The Utility of Transabdominal Ultrasound in Percutaneous Endoscopic Gastrostomy Tube Placement: A Novel Approach

Abstract

Gastrostomy (G) tube placement can be performed through a variety of techniques. One of the least invasive and effective approaches is through endoscopic guidance. However percutaneous endoscopic gastrostomy tube (PEG) placement can be difficult in patients with prior surgeries and altered anatomy. Oftentimes these patients require either fluoroscopic guided placement or even surgery. We present a novel technique utilizing transabdominal ultrasound in combination with endoscopy to guide a new PEG placement in a patient with a malpositioned G tube in the transverse colon. Our patient is a 65 year-old male with chronic respiratory failure requiring tracheostomy and fluoroscopic guided G tube placement one year prior who presented for a dislodged G tube. The G tube was initially replaced at bedside however aspirate from the tube revealed feculent material. A CT scan revealed the original G tube tract had unknowingly extended through the transverse colon prior to entering the stomach. In addition, the G tube internal bumper had become displaced and was now seen lying within the colon. The patient underwent an upper endoscopy and colonoscopy for a new PEG placement and removal of the prior G tube. The upper endoscopy showed a healed scar from the old G tube site. Due to the patient's challenging anatomy, adequate transillumination for a new PEG placement was difficult. To ensure proper placement, transabdominal ultrasound was used. During endoscopy, a steady stream of sterile water was directed at the anterior gastric wall which was visualized in real time on ultrasound, thereby confirming an ideal window for PEG placement without any underlying colon. A PEG was then successfully placed. Colonoscopy was performed which confirmed the prior G tube within the transverse colon which was cut and removed endoscopically. The mucosal defect was closed using an over-the-scope clip. The patient did well post-procedure and was resumed on enteral feeding the following day. Transabdominal ultrasound alone has not been traditionally used to guide G tube placement as air in an insufflated stomach can cause artifact. However using transabdominal ultrasound with visualization of a steady stream of water directed at the gastric wall during endoscopy can circumvent air artifact and aide in ensuring an adequate window for PEG placement. Transabdominal ultrasound can be an invaluable tool as an adjunct to PEG placement in patients with difficult anatomy and prior procedures.2713_A Figure 1 No Caption available.2713_B Figure 2 No Caption available.2713_C Figure 3 No Caption available.