S4515 Feeding Through the Liver: Inadvertent Transhepatic PEG Placement in a Patient With Malignant Esophageal Obstruction

Introduction: Intrahepatic percutaneous endoscopic gastrostomy (PEG) placement is a rare but serious complication with the potential for bleeding and fistulization. We present a case of a mispositioned PEG and explore the rationale and outcomes of conservative management. Case Description/Methods: A 65-year-old man with a medical history of esophageal cancer with hepatic metastases presented for oropharyngeal dysphagia. Labs were consistent with anemia, and mild transaminitis. Computed tomography (CT) abdomen consistent with >10 bi-lobar hypodense liver lesions with 50% hepatic tumor parenchyma burden. He was offered an esophageal stent or PEG tube and chose PEG due to potential complications associated with stenting. Repeat esophagogastroduodenoscopy (EGD) successfully traversed the mass. Despite significant tumor burden and hepatomegaly limiting transillumination, a window was identified and PEG was placed. Ten days later, he presented with abdominal pain, erythema, and discomfort at the PEG site. CT abdomen showed the PEG tube passing through a left hepatic metastatic lesion, with the balloon located in the stomach. After multidisciplinary discussion with surgery, gastroenterology, and family, the PEG was retained for enteral nutrition, as there were no signs of decompensation or active bleeding. Chemotherapy was initiated, and following 3 cycles, the patient demonstrated improved oral intake tolerance. As a result, the PEG was removed, and the gastrocutaneous fistula was successfully closed using cutaneous clips. Discussion: Gastrostomy and jejunostomy tubes are commonly used to support nutrition in patients with limited oral intake. PEG is generally safe and well-tolerated, with minor complications such as site infection (most common), leakage, dislodgement, or obstruction. However, serious complications such as perforation, peritonitis, bleeding, necrotizing fasciitis, solid organ injury, or buried bumper syndrome can occur. Transhepatic PEG placement is a rare but significant complication, with up to 33% of cases requiring surgical intervention. Placement through a non-mature tract, as in our patient, increases the risk of overt bleeding and gastrohepatic fistula formation. There are no established guidelines for managing this complication. Current literature supports conservative management of leaving the PEG in place when the patient is hemodynamically stable and without signs of acute decompensation. Further research is needed to guide optimal treatment.