CASE REPORT gastrostomy tube; small bowel obstruction
Gastrostomy Tube Transmigration: A Rare Cause of Small Bowel Obstruction A 77-year-old woman with an indwelling gastrostomy tube presented with a clinical picture of pneumonia and small bowel obstruction. During gastrostomy closure and performance of a feeding jejunostomy, inadvertent transmigration of the gastrostomy tube was found to be the etiology of the small intestinal obstruction. This case illustrates a rare complication of enteric feeding tubes. [O'Dell KB, Gordon RS, Becker LB: Gastrostomy tube transmigration: A rare cause of small bowel obstruction. Ann Emerg Med July 1991;20:817-819.]
INTRODUCTION Gastrostomy tube enteric feeding is a common method of nutritional maintenance in elderly patients with deglutition abnormalities due to neuromuscular diseases, organic brain syndrome, or malignancies of the oropharynx and esophagusA -3 The emergency physician is often called on to replace gastrostomy tubes despite the fact that this procedure is not without complications. The rare complication of antegrade transmigration of a gastrostomy tube causing distal small intestinal obstruction is demonstrated. CASE REPORT A 77-year-old w o m a n presented to the emergency department from a long-term care facility with the chief complaints of fever and difficulty with gastrostomy tube feedings. She had a history of chronic malnutrition, organic brain syndrome, and intestinal obstruction from perforated diverticulitis. Extreme difficulty in maintaining adequate oral nutrition led to the performance of a permanent gastrostomy with the insertion of a 16F Foley catheter. Before the present admission, she had multiple bouts of gastric outlet obstruction relieved by catheter repositioning. Physical examination revealed a thin woman in minimal distress. Blood pressure was 144/84 m m Hg in both arms; pulse, ll6; oral temperature, 38.0 C; and respirations, 20. The neck was supple, and the pharynx, tympanic membranes, and sclera were unremarkable. The lung examination revealed left lower lobe rhonchi. Abdominal examination revealed mild diffuse tenderness with slight distension without rebound, rigidity, or guarding. Bowel sounds were slightly hyperactive. The gastrostomy stoma was intact with no signs of infection. No abnormal pulsations or masses were appreciated. The stool was guaiac negative. Cardiovascular examination revealed a regular tachycardic rate and rhythm without m u r m u r or gallop. The patient was confused and disoriented, with the remainder of the neurologic examination being normal. Peripheral pulses were bounding and equal. A portable chest radiograph revealed obliteration of the left hemidiaphragm consistent with a left lower lobe pneumonia. The upright abdominal film showed the multiple air-fluid levels suggestive of small bowel obstruction. The ECG showed sinus tachycardia without ischemic changes or evidence of prior infarction. Arterial blood gas on room air was pH of 7.40; Pcoz, 28 m m Hg; and Poz, 70 m m Hg. Other laboratory results included hemoglobin of 12.9 g/dL; hematocrit, 38%; leukocyte count, 20, 100/mm3 with 15% bands; platelets, 201,000/mm3; serum sodium, 132 mEq/L; potassium, 3.2 mEq/L;
20:7 July 1991
Annals of Emergency Medicine
Kevin B O'Dell, MD* Ronald S Gordon, MD* Charlotte, North Carolina Lance B Becket, MDt Chicago, Illinois From the Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina;* and the Section of Emergency Medicine, Department of Medicine, University of Chicago Hospitals.t Received for publication May 14, 1990. Revision received November 7, 1990. Accepted for publication February 22, 1991. Address for reprints: Kevin B O'Dell, MD, Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, North Carolina 28232-2861.
