INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tube placement is an indispensable method for enteral nutrition. The incidence of complications ranges from 0.4% to 40% .These include buried bumper syndrome, infection, tube dislodgement, malfunction, peristomal leakage, bleeding and colonic perforation. We report a rare complication of colonic perforation presenting as a gastrocolocutaneous fistula. CASE DESCRIPTION/METHODS: 55-year-old male with Stage IV gastroesophageal junction neuroendocrine carcinoma with ongoing chemoradiotherapy had a PEG tube placed for dysphagia. There were no post procedural complications. Two months post procedure, patient presented with pancytopenia and a two-week history of persistent diarrhea, malodorous peristomal drainage and weight loss. Computerized tomography (CT) imaging with intravenous (IV) contrast confirmed the presence of a gastrocolocutaneous fistula (Image A, left) with internal bolster located in the transverse colon. Due to immunocompromised status, endoscopic closure was pursued with a colonoscopy and esophagogastroduodenoscopy (EGD). A pediatric colonoscope with distal cap attachment was used, an internal bolster with colocutaneous fistula with no cologastric fistula was seen. (Image B). The site was tattooed with 6mL of Spot (carbon black). The gastrostomy tube was removed, and three hemostatic clips were used for closure (Image C, left). No air leak was noted over the exterior abdominal wall. This was followed by EGD, the residual gastrocolic fistula was closed by a mini over the scope clip (OTSC) OVESCO 10/3t (Image C, right). A CT scan with oral contrast demonstrated no residual leak/fistula. (Image A, right) Total parenteral nutrition (TPN) was initiated. Patient continued to do well, and post-procedural hospital stay was uneventful. DISCUSSION: Gastrocolocutaneous fistula after PEG placement has an incidence of 0.5%–3%. Risk factors include lax mesentery, prior abdominal surgery leading to adhesions and improper insufflation of the stomach. Peritoneal signs represent acute presentations, delayed presentations manifest as feculent peristomal leakage, persistent diarrhea and weight loss. Diagnosis can be made with oral and IV enhanced imaging. Conservative management includes removal and allowing fistula healing. Surgical intervention is warranted when systemic signs or persistent fistulous tract is present. Endoscopic closure with OTSC is described as a treatment option for uncomplicated patients.