Rare Complications: Hepatic Injury Following PEG Tube Placement

Abstract

Background Percutaneous endoscopy gastrostomy (PEG) tube placement is commonly performed in patients with functional gastrointestinal tracts but inability to maintain adequate oral intake. Mortality due to PEG tube placement is <1%; however minor and major risks exist including infection and intrabdominal organ injury. Case Presentation A 35-year-old man with history of Down Syndrome and Type 2 Diabetes was admitted with COVID-19 pneumonia. He initially required intubation and underwent tracheostomy two weeks into admission. Respiratory status stabilized, and he was evaluated for a PEG tube to continue tube feeds. History from the patient’s family member revealed that the patient briefly had a feeding tube as a child. The consulting Gastroenterology service evaluated the patient and did not deem the prior procedure a barrier to PEG tube placement. The patient had a normal upper endoscopy, and a gastrostomy tube was placed via transillumination. Tube feeds were initiated with advancement to bolus feeds well-tolerated. However, one week after PEG tube placement, he reported intermittent chills, myalgias, and fevers up to 103 F with leukocytosis to 18,000/μl. Abdominal exam was notable for slight distention but no guarding or rigidity. CT of the abdomen and pelvis showed the PEG tube traversing the left hepatic lobe enroute to the stomach and a consequent 3-centimeter intrahepatic fluid collection. Patient was emergently taken for laparoscopic revision and drainage of the fluid collection. With operative management and appropriate antimicrobial therapy, his symptoms fully resolved. Discussion Liver injury from PEG tube placement is a rare complication with a patient presentation that can range from asymptomatic to critical illness. There are less than twenty cases documented in the literature. Prior abdominal surgery or PEG tube can increase the risk of intraabdominal injury. Awareness of risks associated with the procedure can facilitate early recognition and definitive management of a potentially life-threatening complication.