Intermittent diarrhea as a delayed presentation of percutaneous endoscopic gastrostomy (PEG)-associated fistula

A 60-year-old patient with severe dysphagia, weight loss, and recurrent aspiration pneumonia required a percutaneous endoscopic gastrostomy (PEG) for long-term feeding. After 24 uneventful days, she developed an enigmatic recurring but intermittent diarrhea. On day 62, staff noted a feculent odor from her gastrostoma, along with undigested formula in her stools. This prompted her hospitalization. A plain abdominal radiograph demonstrated the PEG tube in the upper abdomen, but could not differentiate if its tip was misplaced. Next, an abdominal barium-contrast computed tomography scan was performed but was inadvertently misinterpreted as normal. Finally, a colonoscopy demonstrated that the tip of the PEG tube was malpositioned in the transverse colon, resulting in a colocutaneous fistula (CCF). The PEG tube was withdrawn uneventfully through the gastrostoma. A laparotomy was performed. Strong adhesions were found between the stomach and the colon; these were lysed and the CCF tract was excised. The patient recovered. CCF should be considered in the differential diagnosis of PEG patients with unexplained diarrhea even if the diarrhea is delayed or intermittent; the diagnosis should be confirmed by a tubogram.