An 87-year-old man was admitted for congestive heart failure (CHF) exacerbation. In addition, a past cerebrovascular accident (CVA) with resulting dysphagia required placement of a feeding tube. The feeding tube was a percutaneously placed gastric tube, placed by gastroenterology 1 month before admission.
During hospitalization, the patient tolerated his tube feeds until hospital day 4, when he developed loose stools. The diarrhea progressed with liters of watery stool daily, necessitating placement of a rectal tube. Various stool studies were sent and failed to reveal an etiology. Bulking agents were added to his tube feeds but did not improve the consistency or volume of his stools. The primary team noted a remarkable similarity in appearance between the tube feeds and the stool. During a tube check, it was discovered that the tip of the feeding tube was in the colon and not the stomach.
On further investigation, it was determined that a loop of colon was overlying the stomach when the tube was placed. Consequently, while entering the stomach, the gastroenterologists inadvertently passed through the colon. Over time, a fistula formed between the stomach and the adjacent bowel (through which the tube passed during insertion); ultimately, the tube migrated back into the colon, which meant that the feedings were bypassing the entire digestive apparatus of the small intestine.
After the error was recognized, another tube was placed in the stomach and the previously placed tube was removed. However, the delay in identifying the problem resulted in sustained inadequate nutrition and significant decompensation.
1. Gauderer MW. Twenty years of percutaneous endoscopic gastrostomy: origin and evolution of a concept and its expanded applications. Gastrointest Endosc. 1999;50:879-883. [go to PubMed]
2. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27:355-373. [go to PubMed]
3. Löser C, Aschl G, Hébuterne X, et al. ESPEN guidelines on artificial enteral nutrition—percutaneous endoscopic gastrostomy (PEG). Clin Nutr. 2005;24:848-861. [go to PubMed]
4. Byrne KR, Fang JC. Endoscopic placement of enteral feeding catheters. Curr Opin Gastroenterol. 2006;22:546-550. [go to PubMed]
5. Jain R, Maple JT, Anderson MA, et al; ASGE Standards of Practice Committee. The role of endoscopy in enteral feeding. Gastrointest Endosc. 2011;74:7-12. [go to PubMed]
6. Figueiredo FAF, da Costa MC, Pelosi AD, Martins RN, Machado L, Francioni E. Predicting outcomes and complications of percutaneous endoscopic gastrostomy. Endoscopy. 2007;39:333-338. [go to PubMed]
7. Gomes CAR Jr., Lustosa SAS, Matos D, Andriolo RB, Waisberg DR, Waisberg J. Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances. Cochrane Database Syst Rev. 2010;11:CD008096. [go to PubMed]
8. Freeman C, Ricevuto A, DeLegge MH. Enteral nutrition in patients with dementia and stroke. Curr Opin Gastroenterol. 2010;26:156-159. [go to PubMed]
9. Schurink CAM, Tuynman H, Scholten P, et al. Percutaneous endoscopic gastrostomy: complications and suggestions to avoid them. Eur J Gastroenterol Hepatol. 2001;13:819-823. [go to PubMed]
10. Kurien M, McAlindon ME, Westaby D, Sanders DS. Percutaneous endoscopic gastrostomy (PEG) feeding. BMJ. 2010;340:c2414. [go to PubMed]
11. Richter-Schrag HJ, Richter S, Ruthmann O, Olschewski M, Hopt UT, Fischer A. Risk factors and complications following percutaneous endoscopic gastrostomy: a case series of 1041 patient. Can J Gastroenterol. 2011;25:201-206. [go to PubMed]
12. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis. 2007;16:407-418. [go to PubMed]
13. Foutch PG, Talbert GA, Waring JP, Sanowski RA. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract. Am J Gastroenterol. 1988;83:147-150. [go to PubMed]
14. Friedmann R, Feldman H, Sonnenblick M. Misplacement of percutaneously inserted gastrostomy tube into the colon: report of 6 cases and review of the literature. JPEN J Parenter Enteral Nutr. 2007;31:469-476. [go to PubMed]
15. Zopf Y, Maiss J, Konturek P, Rabe C, Hahn EG, Schwab D. Predictive factors of mortality after PEG insertion: guidance for clinical practice. JPEN J Parenter Enteral Nutr. 2011;35:50-55. [go to PubMed]
16. Potack JZ, Chokhavatia S. Complications of and controversies associated with percutaneous endoscopic gastrostomy: report of a case and literature review. Medscape J Med. 2008;10:142. [go to PubMed]