3121 Spontaneous Breakage and Antegrade Enteral Migration of Jejunal Extension Tubing

INTRODUCTION: Gastroenteric tube feeding can provide essential nutrition for patients with neurologic or mechanical dysphagia. Many patients undergo pre-pyloric feeding; however, some patients require post-pyloric feeding through jejunal access. These present additional challenges in placement with potential for complications. Here we discuss a rare complication of a jejunal extension portion of a gastrojejunostomy (G-J) tube separating and becoming a foreign body. CASE DESCRIPTION/METHODS: A 77-year old woman with a past medical history of rheumatic heart disease with mitral stenosis and pulmonary hypertension (pHTN) was admitted for acute decompensated pHTN. Three months prior the patient had underwent radiologic percutaneous placement of a pull-type gastric-tube (G-tube) for dysphagia due to severe deconditioning. One week later she developed gastroparesis and the tube was exchanged under fluoroscopy with a 9-french G-J tube extension. Upon admission patient was tolerating tube feeds without complication and underwent intravenous diuresis for her pHTN exacerbation. On hospital day seven she reported onset of abdominal pain and bloating. Physical exam noted new right-upper quadrant tenderness and mild distention, G-J tube insertion site appeared normal without leakage or skin breakdown. Abdominal x-ray showed the jejunal extension tubing had separated from the G-tube balloon insertion and was visualized projecting coiled over right lower quadrant (Figure 1). Tube feeds were held and the gastroenterology service was consulted. At time of re-examination abdominal symptoms had resolved. Given the positioning of the tubing, serial abdominal imaging and supportive measures of daily suppositories to facilitate spontaneous passage by rectum were recommended. The patient was restarted on tube feeds through the remaining G-tube without complication. Ultimately the jejunal extender proceeded through the colon (Figure 2) and passed by rectum 5 days later without complication (Figure 3). DISCUSSION: The placement of jejunal extensions through existing gastrostomy tubes is typically a well-tolerated procedure and antegrade migration of jejunal tubing is rare. In this case the jejunal tubing somehow separated from its gastrostomy tube anchor. In the event of this rare complication it is reasonable to monitor for spontaneous passage with serial imaging as demonstrated in this case, with consideration for surgical exploration or endoscopic retrieval if there is non-progression of the tube or an associated complication.