S2976 Mind Your Step - A Dangerous Complication of Foley Catheter Placement to Preserve Cutaneofistula

Abstract

Introduction: Foley catheters are commonly used as place holders for dislodged percutaneous endoscopic feeding tubes in the acute setting to maintain the fistula tract. Common complications of replacement foley tubes include migration and obstruction. Herein, we present a case of iatrogenic small bowel obstruction and ischemia caused by a migrated foley catheter that was used to replace a dislodged percutaneous endoscopic jejunostomy (PEJ) tube. Case Description/Methods: A 62-year-old male with PMH of alcohol use disorder and chronic pancreatitis presented after stepping on and accidentally dislodging his PEJ which had been placed 3 weeks prior at an outside facility. On admission, a foley catheter was placed by the surgical team to maintain the fistula tract and was confirmed via x-ray. The following morning, a CT scan was ordered due to new abdominal pain and to confirm position due to concern of anterograde migration. Immediately after the scan, the patient became altered, hypotensive and had new significant abdominal tenderness. CT images showed migration of the foley with marked dilation of the stomach and proximal small bowel suggestive of small bowel obstruction (Fig. 1, 2). A focus of air was noted along the foley balloon, indicative of perforation (Fig. 3) and pneumatosis intestinalis raised the concern for ischemia (Fig 4). Serum lactic acid was elevated to 12.7 mmol/L. The patient was taken to the OR for emergent ex-lap. The catheter migration caused a serosal tear in the jejunum which was repaired surgically. A new jejunostomy tube was placed, and the patient recovered uneventfully. Discussion: Dislodgement of PEG or PEJ tubes is one of the most common complications of placement. If a tube is dislodged within the first two weeks, the tract is not matured and warrants treatment as a bowel perforation with surgical management. In late dislodgement of feeding tubes, it is imperative that the tract be preserved rapidly. Often, a foley catheter is used. If such is the case, efforts should be made to ensure proper external fixation. This can be accomplished with suture or Tegaderm dressing to the skin. Another potential practice could be to mark the foley catheter at the depth of insertion with nursing examination every shift to ensure no movement of the catheter. If no longer visualized, the foley should be withdrawn until the mark is again seen. As we continue to increase awareness and standardize methods to prevent these complications, we can reduce complication rates and benefit our patients.Figure 1.: The intestinal obstruction is highlighted here by extremely distended stomach here and dilated loops of bowel with the retained foley.Figure 2.: The loops of small bowel can be observed here with the foley balloon inflated seen within the pelvis and air can be seen surrounding the balloon.Figure 3.: Here it is highlighted the air approximating the foley balloon.Figure 4.: The catheter is observed here causing potential pneumatosis intestinalis.