging and blood work is not avoidable in such patients. However simple re-adjustment of the gastrostomy tube can resolve the problem1901_A Figure 1. Gastric Volvulus around the migrated PEG tube1901_B Figure 2. PEG tube after being replaced.