We describe a 9 year-old Caucasian girl with a complex background of premature birth, cerebral palsy, spastic quadriplegia, generalised dystonia and visual impairment who developed a gastro-colonic fistula following Vygon Mic-Key button change.
She first presented to our Emergency Department (ED) with a 3 weeks-history of watery diarrhoea occurring after every feed and weight loss. She had several admissions to her local hospital over the previous weeks and had been treated for possible gastroenteritis without any improvement.
On admission she was severely dehydrated and was having recurrent seizures. She required a number of fluid boluses. Her gastrostomy site was bleeding and her perianal area was quite inflamed.
Blood tests showed leukocytosis with neutrophilia, hypernatraemia, hypokalaemia, deranged creatinine and urea and prolonged APTT. Blood gas revealed metabolic acidosis. Inflammatory markers, urine and stools cultures (including testing for Clostridium Difficile) were within normal limits. There were dilated bowel loops on abdominal X-ray. After her resuscitation, decision made was to stop her enteral feeds and start her on parenteral nutrition and intravenous metronidazole, ceftriaxone and gentamicin. A further contrast study done through her gastrostomy showed the Mic-Key button extension lying in the transverse colon.
She underwent a laparotomy which showed a gastro-colonic fistula with the wall of the transverse colon attached to the internal abdominal wall. There were no signs of peritoneal contamination. Gastro-colonic fistula was closed and a new gastrostomy was performed. Five days after the operation, the patient tolerated her feeds, diarrhea disappeared, parenteral nutrition was stopped and she reached full enteral feeds.
On further questioning it became clear that her symptoms started at the time of her last Vygon Mic-Key button replacement that took place in the Community where she was receiving her usual care. It is possible that during the initial percutaneous endoscopic gastrostomy (PEG) insertion, the tube passed through the transverse colon before entering the posterior wall of the stomach therefore forming a gastro-colonic fistula. On changing the Vygon Mic-key button, it was placed into the transverse colon rather than going all the way to the stomach. As a result, enteral feeds and medications bypassed the usual way and were given directly into the transverse colon. This explained the diarrhoea and the rest of her symptoms such as the weight loss and the seizures (poor absorption of nutrients and medicines).
A gastrostomy tube is an artificial device placed into an opening made through the abdominal wall and into the stomach lumen (Figure A).
Until 1980 all permanent intragastric feeding tubes were inserted surgically by a laparotomy. Following 1980, it has become widely accepted that endoscopic insertion is less invasive, more rapid, creates less incisional pain, and reduces length of stay and procedure costs, as well as being at least as safe as the surgical approach (1).
As all surgical procedures there are a number of complications. One of these complications is malposition of tube which is placed in an organ other than the stomach such as small bowel, large bowel, peritoneal cavity or abdominal wall (2). During the procedure, if a loop of small or large bowel is between the stomach and the abdominal wall, it may be caught by the needle and as result, the PEG tube will be inserted through the bowel wall into the stomach; as the time passes, the tract around the gastrostomy epithelializes and forms a fistula, for example a gastro-colonic (Figures B and C). If the fistula does not have time to mature (about six weeks), the removal or replacement of the tube may dislodge the tube from the stomach to another organ such as the colon (as in our case) with a high risk of peritonitis (2) (Figure C).
Gastro-colonic fistula should be considered in any patients with PEG who develops diarrhoea after replacement of the gastrostomy tube (3). Gastro-colonic fistula associated with diarrhea is often seen after the replacement of the original PEG with a Mic-Key button because it is shorter than a PEG tube and can easily be found directly into the colon (4). Investigations needed after a suspicion of a PEG malposition are: 1) CT scan with oral/gastrostomy gastrograffin to show the position of the hub and the tube. 2) Contrast study of the gastrostomy tube by injecting gastrograffin in the tube and performing a plane X-ray of the abdomen or doing a fluoroscopy to show the position of the hub and any extravasation of the contrast into the peritoneal cavity. 3)Endoscopy can confirm the migration of the PEG from the stomach (1, 5). 4) Gastrograffin enema identifying a filling defect in the colon can verify the position of the hub in the colon (1, 5).
Gastro-colonic fistula is a known complication of PEG insertion and if it is not recognized, can lead to life-threating symptoms as hypovolemic shock and death. Clinicians should be aware of signs and symptoms of PEG malposition, that are obviously non-specific, and they should ask for the proper diagnostic investigations.
Fig.A, B, C. (A) Normal insertion of a gastrostomy tube. (B) Formation of a gastro-colonic fistula. (C) Mic-key button in the colon after the formation of a gastro-colonic fistula. Re-designed by T. Alterio from: Okutani D et al. “A case of gastrocolocutaneous fistula as a complication of percutaneous endoscopic gastrostomy”. Acta Medica Okayama. Vol. 62, 2008 Issue 2, Art. 9
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