S4116 Avoiding a Vascular Misadventure: The Case for Ultrasound-Assisted PEG

Introduction: Percutaneous endoscopic gastrostomy (PEG) is the preferred modality for enteral nutrition in patients with limited oral intake. Ultrasound-assisted PEG placement should be considered in patients with challenging anatomy to ensure safe tube placement. Case Description: Mr. R, a 59-year-old man with hypertension, hyperlipidemia, and type 2 diabetes mellitus, presented with acute left-sided weakness and subsequent unresponsiveness. Imaging revealed a right pontine hemorrhage, necessitating intubation and nasogastric tube placement. Given ongoing enteral nutrition needs, gastroenterology was consulted for PEG placement. A computed tomography abdomen/pelvis without intravenous contrast suggested mesenteric vessels anterior to the stomach, raising concern for vascular injury risk. Therefore, ultrasound-assisted PEG placement was pursued. After appropriate gastric insufflation, a site in the stomach body demonstrated excellent transillumination and external indentation. Ultrasound identified pulsatile blood flow along portions of the abdominal wall. A safe zone without vascular structures was marked. A 20 Fr EndoVive Safety gastrostomy tube was successfully placed using the pull method. The patient tolerated tube feeds post-procedure without complications. Discussion: Standard PEG placement typically does not require ultrasound guidance in average-risk patients when proper techniques are applied. However, in high-risk anatomical scenarios, ultrasound can mitigate procedural bleeding risks. This case highlights the utility of ultrasound in identifying aberrant or adjacent vasculature, preventing potential complications. Prior reports support ultrasound-assisted PEG placement in patients with abdominal wall varices, hepatomegaly, or coagulopathy. Gastroenterologists should consider ultrasound guidance in patients with altered anatomy or increased vascular proximity to enhance procedural safety.