817/165
TUBE TRANSMIGRATION O'Dell, Gordon & Becker
FIGURE 1. Palpation of distal jejunal intralurninal gastrostomy tube. FIGURE 2. Intraluminal catheter being delivered through the jejunotomy. chloride, 98 mEq/L; CO2, 21 m m Hg; glucose, 108 mg/dL; blood urea nitrogen, 22 mg/dL; creatinine, 1.5 mg %; and amylase, 120 dye units/dL. T h e p a t i e n t was a d m i t t e d and placed on a ten-day course of IV cefuroxime with resolution of the lobar p n e u m o n i a . The i n c o m p l e t e bowel obstruction, however, failed to resolve. D e c o m p r e s s i o n w i t h both n a s o g a s t r i c and i n t e s t i n a l t u b e s yielded only temporary relief. Serial plain abdominal radiographs failed to demonstrate complete intestinal obstruction. Upper gastric radiography w i t h b a r i u m r e v e a l e d no gastric lesions or proximal obstruction. Due to stomal problems, the gast r o s t o m y was closed and a simultaneous feeding jejunostomy was performed. During the jejunostomy, a firm tube was palpated inside the jej u n u m distal to the l i g a m e n t of Treitz. This was thought at first to be the nasogastric tube, but a tube rem a i n e d after the nasogastric tube was withdrawn (Figure 1). Further palpation revealed the typical " Y " shape of a Foley catheter. The catheter could not be moved and a small j e j u n o t o m y was p e r f o r m e d for removal (Figure 2). The catheter's balloon proved to be inflated with 15 mL of fluid. Changes consistent with chronic, partial small bowel obstruction were present in the j e j u n u m proximal to the catheter. The jejunotomy then was used to construct a typical Witzel jejunostomy. The pa166/818
tient had an unremarkable postoperative course. The actual circumstances of the precedent events leading to the transmigration could not be determined. It was m o s t probable that the patient's feeding gastrostomy tube was noted to be missing and assumed to have been removed by the patient during an episode of agitated confusion. DISCUSSION Gastrostomy is among the oldest gastric procedures, with a complication rate of 10% to 35%. 4.6 Infants and newborns are at higher risk for c o m p l i c a t i o n s t h a n are adults.67 Gastric ulceration and hemorrhage have been seen in several studies and thought to be secondary to stress ulcerations or m e c h a n i c a l pressure. Gastric obstruction is another comm o n complication due to distal prol a p s e i n t o t h e p y l o r u s or d u o denum. 6-9 Gastric torsion and retrograde migration into the esophagus have resulted in mortalities, lo Retrograde intussusception has been reported in the newborn and geriatric age groups and is thought to be due to u n m o n i t o r e d rapid t u b e w i t h drawal.6,9 Antegrade migration of a gastrostomy tube has been described in all age groups and is due to peristalsis against the catheter balloon as well as i n a d e q u a t e external tube fixation.6-s, 1°-12 These patients experience symptoms of gastric outlet obstruction and poorly tolerated gastrostomy tube feedings. Ampulla of Vater compression with resultant obs t r u c t i v e j a u n d i c e also has b e e n reported.1 Gastrostomy tube transmigration through a gastric stoma resulting in Annals of Emergency Medicine
small bowel obstruction has been reported previously in only a single case.t3 It was treated by percutaneous transabdominal balloon puncture under fluoroscopic control with subs e q u e n t passage of the c a t h e t e r . T r a n s m i g r a t i o n w i t h tube passage through the rectum also has been reported, t4 In this case of g a s t r o s t o m y tube transmigration, the nature of the obstructing object made preoperative diagnosis very difficult and was the cause of significant delay in operative intervention. Retrospective review of all preoperative radiographs failed to reveal the presence of the catheter. It is suggested that catheters used in feeding gastrostomies be manufactured with a radiopaque line to allow for easier ascertainment of their location.
SUMMARY A rare case of small bowel obstruction secondary to transmigration of a f e e d i n g g a s t r o s t o m y t u b e is described. The e m e r g e n c y p h y s i c i a n m u s t be aware of the multitude of complications of feeding gastrostomies, especially as the geriatric population requiring er~teric nutritional support increases. C l i n i c a l l y suspected gastrostomy-related obstruction can be evaluated by plain film radiography, contrast tube injections, and contrast upper gastrointestinal and small bowel follow-through examinations. REFERENCES 1. Pomerantz MA, Saloman J, Dunn R: Permanent gastrostomy as a solution to some nutritional problems in the elderly. J A m Geriatr Soc 1980;28:104-107. 2. Engel S: Gastrostomy. Surg Clin North A m 1969; 49:1289-1295. 3. Rata SD, Portin BA, Bemhoft WH: Experience with gastrostomy for postoperative gastric decompression. Dis Colon Rectum 1974;17:480-481.
20:7 July 1991
TUBE TRANSMIGRATION O'Dell, Gordon & Becker
4. Gallagher MW, Tyson KT, Asheraft KW: Gastrostomy in pediatric patients: An analysis of complications and techniques. Surgery 1973~74:536-539. 5. Campbell TR, Saski TM: Gastrostomy in infants and children: An analysis of complications and techniques. A m Surg 1974;40:505~508. 6. Haws EB, Sieber WK, Kieswelter WB: Complications of tube gastrostomy in infants and children: 15 year review of 240 eases. Ann Surg 1966;164:204-209. 7. Conner RG r Scaly TM: Gastrostomy and its compli-
20:7: July 1991
cations. Ann Surg 1956;143:245-250.
tomy tube migration. A m Surg 1973;39:122-123.
8. Vazquez RM, Goldin M, Economou SG: Gastric ob struction from gastrostomy tube. IIIinois Med J 1970; I37:357-359.
12. Gustarson S, Klingen G: Obstructive complications of Foley catheter gastrostomy. Acta Chir Scand 1978; 144:325-327.
9. Hopens T, Schwesinger WH: Complications of tube gastrostomy: Radiologic manifestations. S Med J i983; 76:9-12.
13. Handler E, Naimark A: Percutaneous treatment of small bowel obstruction due to a gastrostomy. J Can Assoc Rad 1984;35:401-403.
10. Currarino G, Votteler T: Prolapse of the gastrostomy catheter in children. AJR 1975;123:737-741. ll. Sherman ML, Cosgrove MJ, Dennis JM: Gastros-
Annals of Emergency Medicine
14. Wold EL, Frager D, Baneventano TC: Radiologic demonstration of important gastrostomy tube complica~ tions. Gastrointest Radioi 1986;11:20-26.
819/167
Gastrostomy Tube Transmigration: A Rare Cause of Small Bowel Obstruction A 77-year-old woman with an indwelling gastrostomy tube presented with a clinical picture of pneumonia and small bowel obstruction. During gastrostomy closure and performance of a feeding jejunostomy, inadvertent transmigration of the gastrostomy tube was found to be the etiology of the small intestinal obstruction. This case illustrates a rare complication of enteric feeding tubes. [O'Dell KB, Gordon RS, Becker LB: Gastrostomy tube transmigration: A rare cause of small bowel obstruction. Ann Emerg Med July 1991;20:817-819.]
INTRODUCTION Gastrostomy tube enteric feeding is a common method of nutritional maintenance in elderly patients with deglutition abnormalities due to neuromuscular diseases, organic brain syndrome, or malignancies of the oropharynx and esophagusA -3 The emergency physician is often called on to replace gastrostomy tubes despite the fact that this procedure is not without complications. The rare complication of antegrade transmigration of a gastrostomy tube causing distal small intestinal obstruction is demonstrated. CASE REPORT A 77-year-old w o m a n presented to the emergency department from a long-term care facility with the chief complaints of fever and difficulty with gastrostomy tube feedings. She had a history of chronic malnutrition, organic brain syndrome, and intestinal obstruction from perforated diverticulitis. Extreme difficulty in maintaining adequate oral nutrition led to the performance of a permanent gastrostomy with the insertion of a 16F Foley catheter. Before the present admission, she had multiple bouts of gastric outlet obstruction relieved by catheter repositioning. Physical examination revealed a thin woman in minimal distress. Blood pressure was 144/84 m m Hg in both arms; pulse, ll6; oral temperature, 38.0 C; and respirations, 20. The neck was supple, and the pharynx, tympanic membranes, and sclera were unremarkable. The lung examination revealed left lower lobe rhonchi. Abdominal examination revealed mild diffuse tenderness with slight distension without rebound, rigidity, or guarding. Bowel sounds were slightly hyperactive. The gastrostomy stoma was intact with no signs of infection. No abnormal pulsations or masses were appreciated. The stool was guaiac negative. Cardiovascular examination revealed a regular tachycardic rate and rhythm without m u