Clin Endosc.  2018 Jan;51(1):99-102. 10.5946/ce.2017.035.

Management of Percutaneous Endoscopic Gastrostomy Site Gastric Ulcer in a Patient with an Esophageal Stricture and Hiatus Hernia

Affiliations
  • 1Department of Gastroenterology and Hepatology,Changi General Hospital, Singapore. james.li@mohh.com.sg
  • 2Department of Diagnostic Radiology, Changi General Hospital, Singapore.

Abstract

Percutaneous endoscopic gastrostomy (PEG) is commonly performed for feeding difficulties, in patients suffering from complications of nasopharyngeal carcinoma and its treatment, namely radiotherapy and surgery. This case report describes the challenges in hemostasis and subsequent re-establishment of enteral access for feeding, in an elderly patient with a history of NPC, treated surgically, followed by radiotherapy, who presented with massive hematemesis following reinsertion of her PEG shortly after an accidental dislodgement. Her previous nasopharyngectomy, wide field radiation therapy, and radical neck dissection precluded nasogastric tube feeding, and the presence of a large hiatus hernia made reinsertion of a new PEG technically challenging. This case highlights the methods used to overcome the above challenges.

Keyword

Gastrostomy; Intubation, gastrointestinal; Hernia, hiatal; Ulcer; Enteral nutrition

MeSH Terms

Aged
Enteral Nutrition
Esophageal Stenosis*
Gastrostomy*
Hematemesis
Hemostasis
Hernia, Hiatal*
Humans
Intubation, Gastrointestinal
Neck Dissection
Radiotherapy
Stomach Ulcer*
Ulcer

Figure

  • Fig. 1. Gastroscopic view showing Forrest IIb ulcer located at the antrum opposite the tip of the percutaneous endoscopic gastrostomy tube.

  • Fig. 2. Retroflex view on gastroscopy demonstrating tight gastric space secondary to hiatus hernia, with most of the corpus located above the diaphragm.

  • Fig. 3. Stomach insufflation via existing the percutaneous endoscopic gastrostomy tube prior to tube change. The gastric fundus and most of the corpus is located within the intrathoracic space.

  • Fig. 4. An interim 20-Fr low profile percutaneous endoscopic gastrostomy tube was inserted via the existing tract, with the tip placed in the duodenum.

  • Fig. 5. A new 20-Fr percutaneous endoscopic gastrostomy tube was inserted at a different anatomical site under fluoroscopic guidance.


Reference

1. Wei WI, Sham JS. Nasopharyngeal carcinoma. Lancet. 2005; 365:2041–2054.
Article
2. Lee AW, Sze WM, Au JS, et al. Treatment results for nasopharyngeal carcinoma in the modern era: the Hong Kong experience. Int J Radiat Oncol Biol Phys. 2005; 61:1107–1116.
Article
3. Tham IW, Hee SW, Yeo RM, et al. Treatment of nasopharyngeal carcinoma using intensity-modulated radiotherapy-the national cancer centre Singapore experience. Int J Radiat Oncol Biol Phys. 2009; 75:1481–1486.
Article
4. Yen TT, Lin CH, Jiang RS, Shih YT, Yen HR, Liang KL. Incidence of late-onset pneumonia in patients after treatment with radiotherapy for nasopharyngeal carcinoma: a nationwide population-based study. Head Neck. 2015; 37:1756–1761.
Article
5. Luman W, Kwek KR, Loi KL, Chiam MA, Cheung WK, Ng HS. Percutaneous endoscopic gastrostomy--indications and outcome of our experience at the Singapore general hospital. Singapore Med J. 2001; 42:460–465.
6. Hede GW, Faxén-Irving G, Olin AÖ, Ebbeskog B, Crisby M. Nutritional assessment and post-procedural complications in older stroke patients after insertion of percutaneous endoscopic gastrostomy - a retrospective study. Food Nutr Res. 2016; 60:30456.
Article
7. Delatore J, Boylan JJ. Bleeding gastric ulcer: a complication from gastrostomy tube replacement. Gastrointest Endosc. 2000; 51(4 Pt 1):482–484.
Article
8. Kanie J, Akatsu H, Suzuki Y, Shimokata H, Iguchi A. Mechanism of the development of gastric ulcer after percutaneous endoscopic gastrostomy. Endoscopy. 2002; 34:480–482.
Article
9. Chong C, Derigo L, Brown D. Massive gastric bleeding: a rarely seen subacute complication of percutaneous endoscopic gastrostomy. Intern Med J. 2007; 37:787–788.
Article
10. Wiener GJ. Complication caused by the tip of gastrostomy tubes and foley catheters. Am J Gastroenterol. 1999; 94:3656–3657.
Article
11. Nishiguchi Y, Fuyuhiro Y, Lee JT, et al. Percutaneous endoscopic gastrostomy, duodenostomy and jejunostomy. Diagn Ther Endosc. 1994; 1:37–43.
Article
12. Spiegelman G, Goldberg RI. Gastric ulceration following PEG replacement. Gastrointest Endosc. 1992; 38:397–398.
Article
13. Mahadeva S, Chua CJ, Malik A, Chin KT, Jeyasingam R. Iatrogenic gastric ulceration in patients with percutaneous endoscopic gastrostomy feeding. Intern Med J. 2007; 37:732–733.
Article
14. Xenos ES. Percutaneous endoscopic gastrostomy in a patient with a large hiatal hernia using laparoscopy. JSLS. 2000; 4:231–233.
15. Ulla JL, Alvarez V, Carpio D, Ledo L, Vázquez-Sanluis J, Vázquez-Astray E. Upper gastrointestinal bleeding in a patient with a balloon bumper PEG feeding tube. Surg Laparosc Endosc Percutan Tech. 2005; 15:94.
Article
Full Text Links
  • CE
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr