Introduction: Percutaneous endoscopic gastrostomy (PEG) tubes, introduced in 1980, have worldwide recognition for overall safety in providing enteral feeding to patients with poor oral intake. PEG tubes can be removed via percutaneous or endoscopic means and the rate of complications vary but can be as low as 1-2%. Major complications include bleeding, aspiration pneumonia, internal organ injury, buried bumper syndrome, and tumor seeding of the stoma. After placement, minor complications including granuloma formation, local wound infection, peristomal leakage, and tube dislodgement. This case presents the rare complication of intermittent gastric outlet obstruction (GOO) due to internal bumper dislodgement during PEG tube removal via external traction.
Case Description/Methods: A 64 year old male with amyotrophic lateral sclerosis (ALS) complicated by chronic respiratory failure and dysphagia required PEG-tube removal via external traction due to leakage malfunction. Prior tube had been in use for 3 years and was exchanged to a 22Fr balloon G tube. Procedure was technically uncomplicated, but post procedurally, patient complained of epigastric pain, nausea and lack of bowel movements, concerning of gastric outlet obstruction vs. small bowel obstruction. Epigastric tenderness and hypoactive bowel sounds were present on exam. Abdominal xray showed round density in LUQ concerning for a foreign body. On day 3 post exchange, GI was consulted and performed EGD for foreign body removal. An old internal PEG tube bumper was seen freely mobile within the gastric antrum. Antral erosions were present. Internal bumper of 2.5 cm was removed with a Roth net. Patient declined any further pain or discomfort immediately after the procedure.
Discussion: PEG tube insertion and exchange are mostly safe, uncomplicated procedures. We report an unusual complication of gastric outlet obstruction due to residual bumper in the antrum after removal of PEG tube. In the literature, removal of PEG tube by cutting the tube at the skin level and waiting for natural passage has been described. One combined retrospective and prospective study revealed that visible passage of residual tube was only noted by 55% of patient, with mean passage time being 2.4 days. Similar to our patient, only one patient has been described to have pain until passage of the PEG tube 4 days later. This highlights the importance of ensuring tube remains intact after its removal and the need for increased awareness on the intervals recommended for tube replacements.
