Purpose: Learning objectives: To recognize that PEG tube balloon may migrate and get impacted in the second portion of duodenum leading to disturbance of pancreatic and biliary juice secretion at the papilla. PEG tube balloon impaction in the duodenum should be in the differential diagnoses list in patients who have PEG tube and pancreatitis with/without elevated LFTs. Case: A 62-year-old female was admitted to the hospital with complaints of fever, chills, difficulty breathing, and tachycardia. Her past medical history was significant for diabetes mellitus, seizure disorder, and Pick's disease with severe dementia. She also had PEG tube in place due to dysphagia. Her medications included insulin and valproic acid. On admission day, her physical examination was significant for tachycardia, tachypnea, and temperature of 102 F. Cardiopulmonary exam revealed bibasilar crackles. Her abdomen was benign with PEG in place. Her chest X-ray showed bibasilar consolidation. The diagnosis of pneumonia was made and broad spectrum antibiotics were commenced. On day 5 of hospitalization her condition began deteriorating. Work-up showed elevated WBC along with ESR, CRP, amylase, lipase, and LFTs which were suggestive for a pancreaticobiliary inflammatory process. CT abdomen showed diffuse pancreatitis without any evidence of phlegmon or abscess. The balloon of the G-tube appeared to be impacted in the duodenum near the ampulla of Vater. The PEG tube balloon was deflated and the tube was pulled up and guarded at 4 cm. After that her WBC, amylase, lipase, and LFTs started trending down significantly and returned to normal levels within a week. Discussion: Obstructive pancreatitis and cholangitis induced by migrated PEG-tube are the very rare complications of PEG tube. Although PEG-tube feeding is generally considered safe with a low rate of serious complications, dislocation of the PEG-tube into the duodenum can lead to symptoms of obstructive pancreatitis and cholangitis. Because a balloon with PEG-tube is hard to pass through the pyloric ring, a migrated balloon may obstruct the pyloric ring and cause vomiting.Figure: [784]