Adham E. Obeidat, MD1, Ratib Mahfouz, MD2, Mohammad Darweesh, MD3, Herbert Lim, MD4 1University of Hawaii, Honolulu, HI; 2Brown University, Warwick, RI; 3East Tennessee State University, Johnson City, TN; 4The Queen's Medical Center, Honoluliu, HI
Introduction: Alternative means of providing nutrition is necessary in patients who are not able to tolerate oral intake. While nasogastric and orogastric tubes can provide temporary access for feeding, percutaneous endoscopic gastrostomy tube (PEG) can be a better solution for patient who require longer duration of nutritional support. Although PEG tube insertion is generally a safe procedure, it is not completely complication free. Some of the known complications are infection, necrotizing fasciitis and less commonly, gastric outlet obstruction (GOO).
Case Description/Methods: This is an 81-year-old woman with a past medical history of hypothyroidism and Parkinson disease complicated by dementia and dysphagia with a feeding PEG tube who presented to the emergency room with one day of hematemesis and black tarry stool. She also reported abdominal pain but denied dysphagia or change in bowel habits. She had no history of gastrointestinal (GI) bleeding and not on any antiplatelets or anticoagulants. In the ER, patient was tachycardic and hypotensive but afebrile. Her complete blood count (CBC) was significant for white blood cell (WBC) count of 12.17 x10(3)/uL, hemoglobin of 10.4 g/dL (baseline of 11.6 g/dL) and normal platelet count. Basic metabolic panel was only significant for hypocalcemia of 5.5 mg/dL. Liver function test and coagulation profile were within normal limits. The patient was given three units of packed red blood cells, made NPO and started on proton pump inhibitor (PPI). Given the recurrent hematemesis and decreased level of consciousness, the patient was intubated and was placed on mechanical ventilation. Gastroenterology consulted for further management. Esophagogastroduodenoscopy (EGD) showed Los Angeles grade D esophagitis (Figure-1) and non- bleeding gastric ulcer. Moreover, the gastrostomy tube balloon tip was trapped in the duodenal bulb. The balloon was retracted to the gastric wall and distance taped above the bumper (Figure-2). Tube feeding has been resumed and the patient was discharged on daily PPI.
Discussion: EGD in this patient revealed that the balloon tip was displaced and trapped in the duodenal bulb leading to GOO, which is an uncommon complications of PEG tube placement. This led to gastric acid buildup causing severe esophagitis, gastritis and a non-bleeding gastric ulcer with symptomatic upper GI bleeding. This happened due to migration of the inflatable balloon away from the abdominal wall leading to sliding of the gastrostomy tube inside the GI tract.
Figure: Endoscopic image shows the gastrostomy tube balloon tip causing gastric outlet obstruction
Disclosures: Adham Obeidat indicated no relevant financial relationships. Ratib Mahfouz indicated no relevant financial relationships. Mohammad Darweesh indicated no relevant financial relationships. Herbert Lim indicated no relevant financial relationships.
Adham E. Obeidat, MD1, Ratib Mahfouz, MD2, Mohammad Darweesh, MD3, Herbert Lim, MD4. P1023 - A Rare Case of Gastric Outlet Obstruction With Severe Reflux Esophagitis Due to Gastrostomy Tube Balloon Tip Displacement, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.