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Case Report |
1 Department of Radiology, Hospital of the University of Pennsylvania, 3400
Spruce Street, Philadelphia, PA 19104.
2 Department of Surgery, Hospital of the University of Pennsylvania,
Philadelphia, PA.
Received April 29, 2004;
accepted after revision May 18, 2004.
Address correspondence to M. S. Levine
(marc.levine{at}uphs.upenn.edu).
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The patient was referred to our department, and injection of the PEG tube with water-soluble contrast material (diatrizoate meglumine and diatrizoate sodium [Gastroview]; Mallinckrodt) showed the tip of the tube in the lumen of the distal transverse colon with antegrade colonic filling to the splenic flexure and retrograde filling of the proximal transverse colon. A thin track that extended superiorly from the transverse colon at the site of the PEG tube to the gastric fundus was opacified, with a tiny amount of contrast material entering the lumen of the fundus, indicating the presence of a gastrocolic fistula (Figs. 1A, 1B). No contrast material entered the peritoneal cavity, and the patient had no clinical signs of peritonitis.
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The PEG tube was withdrawn from the transverse colon through the anterior abdominal wall without complication. The patient was electively taken to the operating room, and a standard Stamm gastrostomy tube was placed uneventfully. No colonic repair was required. After a short postoperative recovery, the patient had no further difficulty with enteral feedings via the new gastrostomy tube.
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Although a gastrocolic fistula may form at the time of PEG tube placement, affected individuals usually remain asymptomatic for several months until the PEG tube migrates into the transverse colon or until the tube is replaced [7]. One patient developed symptoms 9 months after the original PEG tube placement [8]. Once the tube lodges in the transverse colon, patients typically present with a sudden onset of transient diarrhea within minutes after PEG tube feedings, with the passage of undigested feeding formula per rectum, as in our patient [3, 4, 7]. Other patients may observe fecal material in the PEG tube or may present with foul-smelling eructations or feculent vomiting resulting from retrograde passage of fecal material from the colon into the stomach via the gastrocolic fistula [4, 6, 7]. Such a constellation of clinical findings should suggest this complication in patients with PEG tubes.
When migration of a PEG tube into the transverse colon is suspected on clinical grounds, a radiographic study can be performed by administering water-soluble contrast material via the tube to confirm this finding [3, 5-8] (Figs. 1A, 1B). In some patients, the radiographic study may also delineate a gastrocolic fistula, as in our case. In others, a fistula may not be visualized if the track to the stomach has largely healed or resolved [4]. In such cases, a barium enema or water-soluble contrast enema can be used to show a gastrocolic fistula not visualized by injection of contrast material into the PEG tube because of the greater pressures generated by this procedure [4].
When a PEG tube has migrated into the transverse colon via a gastrocolic fistula, an emergent laparotomy is indicated only if there is associated peritonitis [7]. In most cases, however, the tube can be removed without the need for surgery, and the residual track to the skin closes within several days [7]. If a new feeding tube is required, another percutaneous gastrostomy tube can be placed surgically, and, if necessary, a residual gastrocolic fistula can be excised at the time of surgery.
In conclusion, radiologists should be aware that migration of a PEG tube into the transverse colon via a gastrocolic fistula may occasionally occur as a complication of PEG tube placement. This complication should be considered when patients with PEG tubes develop a sudden onset of transient diarrhea immediately after PEG tube feedings. In such cases, water-soluble contrast material may be administered via the tube to determine if it has migrated into the transverse colon and if a gastrocolic fistula is present.
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