A245 TRANSHEPATIC PEG-TUBE INSERTION: A CASE REPORT AND REVIEW OF THE LITERATURE

Minor complications of percutaneous endoscopic gastrostomy (PEG) tube insertion include infection, peristomal leakage, tube obstruction and transient ileus. Major complications such as bowel perforation, fistulae, bowel obstruction and buried bumper syndrome may require surgical intervention. To describe an infrequent but serious complication of PEG tube placement. A case report and review of the literature were performed. Case report A 50-year-old man presented with severe acute respiratory distress syndrome from adenovirus pneumonia. He required venovenous extracorporeal membranous oxygenation (VV-ECMO). Treatment with intravenous immune globulin and brincidofovir allowed for weaning off VV-ECMO. Given inability to wean from ventilator, tracheostomy and PEG tube insertion were performed. During PEG tube insertion, 1:1 finger movement was visualized, however transillumination was not seen. Lidocaine was infiltrated and then seeker needle and guidewire were passed. The guidewire was grasped endoscopically and brought out to mouth, where the PEG tube was attached and inserted orally to the skin in a single pass. Eight days post-PEG insertion, the patient developed abdominal pain and his hemoglobin decreased. CT angiography revealed thigh hemorrhage (patient was anticoagulated for heparin induced thrombocytopenia). PEG tube was incidentally visualized passing through the lateral tip of the left lobe of the liver, without signs of intra-abdominal bleeding. A surgical consultation was obtained but no intervention was required. The patient’s swallowing progressively improved, and the PEG tube was removed after six months of use. The external tube was cut and discarded. The internal bumper was then snared and removed endoscopically. Literature review Transhepatic PEG tube insertion presents as abdominal pain post-procedure. It is often diagnosed by CT but can be diagnosed by fluoroscopy or ultrasound. Laparotomy and surgical repair have been required to manage major complications such as massive hemorrhage. This may present clinically as bleeding via the PEG tube. Fluoroscopy has also identified PEG tube in continuity with the portal venous system. In order to remove a transhepatic PEG tube in the absence of indication for surgery, the external portion of the PEG should be cut, the internal bumper should be snared and removed endoscopically to prevent transhepatic passage of the bumper. Transhepatic placement is an infrequent but serious complication of PEG tube insertion. Relying on transillumination and 1:1 finger movement potentially decreases this complication. Surgical consultation should be obtained as laparotomy may be required in the context of intraabdominal hemorrhage. When removing a transhepatic PEG tube, the internal bumper should be retrieved endoscopically. CT revealing transhepatic PEG tube None

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