Percutaneous Endoscopic Gastrostomy (Peg) Tube Dislodgment Into The Duodenum Resulting In Intestinal Obstruction, Gastric Pneumatosis, And Portal Venous Gas

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tube is a safe procedure, although complications can occur. Tube dislodgment is a rare but important one with an incidence of around 4% to 13%. Dislodgment can occur externally and internally. When it happens internally, it can lead to gastrointestinal obstruction, perforation pneumatosis and Acute pancreatitis. We present a rare case of PEG tube Dislodgment to Distal part of the Descending Duodenum, leading to gastric pneumatosis along with Portal venous gas. We also presented the distinction between totally benign gastric emphysema from highly lethal emphysematous gastritis when a patient presents with gastric pneumatosis. CASE DESCRIPTION/METHODS: 80-year-old Male with History of Hypertension,Cerebrovascular accident with residual weakness and oropharyngeal dysphagia having a PEG tube,Dementia brought from nursing home for retching and Non-Bloody, Non-Bilious Vomiting multiple times since one day. Vital signs were stable.Physical exam was significant for mild diffuse abdominal tenderness but no guarding or rigidity. PEG tube was loose and saggy from its original position. Initial Labs were remarkable for Hemoconcentrated CBC, Hypernatremia, Otherwise Urinalysis, lipase, lactic acid, LFT were all within normal limits. Computed tomography (CT) scan of the abdomen and pelvis without intravenous contrast revealed PEG tube dislodgment into the distal descending part of the Duodenum, Also seen was gastric dilation with Intestinal obstruction and pneumatosis of the stomach and mild portal vein gas(Image 1,2).Dislodged PEG tube was removed, replaced and confirmed with Gastrographin study at the bedside.EGD was unremarkable. He was managed conservatively, Repeat Imaging showed resolution of the pneumatosis and was discharged. DISCUSSION: Gastrostomy tubes can be placed endoscopically or by surgery (laparoscopic or open).If tube dislodgement occurs before the tract is mature (<4 wk),PEG should be removed, and the tract should be allowed to heal for a few days before a new gastrostomy is placed endoscopically.If dislodgement occurs after maturation (( >4 wk),a new tube can be placed blindly at the bedside.Our patient also presented with Gastric pneumatosis(air within the gastric wall) along with portal venous gas.It has been traditionally classified into two categories: emphysematous gastritis (EG) and gastric emphysema (GE),both have similar radiographic findings but are two distinct clinical entities. (Table 1).Figure 1.: Axial and Coronal Computed tomography scan of the abdomen showing the migration of the percutaneous endoscopic gastrostomy tube, with the balloon and tip in the distal descending portion of the Duodenum (arrow).Figure 2.: Axial Computed tomography scan of the abdomen showing intramural air in the posterior wall of the stomach (down arrow) and portal vein gas (Left arrow).Table 1.: Table showing the Differences between gastric emphysema (GE) and emphysematous gastritis (EG).