Kapil Gupta, MD1, Akiva Marcus, MD, PhD2
1University of Miami / JFK Medical Center Palm Beach Regional GME Consortium, Atlantis, FL; 2University of Miami / JFK Medical Center, West Palm Beach, FL
Introduction: The natural progression of amyotrophic lateral sclerosis (ALS) usually leads to malnutrition because of decreased oral intake from dysphagia, reduced salivation, and anorexia. A decrease in weight of 5-10 kg or BMI < 20 requires intervention to improve nutrition. Intervention includes placing a feeding gastrostomy surgically, endoscopically (percutaneous gastrostomy or PEG), or radiologically. Complications range from dislodgement to parietal necrosis and death. This case involves a patient with severe malnutrition who had a significant gastric perforation during PEG tube placement, which we attribute to a patient’s nutritional status and mucosal/muscular atrophy.
Case Description/Methods: 80 yr-old man with PMH of end-stage ALS presented to the hospital for failure to thrive and significant weight loss. He underwent an EGD for PEG tube placement. During the EGD, the gastric body was notable for diffuse atrophic mucosa and hiatal hernia. Using standard technique, a 20 Fr EndoVive Safety gastrotomy tube was safely pulled through the mouth using guidewire into the stomach. The trocar needle was removed, and the PEG was pulled out from the stomach through the skin. When confirming position of the PEG tube by relook endoscopy, we found a 4 cm perforation in the stomach at the diaphragmatic hiatus with associated hemorrhagic mucosa. At which point, a large amount of subcutaneous emphysema was seen in the chest and neck. The gastroscope was immediately withdrawn, and surgery was called. The patient was transferred to the ICU. After a discussion with surgery, patient, and his family, they agreed to palliative care as patient adamantly refused further procedures. The patient was transferred to hospice care and expired three days later.
Discussion: This case is a rare presentation of a severe complication during PEG tube placement that we attributed to the poor nutritional status of the patient. We believe that the gastric mucosa and muscular atrophy from severe malnutrition led to the large perforation when the guidewire or the internal bumper of the PEG transversed the diaphragmatic hernia. This is the first case describing a complication of PEG tube placement in a severely malnutritioned ALS patient. In conclusion, this case highlights the possibility of altering procedural techniques for PEG tube placement and the necessity for increased caution during PEG tube placement in ALS patients with severe malnutrition.
Citation: Kapil Gupta, MD; Akiva Marcus, MD, PhD. P0383 - GASTRIC PERFORATION DURING PEG TUBE PLACEMENT IN ALS PATIENT WITH SEVERE MALNUTRITION. Program No. P0383. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.