There are various recognised complications of PEG tube insertion, including wound infection, tube migration, aspiration, gastric haemorrhage, stomal leak, ileus and bowel injury.3
In fact, 3–8% of patients having PEG placements will experience a major complication while 14–23% experience a minor complication.1 2
Malposition of PEG is a serious complication and can occur at the time of insertion or chronically.4
It is thought to happen chronically if the PEG is pulled too tightly and subsequently erodes through the gastric wall or can occur when the tube is changed if it has been sited through the bowel at time of insertion. The site of malposition can be through the small bowel or colon. These patients often present with transient diarrhoea after PEG feeding.5
Faecal material may be seen in the PEG tube when it is left on free drainage and faecalent vomiting may occur due to passage of faeces from the colon to the stomach through the gastrocolic fistula.6
Most of these patients are discovered late especially at the time of a PEG tube change.
Iatrogenic bowel injury during PEG insertion is more commonly seen in older or very young patients as the colonic mesentery is lax. Excessive insufflation of air into the stomach during the procedure is thought to cause gastric rotation, which can pull the transverse colon to the stomach.7
If the tube passes through the bowel and is pulled tight the patient may remain asymptomatic until the time of tube replacement.
A small amount of pneumoperitoneum after PEG insertion is usually considered as a benign finding. In our case, the patient had a significant pneumoperitoneum (>2 cm)3
and further investigations were performed to determine its nature. Most PEG insertions do not result in pneumoperitoneum but in as much as 38% of cases8
there will be pneumoperitoneum. This will be a benign finding in the majority of these cases but further investigations are warranted if free air (no matter how small) fails to resolve within 72 h of the PEG insertion. We believe that the incidence of malposition of PEG is under-reported due to the reluctance to investigate small pneumoperitoneum early in the course of management.
Diagnosis of bowel injury secondary to PEG tube insertion can be a diagnostic challenge. The PEG tube candidates usually have altered levels of consciousness, communication problems and tend to be malnourished. The early signs of bowel injury, such as pain and tenderness, are easily missed in these frail patients. Therefore, it is reasonable to have a low threshold for further investigations in patients who develop pneumoperitoneum after a PEG tube insertion to look for iatrogenic bowel injury.
- There should be a low threshold for further investigations looking for iatrogenic bowel injury as a small post-procedural pneumoperitoneum could be the only finding in these fragile patients.