Gastrointestinal: PEG feeding tube migration into the colon; a late manifestation

Abstract

A 53 year-old man presented with a 5-month history of severe diarrhoea and abdominal cramping immediately occurring after tube feeding. The Percutaneous Endoscopic Gastrostomy (PEG) tube was inserted 2 years previously, for enteral feeding, following diagnosis of an oropharyngeal carcinoma. The patient had no signs or symptoms of peritonitis. The skin surrounding the tube was inflamed with brown odorous fluid exuding. Upon checking the tube position using upper endoscopy no inner bumper was seen within the stomach. A fistulogram through the feeding tube revealed typical haustration of the colon rather than expected gastric appearances (Figure 1A). CT confirmed misplacement, localizing the position of the bumper in the transverse colon (Figure 1B, arrow). A gastrocolic fistula could not be visualized. Colonoscopy showed the inner bumper located near the splenic flexure (Figure 2A). The colon surrounding the inner bumper showed a soft tissue proliferation which was histologically identified as heterotopic gastric tissue (Figure 2B, arrows). The tube was removed endoscopically using a wire loop. Subsequently, a new PEG tube was inserted using ultrasound guidance. On insertion there were no signs of a persistent colocutaneous or gastrocolic fistula and tube feeding was restarted. Figure 1 Figure 2 Prior to the original PEG tube insertion, this patient had a history of polytrauma and underwent splenectomy. Anatomically, this facilitated an interposition of the colon between the anterior abdominal wall and the stomach. This, potentially, resulted in the placement of the initial PEG tube transcolonically on its way into the stomach, causing the development of an iatrogenic gastrocolic fistula. Over time, the inner PEG bumper imperceptibly migrated from the stomach into the colon, ultimately causing the reported symptoms. The heterotopic gastric tissue around the tube in the colonic wall provides independent proof for this migration. Since introduction of percutaneous endoscopic gastrostomy in 1980 by Gauderer and colleagues, the procedure has become a well-accepted and safe technique for long-term feeding of patients. The technique is performed by puncturing the stomach through the abdominal wall. The gastric wall is visualized through the abdominal wall by transillumination using a gastroscope and a fingerprint impression applied to the abdominal wall indents the gastric wall, aiding direct puncture of the needle into the stomach. In general the complication rate is low and migration of a PEG tube into the colon originally positioned in the stomach is an extraordinarily rare complication, typically occurring within days to month after insertion. It has also been found in patients with previous abdominal surgery. Characteristically, symptoms of a colonic PEG migration include sudden onset of diarrhoea and cramping, immediately after tube feeding and an odorous faecal exudate from the stoma. In most cases the PEG tubes can be removed endoscopically with spontaneous closure of the colocutaneous fistula within days. Contributed by