Dean Kristl, MD, Abubaker A Ali, MD, Charles E Lucas, MD, Choichi Sugawa, MD. Wayne State University
Introduction: Percutaneous endoscopic gastrostomy (PEG) is a very common method for enteral nutrition. Accidental dislodgement of PEG tube is a common complication. Soon after dislodgement, Foley catheters are often placed through the mature gastrocutaneous fistula to prevent tract closure until more definitive replacement occurs. This report describes a patient in whom the replacement Foley catheter migrated distally and required colonoscopic retrieval.
Case Report: A 65 year old male with a past medical history of bilateral adrenal adenoma, stroke, dementia, and dysphagia was transferred from a nursing home due to a missing feeding tube. Previously he had a PEG tube placed for dysphagia. It became dislodged several weeks after placement and was replaced with a Foley catheter. The patient arrived in the emergency department with normal vital signs. Physical examination showed a soft, non-distended, and non-tender abdomen with a gastrocutaneous fistula and no Foley catheter. Abdominal x-rays showed a tubular structure in the right upper quadrant, without pneumoperitoneum. CT scan showed a Foley catheter in the proximal jejunum without obstruction. The patient was admitted, kept NPO, given IV fluids, and underwent push enteroscopy due to concerns the inflated catheter bulb would not pass the ileocecal valve. The scope was advanced approximately 70 cm beyond the ligament of Treitz and the catheter was not visualized. The patient remained asymptomatic and was observed for seven days while being administered laxatives and enemas. Plans were made to perform colonoscopy and, if this failed, to perform exploratory laparotomy. Colonoscopy revealed a Foley catheter with inflated balloon in the ileocecal region. It was retrieved uneventfully with a snare. The patient was then discharged back to the nursing home.
Discussion: PEG tubes, introduced in the 1980s, have become a widely used technique of enteral feeding. A major complication of PEG placement is dislodgement, reported in 12.8% of cases in a recent retrospective study. A mature gastrocutaneous fistula tract forms in approximately 2-3 weeks but can narrow and even close in hours once a tube is dislodged. If no gastrostomy tube is accessible, a Foley catheter is a good alternative to prevent tract closure. Complications of balloon catheter replacement include obstruction, ulcers, or intussusception. These are due to the tube lacking an external fixation device. This case illustrates distal Foley migration. This complication has been described and has been treated by either percutaneous puncture of the balloon or operative exploration. Despite having an inflated balloon, this patient did not have obstruction. Retrieval of the migrated catheter was achieved without operative exploration. Morbidity of Foley catheter replacement of dislodged PEG tubes is sparse. They are a cheap and effective way to maintain a patent gastrocutaneous tract. However, the expense associated with their complications can be avoided with prompt replacement by a formal gastrostomy tube. ER physicians should be aware of this as they are often the first health care provider to see these problems.