r m u r or gallop. The patient was confused and disoriented, with the remainder of the neurologic examination being normal. Peripheral pulses were bounding and equal. A portable chest radiograph revealed obliteration of the left hemidiaphragm consistent with a left lower lobe pneumonia. The upright abdominal film showed the multiple air-fluid levels suggestive of small bowel obstruction. The ECG showed sinus tachycardia without ischemic changes or evidence of prior infarction. Arterial blood gas on room air was pH of 7.40; Pcoz, 28 m m Hg; and Poz, 70 m m Hg. Other laboratory results included hemoglobin of 12.9 g/dL; hematocrit, 38%; leukocyte count, 20, 100/mm3 with 15% bands; platelets, 201,000/mm3; serum sodium, 132 mEq/L; potassium, 3.2 mEq/L;
20:7 July 1991
Annals of Emergency Medicine
Kevin B O'Dell, MD* Ronald S Gordon, MD* Charlotte, North Carolina Lance B Becket, MDt Chicago, Illinois From the Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina;* and the Section of Emergency Medicine, Department of Medicine, University of Chicago Hospitals.t Received for publication May 14, 1990. Revision received November 7, 1990. Accepted for publication February 22, 1991. Address for reprints: Kevin B O'Dell, MD, Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, North Carolina 28232-2861.
817/165
TUBE TRANSMIGRATION O'Dell, Gordon & Becker
FIGURE 1. Palpation of distal jejunal intralurninal gastrostomy tube. FIGURE 2. Intraluminal catheter being delivered through the jejunotomy. chloride, 98 mEq/L; CO2, 21 m m Hg; glucose, 108 mg/dL; blood urea nitrogen, 22 mg/dL; creatinine, 1.5 mg %; and amylase, 120 dye units/dL. T h e p a t i e n t was a d m i t t e d and placed on a ten-day course of IV cefuroxime with resolution of the lobar p n e u m o n i a . The i n c o m p l e t e bowel obstruction, however, failed to resolve. D e c o m p r e s s i o n w i t h both n a s o g a s t r i c and i n t e s t i n a l t u b e s yielded only temporary relief. Serial plain abdominal radiographs failed to demonstrate complete intestinal obstruction. Upper gastric radiography w i t h b a r i u m r e v e a l e d no gastric lesions or proximal obstruction. Due to stomal problems, the gast r o s t o m y was closed and a simultaneous feeding jejunostomy was performed. During the jejunostomy, a firm tube was palpated inside the jej u n u m distal to the l i g a m e n t of Treitz. This was thought at first to be the nasogastric tube, but a tube rem a i n e d after the nasogastric tube was withdrawn (Figure 1). Further palpation revealed the typical " Y " shape of a Foley catheter. The catheter could not be moved and a small j e j u n o t o m y was p e r f o r m e d for removal (Figure 2). The catheter's balloon proved to be inflated with 15 mL of fluid. Changes consistent with chronic, partial small bowel obstruction were present in the j e j u n u m proximal to the catheter. The jejunotomy then was used to construct a typical Witzel jejunostomy. The pa166/818
tient had an unremarkable postoperative course. The actual circumstances of the precedent events leading to the transmigration could not be determined. It was m o s t probable that the patient's feeding gastrostomy tube was noted to be missing and assumed to have been removed by the patient during an episode of agitated confusion. DISCUSSION Gastrostomy is among the oldest gastric procedures, with a complication rate of 10% to 35%. 4.6 Infants and newborns are at higher risk for c o m p l i c a t i o n s t h a n are adults.67 Gastric ulceration and hemorrhage have been seen in several studies and thought to be secondary to stress ulcerations or m e c h a n i c a l pressure. Gastric obstruction is another comm o n complication due to distal prol a p s e i n t o t h e p y l o r u s or d u o denum. 