Small Bowel Obstruction Secondary to Migrated PEG Tube Alleviated by Double Balloon Enteroscopy (DBE): Non Surgical Management of a Rare Complication

Abstract

Purpose: PEG is the preferred method for feeding patients requiring long term enteral nutrition because of its ease of placement and procedure-related mortality rate of less than 1-3%. Numerous rare complications have been described in the literature including infection, perforation, bleeding and buried bumper syndrome. However small bowel obstruction secondary to a migrated feeding tube is one of the rarest complications reported in the literature. Methods: We report a case of a migrated feeding tube that led to small bowel obstruction (SBO) and was successfully retrieved through DBE. This noninvasive technique saved the patient from laparotomy, likely bowel resection, decreased hospital length of stay, and undue complications associated with surgery. A 66 year old female with a past medical history of CAD, stroke, and severe dementia presents with vomiting and loss of her PEG tube. Physical exam reveals a mildly tender abdomen but overt signs of pain could not be appreciated given the patient's neurological status. Computerized tomography of the abdomen revealed the peg tube and balloon to be migrated within the ileum leading to obstruction and dilatation of the proximal small bowel. No overt free air or bowel wall thickening had developed and thus a non-surgical approach, double balloon enteroscopy via the anal approach, was considered. Results: Using sequential inflation and deflation of the overtube and endoscope balloons with pleating of the bowel, the colon and ileum were traversed. Upon entering the mid-to-distal ileum the migrated feeding tube was appreciated and a small ulceration was seen at the distal margin of the feeding tube. A 0.035in Jagwire was advanced through the lumen of the feeding tube, followed by a CRE dilating balloon (10-12 mm). The balloon was inflated to maximum size of 12 mm to provide proper traction. The endoscope was then gradually withdrawn under direct visualization, with removal of the feeding tube via the anus. Conclusion: The patient's symptoms subsequently resolved, and she was discharged to her nursing facility. The etiology of how the PEG tube became dislodged is still unknown, however it is speculated that iatrogenic mishandling of the tube may have caused it to fracture and migrate forward. The following is the first such case from our review of the literature to alleviate SBO with DBE due to a migrated feeding tube.