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Gastric Outlet Obstruction Caused by Replacement Gastrostomy Tube
Image of the Month Gastric Outlet Obstruction Caused by Replacement Gastrostomy Tube RICHARD C. FELDSTEIN, JENNIFER LEONG, and BETHANY DEVITO North Shore University Hospital, Department of Gastroenterology, Hepatology and Nutrition, New York University School of Medicine, Manhasset, New York
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90-year-old woman was admitted for a 2-week history of fever and persistent peristomal leakage. A percutaneous endoscopic gastrostomy (PEG) was placed a year earlier as a result of multiple strokes resulting in dysphagia. During the ensuing year, the gastrostomy tube was replaced multiple times at the bedside as a result of minor complications. The physical exam revealed a macerated peristomal site with surrounding erythema, induration, and serosanguineous drainage. The abdominal exam was otherwise normal without evidence of obstruction. An upper endoscopy was performed for placement of a new PEG; however, on examination, absence of the pyloric opening was noted (Figure A).1 Furthermore, the PEG tube was extending from the gastrocutaneous site to the opposite wall, with torsion of the distal stomach (Figure B). A subsequent gastrostomy tube study revealed contrast extrusion into the duodenum, suggesting the balloon was inflated in the small bowel. It was suspected that as a result of persistent manipulation of the PEG tube, torsion of the distal stomach and duodenum ensued, with a resultant anatomic gastric outlet obstruction. The wound dehiscence and cellulitis were believed to be a result of leakage of gastric secretions around the peristomal site caused by the obstruction. Repeat esophagogastroduodenoscopy after deflation of the balloon bumper revealed normal anatomy. Intubation of the duodenum noted a clean based ulcer attributed to pressure necrosis from the inflated balloon. A replacement PEG tube was inserted through the tract and anchored securely to the abdominal wall without any complication. The localized wound infection has since healed. PEG tube placement is a low-risk procedure routinely performed for patients who are unable to take food orally. Common indications for placement include neurologic conditions with associated impaired swallowing, oropharyngeal,
laryngeal, and esophageal neoplasms, facial trauma, and the need for supplemental feedings in patients with miscellaneous catabolic conditions. Overall, the complication rate ranges from 3%–14%, and mortality approaches 1%.1 Various major and minor complications have been described in the literature. Commonly encountered problems include pain at the insertion site, leakage around PEG tube, tube displacement by patient or health care personnel, tube obstruction, and local ulceration or wound infection.2 This case is an example of an anatomically created gastric outlet obstruction, without the typical symptoms of nausea, vomiting, and distention. Two theories have been postulated to explain the above. As described by Lamont and Rode,3 passage of a gastrostomy tube past the pylorus into the small bowel with insufflation of the balloon can result in fixation within the small bowel. The second theory implicates migration of the PEG tube through the pylorus as a result of improper anchoring to the abdominal wall. Fortunately in this patient, absence of obstruction at the distal tip of the gastrostomy tube allowed for unimpeded feedings, and the stoma provided an exit for air release and excess gastric secretions.
References 1. Ibegbu E, Relan M, Vega KJ. Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding. World J Gastroenterol 2007;13:5282–5284. 2. DeLegge MH. Endoscopic enteral access for enteral nutrition. ASGE Clinical Update 2007;15:2. 3. Lamont AC, Rode H. Retrograde jejuno-duodeno-gastric intussusception. Br J Radiol 1985;58:559 –561. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:xxvi
A
90-year-old woman was admitted for a 2-week history of fever and persistent peristomal leakage. A percutaneous endoscopic gastrostomy (PEG) was placed a year earlier as a result of multiple strokes resulting in dysphagia. During the ensuing year, the gastrostomy tube was replaced multiple times at the bedside as a result of minor complications. The physical exam revealed a macerated peristomal site with surrounding erythema, induration, and serosanguineous drainage. The abdominal exam was otherwise normal without evidence of obstruction. An upper endoscopy was performed for placement of a new PEG; however, on examination, absence of the pyloric opening was noted (Figure A).1 Furthermore, the PEG tube was extending from the gastrocutaneous site to the opposite wall, with torsion of the distal stomach (Figure B). A subsequent gastrostomy tube study revealed contrast extrusion into the duodenum, suggesting the balloon was inflated in the small bowel. It was suspected that as a result of persistent manipulation of the PEG tube, torsion of the distal stomach and duodenum ensued, with a resultant anatomic gastric outlet obstruction. The wound dehiscence and cellulitis were believed to be a result of leakage of gastric secretions around the peristomal site caused by the obstruction. Repeat esophagogastroduodenoscopy after deflation of the balloon bumper revealed normal anatomy. Intubation of the duodenum noted a clean based ulcer attributed to pressure necrosis from the inflated balloon. A replacement PEG tube was inserted through the tract and anchored securely to the abdominal wall without any complication. The localized wound infection has since healed. PEG tube placement is a low-risk procedure routinely performed for patients who are unable to take food orally. Common indications for placement include neurologic conditions with associated impaired swallowing, oropharyngeal,
laryngeal, and esophageal neoplasms, facial trauma, and the need for supplemental feedings in patients with miscellaneous catabolic conditions. Overall, the complication rate ranges from 3%–14%, and mortality approaches 1%.1 Various major and minor complications have been described in the literature. Commonly encountered problems include pain at the insertion site, leakage around PEG tube, tube displacement by patient or health care personnel, tube obstruction, and local ulceration or wound infection.2 This case is an example of an anatomically created gastric outlet obstruction, without the typical symptoms of nausea, vomiting, and distention. Two theories have been postulated to explain the above. As described by Lamont and Rode,3 passage of a gastrostomy tube past the pylorus into the small bowel with insufflation of the balloon can result in fixation within the small bowel. The second theory implicates migration of the PEG tube through the pylorus as a result of improper anchoring to the abdominal wall. Fortunately in this patient, absence of obstruction at the distal tip of the gastrostomy tube allowed for unimpeded feedings, and the stoma provided an exit for air release and excess gastric secretions.
References 1. Ibegbu E, Relan M, Vega KJ. Retrograde jejunoduodenogastric intussusception due to a replacement percutaneous gastrostomy tube presenting as upper gastrointestinal bleeding. World J Gastroenterol 2007;13:5282–5284. 2. DeLegge MH. Endoscopic enteral access for enteral nutrition. ASGE Clinical Update 2007;15:2. 3. Lamont AC, Rode H. Retrograde jejuno-duodeno-gastric intussusception. Br J Radiol 1985;58:559 –561. CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2008;6:xxvi