Manipulation of Gastrostomy Tube Causing Fatal Necrotizing Fasciitis

Abstract

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) tube, a relatively safe procedure, is widely used to provide enteral nutritional support. Most of the major complications occur in patients who have comorbid illness or are immunocompromised. Necrotizing fasciitis is an uncommon soft tissue infection which is a rare complication after PEG placement. Case: A 58 year old woman was diagnosed with gastric cancer and outlet obstruction. A PEG tube and a jejunostomy tube were placed for drainage and feeding. Months later, she was sent from nursing home after PEG dislodgement and an unsuccessful attempt of repositioning the tube. Patient's physical findings on admission included obvious malnutrition, extensive left abdominal wall erythema, induration, tenderness and subcutaneous crepitus. A CT scan showed extensive subcutaneous emphysema with the tip of the gastrostomy tube in the left abdominal wall associated with muscle inflammation. The gastrostomy tube was removed and antibiotics were promptly started, the patient's conditions worsened over three days with the erythema extending towards the back. A repeat CT scan five days later revealed a large abscess in the subcutaneous tissue of her left flank with evidence of fasciitis. Patient refused surgical debridement. Two CT guided abscess drainage procedures were performed with collection of over 500 ml purulent material. The patient was kept NPO with broad spectrum antibiotic coverage. Despite aggressive medical management, her condition deteriorated, and the patient eventually expired 2 weeks later. Disussion: Necrotizing fasciitis is a relatively rare clinical infection characterized by extensive necrosis of the superficial fascia with rapid spread of the infection to surrounding tissue and causing severe systemic toxicity. It is one of the most important recognized complications after PEG placement since its mortality rate reaches 20%. Early diagnosis is critical to improve prognosis. Effective treatment includes early wide surgical debridement with aggressive antibiotic therapy preferably within the first 24 hours. Any change in position of the PEG tube needs an immediate radiology confirmation in order to prevent this deadly complication.Figure