S1887 A Case of PEG-Induced Pancreatitis

Abstract

Introduction: PEG (percutaneous endoscopic gastrostomy) tube placement is a commonly performed procedure for patients in need of long-term enteral nutrition. It is a relatively safe procedure, with some complications including bleeding, infection, buried bumper syndrome, and dislodgement. Even rarer is the tube migration into the duodenum, obstructing the ampulla, causing biliary obstruction and pancreatitis. We present a case of pancreatitis secondary to migrated PEG tube bumper [1, 2]. Case Description/Methods: An 83-year-old male with a history of stroke and dysphagia, who one year prior had a PEG tube placed presenting with vomiting and epigastric pain and tenderness. Initial lipase was 1761 (reference 8-69 U/L), alkaline phosphatase was 145 (reference 36-112 IU/L), transaminases, bilirubin, and triglycerides were normal. Abdominal CT scan showed a migrated PEG tube balloon in second part of the duodenum at level of the ampulla (Figure). As it turned out patient was tolerating oral diet thus PEG was no longer needed. GI team deflated the balloon and removed the PEG without any further complications. With aggressive fluid resuscitation, patient's symptoms resolved after two days. Discussion: Pancreatitis due to migrated PEG tube obstructing the ampulla is a rare entity, with only a few case reports published. Patient's can present with nonspecific symptoms with significantly elevated hepatic and pancreatic enzymes. CT findings can show pancreatic inflammation and biliary/pancreatic duct dilation with PEG bumper at level of ampulla [1, 2]. Physical exam findings would show very little external tubing indicating distal internal migration of PEG bumper. Interestingly this can also cause intermittent gastric outlet obstruction. Treatment is PEG tube removal/replacement, and IV fluids. Marking the tube at the insertion site can help in diagnosis of migration, if it happens. Patients and care givers should be educated about tube care, regular follow-ups to ensure positioning and to ascertain the timing of removal.Figure 1.: Migration of percutaneous gastrostomy tube balloon to second portion of duodenum at level of ampulla.