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PEG TUBE MIGRATION RESULTING IN THE FORMATION OF A GASTROCOLIC FISTULA AND MALNUTRITION: A CASE REPORT

S Makhija¹, J Allard²
¹University of Calgary, Calgary, Alberta; ²University of Toronto, Toronto, Ontario

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tubes are an effective means of providing adequate enteral nutrition for those who are unable to consume nutrients orally. Although extensively used, PEG tubes may have a morbidity rate of up to 16%. PEG tube migration and transverse colonic injuries are serious complications that can result in fistula formation and malnutrition. We present a case of a patient who presented with diarrhea and weight loss months after a PEG tube was inserted.
CASE: A 31 year old male who had a sustaining brain trauma from a motor vehicle accident with residual dysphagia underwent PEG tube insertion. Eight months later, the patient presented with chronic diarrhea of 2 months duration. He lost 25 pounds although his feeding schedule and formulas were unchanged. Initial laboratory investigations and stool cultures were unremarkable, except an elevated stool osmolar gap. After the initial assessment, the patient was discharged and advised to discontinue his dantrolene and cholestyramine and initiate a two-week course of Metronidazole, empirically treating small bowel bacterial overgrowth. One month later the patient returned for outpatient follow up with ongoing diarrhea. In the interim, the patient had trialed other enteral formulas without any improvement. Further investigations included gastroscopy and colonoscopy. During colonoscopy, the tip of the feeding tube was visualized proximal to the splenic flexure. The EGD revealed an opening between the antrum and body of the stomach, which was draining similar material that was seen in the colon. A gastrocolic fistula was recognized and surgical evaluation was requested. A jejunostomy was inserted and the patient began to regain weight and the diarrhea resolved.
CONCLUSIONS: We presented a case of malnutrition secondary to formation of a gastrocolic fistula from PEG tube migration. Further awareness and timely recognition of these complications can prevent further morbidity from PEG tubes.

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