A silent complication following percutaneous endoscopic gastrostomy

An 83-year-old bed-ridden female, who underwent percutaneous endoscopic gastrostomy (PEG) 2 months ago, received a colonoscopy as part of a survey for her anemia. Findings of colonoscopy at 50 cm above the anal verge were shown in Figure 1. Key images from a subsequently done CT scan were presented in Figure 2. In Figure 1, a plastic tube penetrated the colonic wall with granulation seen at the entry and exit site. Figure 2 showed a gastrostomy tube penetrating the redundant colon into the stomach. Laparotomy arranged confirmed penetration of the gastrostomy tube through sigmoid colon. Perforation repair and gastrostomy revision were done. No lasting complication was noted afterwards. PEG is a procedure to percutaneously place a feeding tube into the stomach via endoscopic guidance.1 Although being generally safe, PEG carries risks of complications,2 and colonic injury is a serious, rare (<1%) one.1 In these cases, the PEG tube usually penetrates transverse colon which more commonly lie in front of stomach before entering the latter3; this type of injury is usually asymptomatic and remains undiagnosed until tube replacement, while in symptomatic cases, patient would suffer from diarrhea immediately after feeding, or more seriously, symptoms of peritonitis.2 In the presented case, the PEG tube penetrated the redundant sigmoid colon (Figure 2, arrow), which was even rarer. Surgical repair is the management of choice, while endoscopic repair has been reported.4 To avoid this complication,4 it is important to manually palpate the abdomen, observe the location of indentation endoscopically within the stomach, and also ensure evident trans-illumination by endoscope from within the stomach through the abdominal surface is observed. Methods such as placing the patient in anti-Trendelenburg position to prevent displacement of the colon anteriorly to the stomach, using pilot needles to detect potential gushing of air or feces while penetrating colon before reaching the stomach, were proposed. We aim to highlight the importance of recognizing and addressing this potential complication through this case report. The authors declare no conflicts of interest. Written informed consent was obtained from the patient, and the patient's anonymity is preserved in the article.