S6435 Intraperitoneal Misplacement of a PEG Tube After Routine Bedside Exchange

Introduction: Bedside percutaneous endoscopic gastrostomy (PEG) tube replacement in mature tracts (>4 weeks old) are routinely done with as low as 1.3% rate of complications reported in case series. Here we present a rare case of an intraperitoneal PEG tube misplacement following routine bedside PEG tube exchange. Case Description/Methods: A 38-year-old man with refractory epilepsy and multiple intracranial procedures complicated by neuromediated dysphagia underwent PEG placement. A 24 French (Fr) deformable internal bolster tube was placed using the pull technique, with transillumination and indentation confirming proper positioning. The next day, he was tolerating tube feeds well and PEG was noted to be positioned appropriately. Over the next 6 months, he had 4 abdominal computed tomographies (CTs) for recurrent abdominal pain, all confirming appropriate tube position without complications. Six months post-placement, gastroenterology was consulted for exchanging the mature PEG. The external bumper exhibited no erythema or leakage, and the tube was easily removed with gentle traction. A 24 Fr MIC balloon tube was inserted and flushed with 25 cc water. The patient developed abdominal pain immediately which prompted withholding tube use and a gastrografin study revealed intraperitoneal contrast extravasation. Exploratory laparotomy confirmed tube misplacement through the established tract at the level of the abdominal wall. Pre-existing tract was surgically closed and a new tube was placed. Peritoneal fluid culture grew Candida albicans. About 10 days later, his clinical course was further complicated by acute cholecystitis requiring biliary drain placement. Retrospective review of the prior computed tomography (CT) images with Radiology identified a fat layer between the gastric and abdominal walls, potentially preventing tract maturation. Bedside replacement of the tube may have resulted in false tracking into the peritoneum through the mesenteric fat. Also, once the bumper that was pulling the stomach anteriorly was removed, the decompressed stomach may have moved away from the abdominal wall, increasing the risk of tube misplacement. Discussion: This case serves as an important reminder that “mature” PEG tracts may not guarantee safe bedside exchanges. Although rarely, anatomical variations and incomplete tract formation can predispose to serious complications. Clinical vigilance and thorough imaging review are essential to prevent adverse outcomes.