Delayed Terminal Ileal Obstruction From a Retained Percutaneous Endoscopic Gastrostomy (PEG) Bolster Following Cut-and-Push Replacement in a Frail Elderly Patient: A Case Report

Percutaneous endoscopic gastrostomy (PEG) is commonly used for long-term enteral nutrition in patients unable to feed orally. The cut-and-push technique, where the internal bolster is left to pass spontaneously, is generally safe, but complications are uncommon. We report an 88-year-old bed-bound female with multiple comorbidities, including type 2 diabetes mellitus, chronic kidney disease, dementia, and a prior lower midline laparotomy, who underwent PEG replacement using the cut-and-push method. Three weeks later, she developed a small bowel obstruction. Imaging revealed the retained PEG bolster lodged in the terminal ileum, causing proximal dilatation and distal collapse. Following a 48-hour trial of conservative management without clinical improvement, minimally invasive intervention was attempted. Diagnostic laparoscopy with adhesiolysis was initially performed, followed by an attempted colonoscopic retrieval; however, colonoscopy was unsuccessful because of inadequate bowel preparation. Definitive management required open surgical retrieval through enterotomy via the previous laparotomy scar, which was completed successfully. Postoperatively, the patient required prolonged ventilatory support via tracheostomy and was transferred to a long-term care facility. This case illustrates a rare delayed obstruction from a retained PEG bolster, highlighting the importance of careful patient selection, close follow-up to confirm spontaneous passage, and timely intervention when excretion fails.