When Vomiting Goes Too Far: A Rare Case of Retrograde Jejunal Limb Expulsion

CASE REPORT A 42-year-old woman with diabetic gastroparesis and recurrent hospitalizations for intractable nausea, vomiting, weight loss, and poor oral intake underwent endoscopic placement of a gastrostomy-jejunostomy (GJ) tube for enteral feeding and gastric decompression while planning a gastric peroral endoscopic myotomy. Per institutional protocol, the distal J-limb was advanced beyond the pylorus and secured to the distal duodenum/proximal jejunum with a clip to minimize retrograde migration into the stomach. One week after placement, she returned to the emergency department with recurrent nausea and several bouts of forceful vomiting, culminating in oral expulsion of the entire jejunal limb of the previously placed GJ tube with the attached metal clip through her mouth (Figure 1). The G portion remained intact (Figure 2).Figure 1.: The jejunal limb of the gastrostomy-jejunostomy tube with the attached metal clip emerging through her mouth.Figure 2.: The gastrostomy-jejunostomy tube with the gastric port (orange) and the jejunal port (purple).Management involved cutting the distal J-limb tip with the metallic clip externally to avoid mucosal injury during removal, followed by detaching the jejunal port and gently retrieving the J-tube through the gastrostomy port. Removal was successful without complications. This case represents an extraordinarily rare form of GJ tube dislodgement, characterized by retrograde oral expulsion of the J-limb—a phenomenon that, to our knowledge, has only been reported once previously in the literature, making this the second reported case.1 This case highlights a unique mechanical vulnerability of GJ tubes in patients with severe gastroparesis and recurrent emesis. The primary risk factors of retrograde jejunal limb migration include forceful reverse peristalsis in the setting of severe retching and vomiting associated with underlying gastrointestinal dysmotility, redundancy and looping of the jejunal extension within the gastric lumen, and the use of small-bore jejunal extension tubes (8–12 Fr), which are inherently flexible and provide limited resistance to retrograde peristaltic forces.2 Our patient had a 10 Fr, 91 cm Avanos CORFLO jejunal extension tube in a 24 Fr EndoVive Safety gastrostomy tube. Several technical modifications have been proposed to reduce the risk of migration. Optimal placement of the gastrostomy in the lower antrum and slightly right of midline may shorten and straighten the transgastric course, thereby reducing intragastric looping.3 Additional strategies include minimizing external tube length (typically <10 cm) and using longer jejunal extensions to facilitate deeper postpyloric positioning.3 Device-related alternatives, such as single-piece transgastric jejunostomy tubes with greater rigidity, balloon-anchored jejunal feeding systems, or fixation of the jejunal limb within the small bowel, may further reduce the risk of retrograde displacement.4 DISCLOSURES Author contributions: All authors were involved in the management of this case and contributed to obtaining consent, drafting of the manuscript, and revising it for accuracy. All authors approved the final version of this manuscript. A. Khouri is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.