6-9 Gastric torsion and retrograde migration into the esophagus have resulted in mortalities, lo Retrograde intussusception has been reported in the newborn and geriatric age groups and is thought to be due to u n m o n i t o r e d rapid t u b e w i t h drawal.6,9 Antegrade migration of a gastrostomy tube has been described in all age groups and is due to peristalsis against the catheter balloon as well as i n a d e q u a t e external tube fixation.6-s, 1°-12 These patients experience symptoms of gastric outlet obstruction and poorly tolerated gastrostomy tube feedings. Ampulla of Vater compression with resultant obs t r u c t i v e j a u n d i c e also has b e e n reported.1 Gastrostomy tube transmigration through a gastric stoma resulting in Annals of Emergency Medicine
small bowel obstruction has been reported previously in only a single case.t3 It was treated by percutaneous transabdominal balloon puncture under fluoroscopic control with subs e q u e n t passage of the c a t h e t e r . T r a n s m i g r a t i o n w i t h tube passage through the rectum also has been reported, t4 In this case of g a s t r o s t o m y tube transmigration, the nature of the obstructing object made preoperative diagnosis very difficult and was the cause of significant delay in operative intervention. Retrospective review of all preoperative radiographs failed to reveal the presence of the catheter. It is suggested that catheters used in feeding gastrostomies be manufactured with a radiopaque line to allow for easier ascertainment of their location.
SUMMARY A rare case of small bowel obstruction secondary to transmigration of a f e e d i n g g a s t r o s t o m y t u b e is described. The e m e r g e n c y p h y s i c i a n m u s t be aware of the multitude of complications of feeding gastrostomies, especially as the geriatric population requiring er~teric nutritional support increases. C l i n i c a l l y suspected gastrostomy-related obstruction can be evaluated by plain film radiography, contrast tube injections, and contrast upper gastrointestinal and small bowel follow-through examinations. REFERENCES 1. Pomerantz MA, Saloman J, Dunn R: Permanent gastrostomy as a solution to some nutritional problems in the elderly. J A m Geriatr Soc 1980;28:104-107. 2. Engel S: Gastrostomy. Surg Clin North A m 1969; 49:1289-1295. 3. Rata SD, Portin BA, Bemhoft WH: Experience with gastrostomy for postoperative gastric decompression. Dis Colon Rectum 1974;17:480-481.
20:7 July 1991
TUBE TRANSMIGRATION O'Dell, Gordon & Becker
4. Gallagher MW, Tyson KT, Asheraft KW: Gastrostomy in pediatric patients: An analysis of complications and techniques. Surgery 1973~74:536-539. 5. Campbell TR, Saski TM: Gastrostomy in infants and children: An analysis of complications and techniques. A m Surg 1974;40:505~508. 6. Haws EB, Sieber WK, Kieswelter WB: Complications of tube gastrostomy in infants and children: 15 year review of 240 eases. Ann Surg 1966;164:204-209. 7. Conner RG r Scaly TM: Gastrostomy and its compli-
20:7: July 1991
cations. Ann Surg 1956;143:245-250.
tomy tube migration. A m Surg 1973;39:122-123.
8. Vazquez RM, Goldin M, Economou SG: Gastric ob struction from gastrostomy tube. IIIinois Med J 1970; I37:357-359.
12. Gustarson S, Klingen G: Obstructive complications of Foley catheter gastrostomy. Acta Chir Scand 1978; 144:325-327.
9. Hopens T, Schwesinger WH: Complications of tube gastrostomy: Radiologic manifestations. S Med J i983; 76:9-12.
13. Handler E, Naimark A: Percutaneous treatment of small bowel obstruction due to a gastrostomy. J Can Assoc Rad 1984;35:401-403.
10. Currarino G, Votteler T: Prolapse of the gastrostomy catheter in children. AJR 1975;123:737-741. ll. Sherman ML, Cosgrove MJ, Dennis JM: Gastros-
Annals of Emergency Medicine
14. Wold EL, Frager D, Baneventano TC: Radiologic demonstration of important gastrostomy tube complica~ tions. Gastrointest Radioi 1986;11:20-26.
819/167
