Pressure Gastric Ulcer From an Over-Inflated Gastrostomy Tube Balloon: An Unusual Cause of Upper Gastrointestinal Bleeding

Abstract

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures used for the establishment of enteral feedings in patients with dysphagia and in the elderly population with poor oral intake. Approximately 160,000-200,000 endoscopic PEG tube placement are performed each year in the United States. Despite its high success rate (>95%), major complications have been reported in 1% to 3% of cases. Endoscopically placed PEG tubes are more durable and longer lasting because an internal bumper of the tube holds the gastric wall firmly against anterior abdominal wall. This prevents easy dislodgement of the tube and minor leakage around the stoma. Dislodged endoscopic PEG tubes with a mature gastro cutaneous fistula can be replaced at the bedside with a PEG tube with a balloon. This avoids the need for a repeat endoscopy. Though cost effective the clinician should be properly trained about proper technique to avoid adverse outcomes. One such outcome is described in this case report. 80-year-old female with dementia and multiple co-morbidities presented from a nursing home with complaints of hematemesis and bleeding around PEG tube. Clinically she was noted to be tachycardic (HR 113 bpm), febrile (100.6 degrees). Blood work revealed anemia (Hgb 6.8 gm/dl) and high Blood Urea Nitrogen. On exam, a 22 Fr balloon PEG (15 cc balloon) with dried blood in and around the tubing was observed with melena on rectal exam. EGD revealed a large gastric ulcer with a visible vessel at the point of contact with an overinflated balloon. The internal balloon of the PEG tube appeared to be overinflated (at least 25 cc in a 15 cc balloon), compressing and ulcerating the stomach wall at the area of contact between the balloon and the gastric wall (Figure 1). Successful hemostasis was achieved endoscopically and a new bumper PEG tube placed under endoscopic guidance. Overinflated PEG tube balloon resulting in a large gastric pressure ulcer is an uncommon etiology of upper GI bleeding. This report can be used to emphasize the importance of following the PEG tube manufacturers recommendations and exercise proper technique and caution.Figure: Internal balloon of PEG appeared to be overinflated and compressing the stomach wall in area of ulcer.