Rare Long Term Complication of “Push” Introducing Technique for PEG Tube Insertion
Bibliographic record
Abstract
Purpose: PEG tube insertion can be accomplished by a “pull” (Ponsky) or “push” (Russell) techniques. The Ponsky technique has dominated clinical practice today, however, many tubes, especially for head & neck cancers are still inserted with the Russell technique. Hemorrhagic complications of PEG tube placement and removal are relatively low, estimated at 2.5% in large series. We present a case of a 58 year old man seen urgently in the ER for melena. He has liver cirrhosis from alcohol and Hepatitis C with portal hypertension and has a Levine shunt. He is on Warfarin for DVT and has chronic renal failure. He had esophageal cancer resected 15 years ago, and during that time had a temporary gastrostomy tube. Our patient was well until two days prior to admission when he started having melena stool. He denied any epigastric pain, nausea/vomiting, shortness of breath, or rectal bleeding. He was feeling dizzy and had presyncopal symptoms without loss of consciousness. On examination, he was alert and oriented with no cyanosis, jaundice, clubbing, carotid bruits, or lower limb edema. Blood pressure was 92/60 mmHg and pulse 112/minute and afebrile. Abdomen was soft, no organomegaly and no ascites. No melena or stool was seen on rectal examination. Labs show an INR 11, Hg 3.2 g/dL, platelets 170,000, and creatinine 2.15 mg/dL. The patient was admitted to the CCU and started on Octreotide and Pantoloc® infusions with concern that the bleeding was variceal. Octaplex® was given to reverse his INR, and DDAVP given for his platelet dysfunction, after which he had urgent gastroscopy. The esophagus was completely normal, a small fundal varix was seen in the stomach, and no active bleeding was identified. However, in the body of the stomach, a metallic spring attached to a suture going through the wall was seen with some adjacent ulceration, thought to be the cause of melena. Explanation for the findings in the stomach and what to do about them were unclear. Surgical opinion was not helpful initially, however, another senior surgeon later identified the metallic spring as a likely remnant from the introducer used for PEG placement with the Russell “push” technique. The patient underwent a second endoscopy to remove the spring and release the suture. This is the first case report we are aware of, with a gastric bleed caused by a retained introducer apparatus many years after the PEG was removed. The “Russell introducer” method involves direct puncture of an endoscopically insufflated stomach. Introducer and outer peel-away sheaths are inserted over which the gastrostomy tube is pushed. The case highlights a rare complication of this technique, and suggests care should be taken when PEG is removed.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.005 |
| Meta-epidemiology (narrow) | 0.001 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.002 | 0.001 |
| Scholarly communication | 0.001 | 0.002 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.003 | 0.003 |
| Insufficient payload (model declined to judge) | 0.003 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".